Alper Sözütek

A prospective randomized comparison of single-port laparoscopic procedure with open and standard 3-port laparoscopic procedures in the treatment of acute appendicitis.

Background: This prospective randomized study aimed to evaluate the surgical outcomes of single-incision laparoscopic appendectomy (SILA) comparing with open appendectomy (OA) and standard 3-port laparoscopic appendectomy (SLA) in the treatment of acute appendicitis (AA). Methods: Adult patients older than 18 years presenting with AA were randomized into 3 groups to undergo OA, SLA, and SILA from September 2010 to May 2011. The groups were compared with regard of patient’s characteristics, perioperative findings/complications, operative time, pain severity, analgesic requirement, time to oral tolerance and flatus, length of hospital stay, and cosmetic results. Results: A total of 75 consecutive patients enrolled in the study. Each group included 25 patients. The groups showed no significant differences in patient’s characteristics. The mean operative time was significantly longer in SILA than OA with a mean difference of 7 minutes (P<0.05). Postoperative pain after OA were significantly higher than SLA and SILA (P<0.05). The average time to oral tolerance and flatus was significantly higher in OA than the laparoscopic groups with a mean difference of 1 and 2.5 hours (P=0.04 and 0.023, respectively). The length of hospital stay in SLA and SILA was significantly lower than OA with a mean difference of 0.8 days (P<0.05). There was no difference in overall complications between the groups. There was no difference between SLA and SILA in terms of surgical outcomes. Conclusions: Either SLA or SILA offer patients faster recovery period with acceptable complications than OA. Hence, laparoscopic approach might be considered as first option in the treatment of AA. However, all 3 techniques provide equivalent clinical outcomes despite the significant findings. Therefore, technique selection is based on surgeon’s decision, experience, and availability of laparoscopic instruments.

Phenol procedure for pilonidal sinus disease and risk factors for treatment failure

BACKGROUND The present study was designed to evaluate the results of phenolization for pilonidal sinus disease and the risk factors for treatment failure. METHODS Between June 2005 and July 2009, 76 consecutive patients with nonrecurrent sacrococcygeal pilonidal sinus were treated with a phenol treatment and included in the study. The clinical (age, sex, story of treatment for abscess formation, and comorbidity), operative (localization and number of sinus openings and volume of cavity), and follow-up data (healing time, time off work, postoperative complications, morbidity, and number of phenolization sessions) of the patients was recorded. Gender, age, history of abscess drainage, number of sinus openings, localization of sinus openings, volume of cavity, and the number of phenolization sessions were analyzed as risk factors for treatment failure. RESULTS The overall success rate was 67% (51 of 76 patients). The mean time to complete healing was 16 days (range, 10-45). The time off work was 0 days. Age and gender were not found to be risk factors for treatment failure (P > .05 and P > .05, respectively). Patients with a history of abscess drainage and more than 3 sinus openings had a significantly higher risk of treatment failure (P = .001 and P = .046, respectively). There was no difference between the localization of sinus openings and treatment failure (P > .05). There were statistically significant differences between treatment failure and both the cavity volume and number of phenolization sessions (P = .016 and P = .001, respectively). Patients were followed up for a mean period of 25 months (range, 13-48). One patient (2%) showed recurrence. CONCLUSION With an early return to work and low rates of complications and recurrence, phenolization is a simple outpatient procedure for the treatment of pilonidal sinus disease in selected patients.

