Bulent Aydinli

Management of Fournier's Gangrene: Review of 45 Cases

PurposeFourniers gangrene is a fatal synergistic infectious disease with necrotizing fasciitis of the perineum and abdominal wall along with the scrotum and penis in men and the vulva in women.MethodsThe clinical and operative records of 45 patients with Fourniers gangrene during a 14-year period were analyzed.ResultsThe etiology of the infection was identified in 39 patients. The most common causes were colorectal diseases and urogenital diseases. Four patients died with an overall mortality of 8.8%. The mortality rate was higher in patients with diabetes mellitus, but it was not statistically different. The age, duration of the symptoms, and the presence of rectal abscess were not found to be significant factors regarding mortality rate.ConclusionsSurgery with extensive debridement of all necrotic tissue is the main stay of treatment.

Alveolar Echinococcosis: Spectrum of Findings at Cross-sectional Imaging

Alveolar echinococcosis is a rare parasitic disease caused by the fox tapeworm Echinococcus multilocularis, which is endemic in many parts of the world. Without timely diagnosis and therapy, the prognosis is dismal, with death the eventual outcome in most cases. Diagnosis is usually based on findings at radiologic imaging and in serologic analyses. Because echinococcal lesions can occur almost anywhere in the body, familiarity with the spectrum of cross-sectional imaging appearances is advantageous. Echinococcal lesions may produce widely varied imaging appearances depending on the parasites growth stage, the tissues or organs affected, and the presence of associated complications. Although the liver is the initial site of mass infestation by E multilocularis, the parasite may disseminate from there to other organs and tissues, such as the lung, heart, brain, bones, and ligaments. In severe infestations, the walls of the bile ducts and blood vessels may be invaded. Disseminated parasitic lesions in unusual locations with atypical imaging appearances may make it difficult to narrow the differential diagnosis. Ultrasonography, computed tomography (CT), magnetic resonance (MR) imaging with standard and diffusion-weighted sequences, and MR cholangiopancreatography all provide useful information and play complementary roles in detecting and characterizing echinococcal lesions. Cross-sectional imaging is crucial for differentiating echinococcosis from malignant processes: CT is most useful for depicting the peripheral calcifications surrounding established echinococcal cysts, and MR imaging is most helpful for identifying echinococcosis of the central nervous system.

Typhoid Intestinal Perforations: Twenty-six Year Experience

BackgroundTyphoid fever (TF) is a severe febrile illness caused by Salmonella typhi. One of the most lethal complications of TF is ileal perforation (TIP). Although the mortality of associated with TIP has decreased slightly over the past decade, it is still high.Methods and ResultsThe records of the 82 surgically treated patients with TIP were evaluated retrospectively. There were 64 men with the mean age of 36.3 years (range: 7–68 years). In surgical treatment, debridement with primary closure was performed in 32 patients (39.0%), and wedge resection with primary closure was performed in 9 (11. 0%), resection with primary anastomosis in 9 (11.0%), and resection with ileostomy in 32 (39.0%). The most common postoperative complication was wound infection, which occurred in 24 patients (29.3%). The overall morbidity was highest in the ileostomy group. The overall mortality was 11.0% (9 patients). Age, gender, number, and localization of the perforations (p > 0.05) were not found to affect mortality, but prolonged preoperative period (p < 0.001), extended peritoneal contamination (p < 0.01), and ileostomy procedure (p < 0