Colonic anastomosis leakage related to taenia saginata infestation

A 49-year-old male patient was admitted to our emer-gency service with a one-week history of abdominal pain.Despite using analgesics, abdominal discomfort progressedto generalized abdominal pain, nausea and vomiting. Uponphysical examination, generalized abdominal tendernessand rebound tenderness were detected. Laboratory para-meters revealed leukocytosis [14.3 6103/ml (range 4.5-11)]and a high C-reactive protein level of 247.12 mg/l (range,5). No disorder was determined from other parameters.Plain x-ray abdominal radiography was unremarkable.Abdominal ultrasonography (US) and computerized tomo-graphy (CT) revealed dilated small intestines in the rightlower abdominal quadrant with pericecal free fluid that wascompatible with a possible perforated or plastron appendi-citis (Fig. 1). Urgent surgery was planned after obtaining thepatient’s consent. On exploratory laparotomy, a complicatedmass formation composed of the appendix, cecum andsigmoid colon was identified in the right lower abdominalquadrant. After separation of the sigmoid colon, a perfo-rated cecal area of necrosis and the appendix wereidentified. A right hemicolectomy and a hand-sewnileotransversostomy were performed. On the third post-operative day, the patient’s vital signs began to deteriorateand an enteric fistula was observed at the drainage tube.Therefore, a second-look laparotomy was performed. Onexploration, an anastomotic leakage associated with asegment of the tapeworm was identified (Fig. 2). Theanastomosis was ligated, and an end ileostomy wasperformed due to the generalized fecal peritonitis. Thepostoperative course was uneventful. The patient received asingle dose of niclosamide (46500 mg) 10 days after surgery.The histopathologic examination of the specimen was read

Comparison of standard 4-row versus 6-row3-D linear cutter stapler in creation of gastrointestinal system anastomoses: a prospective randomized trial

OBJECTIVE: This prospective study was conducted to compare the clinical outcomes of a 6-row 3-D linear cutter with the standard 4-row linear cutter in patients who underwent elective gastrointestinal surgery anastomosis. METHOD: Patients who underwent elective open gastrointestinal surgery that included stapled anastomosis using a linear cutter (Proximate®, Ethicon Endo-Surgery, Cincinnati, OH) between January 2011 and May 2011 were included in the study. The patients were randomly assigned to two groups according to the linear cutter that was used in the surgery: the standard 4-row cutter (the S group) or the new 6-row cutter (the N group). The groups were compared based on the patient demographic data, the laboratory parameters, the preoperative diagnosis, the surgery performed, the operation time, intra- or postoperative complications, the time to oral tolerance and the length of the hospital stay. RESULTS: The S group included 11 male and nine female patients with a mean age of 65±12 (35-84) years, while the N group included 13 male and eight female patients with a mean age of 62±11 (46-79) years (p = 0.448, p = 0.443, respectively). Anastomotic line bleeding was observed in eight (40%) patients in the S group and in one (4.7%) patient in the N group (p = 0.006). Dehiscence of the anastomosis line was observed in two (10%) patients in the S group and none in the N group (p = 0.131). Anastomotic leakage developed in three (15%) patients in the S group and in one (4.7%) patient in the N group (p = 0.269). The mean hospital stay was 12.65±6.1 days in the S group and 9.52±2.9 days in the N group (p = 0.043). CONCLUSION: The 6-row 3-D linear cutter is a safe and easily applied instrument that can be used to create anastomoses in gastrointestinal surgery. The new stapler provides some usage benefits and is also superior to the standard linear cutter with regard to anastomotic line bleeding.

ASYMPTOMATIC GOSSYPIBOMA MIMICKING A LIVER MASS

Gossipiboma ozellikle karin ici cerrahi girisimler sonrasinda gorulen hem cerrah hem de hasta icin cok ciddi sonuclara yol acabilecek nadir bir durumdur. Vucut icinde yer alan, pamuk yapidan olusan bir kitleyi tanimlamakta kullanilan bir terimdir. Gossypium (Latince, pamuk) ve boma (Svahilice, unutulan cismin yeri) kelimelerinden koken almaktadir (1). Karin ici cerrahi girisim sonrasi 1/3000-1/5000 arasi degisen oranlarda gorulebilecegi bildirilmekle birlikte yasal, tibbi sorunlar ve bazi hastalarin asemptomatik olabilmeleri nedeniyle bu oranin daha yuksek oldugu dusunulmektedir (2,3). En sik genel cerrahi girisimler sonrasinda gorulmekle birlikte kardiyovaskuler, ortopedik, urolojik islemler sonrasinda da gorulmektedir (4). En sik unutulan yabanci cisim cerrahi tamponlardir (3-5). Erken donemde karin ici abse gibi ciddi komplikasyonlara neden olabilmekle birlikte, yillarca asemptomatik kalip yalanci tumor goruntusu vererek insidental olarakta saptanabilirler (3,6,7).

The relationship between vasopressor dose and anastomotic leak in colon surgery: An experimental trial

BACKGROUND The effect of vasopressors on the healing of gastrointestinal anastomoses is still controversial. The purpose of our study was to research the relationship between dose of dopamine, which is used generally as a vasopressor in shock status, and anastomotic leak in colonic surgery. METHODS Forty-two male New Zealand rabbits were included in the study. Under general anesthesia, the right colon was identified, incised, and divided 5 cm distal to the ileocecal valve. Colonic integrity was then established with end-to-end anastomosis in all animals. The animals were randomized into 6 groups. While group 1 was not given any vasopressors, groups 2, 3, 4, 5, and 6 were administered 5, 10, 15, 20, and 25 microgkg(-1)h(-1) dopamine infusions, respectively, for 2h. On the 4th postoperative day, relaparotomy was performed under general anesthesia. The bursting pressures of anastomoses (BPA) were measured in situ, and then the lines of anastomoses were excised. The levels of hydroxyproline and collagen were measured in this tissue. RESULTS When compared with the control group (140+/-39 mmHg), BPA were found to be statistically increased only in group 5 (238+/-91 mmHg) (p=0.03) and group 6 (277+/-64 mmHg) (p=0.002). There were no differences between groups in terms of the hydroxyproline and collagen levels in the tissue (p>0.05). CONCLUSIONS Although vasopressors appeared to increase the risk of anastomotic leakage as a result of splanchnic vasoconstriction, deterioration of microcirculation, and local hypoxia, we found that BPA were increased with high doses of vasopressor. We speculated that the use of vasopressors without shock might increase blood supply to the anastomotic line by increasing cardiac output.

The Effect of Platelet-Rich-Plasma on the Healing of Left Colonic Anastomosis in a Rat Model of Intra-Abdominal Sepsis

ABSTRACT Objective: The aim of this study was to investigate the effect of platelet-rich plasma (PRP) on the healing of colonic anastomosis in the presence of sepsis. Materials and Method: Fifty Wistar-albino male rats were used. Ten healthy rats were euthanized to prepare PRP, the rest were subjected to colonic anastomosis and randomly allocated into four groups of 10 rats each as anastomosis without PRP (C), without PRP in sepsis (SC), anastomosis with PRP (C-PRP), and with PRP in sepsis (S-PRP). Sepsis was induced by cecal ligation and puncture procedure. All animals were euthanized on postoperative day 7. The body weight change, anastomotic bursting pressure (ABP), tissue hydroxyproline (TH) and histopathological examination of each group were analyzed by using one-way analysis of variance (ANOWA) and Tukeys HSD post-hoc test to assess the differences between the groups. Results: There was no statistical difference among the groups in terms of body weight changes. The ABP was measured at a mean value of 179.5 ± 10.3, 129.3 ± 14.2, 209 ± 14.4, and 167.5 ± 7.5 mm-Hg, in group C, SC, C-PRP, and S-PRP, respectively. The ABP and TH of C-PRP group was significantly higher than three groups (p < .05, for each comparison). In sepsis, PRP significantly raised the mean ABP and TH levels up to the levels of C group. Tissue regeneration was significant with increased collagen formation in C-PRP group than the other groups (p < .05). The healing effect of PRP in the presence of sepsis was significant than S-group (p < .05), while similar to C group (p = .181). Conclusion: PRP application to colonic anastomosis promotes the healing process in rats with intra-abdominal sepsis.

A Giant Aggressive Angiomyxoma of the Pelvis Misdiagnosed as Incarcerated Femoral Hernia: A Case Report and Review of the Literature.

Aggressive angiomyxoma (AA) is an uncommon mesenchymal tumor that is mostly derived from the female pelvic and perineal regions. AA is a locally infiltrative slow growing tumor with a marked tendency to local recurrence. Painless swelling located around the genitofemoral region is the common symptom; thus, it is often misdiagnosed as a gynecological malignancy or a groin hernia. A 35-year-old female patient who previously underwent surgery for left femoral hernia operation resulting in surgical failure was reoperated for a giant AA located in the pelvis. The tumor was completely excised with free margins. Histopathologic examination revealed an AA. The tumor size was measured as 24 × 12 × 6 cm with a weight of 4.2 kg. Immunohistochemically, the cells show positive staining with vimentin, desmin, estrogen, and progesterone receptor. S100, MUC4, CD34, and SMA were negative in the tumor cells. AA should be considered in the differential diagnosis of any painless swelling located in the genitofemoral region, particularly in women of reproductive age. The principle treatment should be complete surgical excision with tumor-free margins. Long-term follow-up and careful monitoring are essential due to its high tendency of local recurrence in spite of wide excision of the tumor. Adjuvant antihormonal therapy yields promising results for preventing recurrence.

The potential efficacy of Survanta (r) and Seprafilm (r) on preventing intra-abdominal adhesions in rats

PURPOSE To investigate the potential efficacy of beractant (Survanta(r)) and Seprafilm(r) on the prevention of postoperative adhesions. METHODS Forty Wistar-albino female rats were used. The rats were randomly allocated into four groups of 10 rats each as control group (CG), beractant group (BG), Seprafilm(r) group (SG), and combined group (COG). All rats underwent cecal abrasion via midline laparotomy. Before abdominal closure, isotonic saline, beractant, Seprafilm, and combined agents were intraperitoneally administered. Adhesions were classified macroscopically with Canbaz Scoring System on postoperative day 10. Ceacum was resected for histopathological assessment. RESULTS Macroscopic adhesion scores were significantly lower in BG, SG, and COG than CG (p<0.05); (45%, 15%, 25%, and 15%; respectively). Histopathological assessment revealed a reduced inflammation and fibrosis score in the study groups than CG (p<0.05). In BG, adhesion development, inflammation and fibrosis scores were lower than SG; however, it was not statistically significant. CONCLUSIONS Intra-abdominal application of beractant is significantly effective for the prevention of adhesion formation with no adverse effect by covering the whole peritoneal mesothelium with excellent gliding properties in a rat model. The combination of both agents is also effective in reducing adhesion formation, however, not superior to single beractant application.

İntraperitoneal drenaj sonrası oluşabilecek ciddi bir komplikasyon: İntestinal evisserasyonlar

GIRIŞ Intraperitoneal drenaj, karin ici cerrahi girisimini takiben karin ici boslukta birikebilecek kan, sivi gibi materyalleri onlemek ve/veya yapilan anastomozu takip edebilmek amaciyla uygulanan eski yontemlerden biridir (1). Dren uygulamasi 2000 yildan daha fazla suredir bilinen bir yontem olmakla birlikte, her girisim sonrasi rutin olarak uygulanmasi gunumuzde bile halen tartisma konusudur (2). 1887’de Lawson Tait supheli durumlarda dren konulmasini onermis olmasina ragmen, gunumuzde bircok cerrah bu gorusu goz ardi etmekte ve rutin olarak drenaj uygulamaktadir (3). Bununla birlikte drenaj, basit ve masum bir uygulama degildir. Dren lumeni hizli bir sekilde fibrin ile tikanabilmekte ve islevsiz hale gelip kendisi yabanci cisim reaksiyonuna sebep olarak potansiyel enfeksiyon kaynagi haline gelebilmektedir. Daha fazlasi ozellikle lumenli organlarin ve/veya damarlarin duvarinda hasarlanmaya sebep olarak fistul olusumuna ve kanama riskinin artisi gibi hayati tehdit edici komplikasyonlara zemin hazirlayabilmektedir (2,4,5). Dren cekilmesini takiben gelisebilen karin ici organ evisserasyonlari, sorunsuz giden bir ameliyat sonrasi hem hasta hem de cerrah acisindan istenmeyen sikintilara neden olabilen nadir, fakat ciddi bir komplikasyondur (2,6,7). Calismamizda, cesitli nedenlerden dolayi cerrahi girisim + drenaj uygulanmis ve dren cekilmesini takiben intestinal evisserasyon gelisen uc hastamizi sunmayi ve literatur esliginde dren kullanimini tartismayi amacladik.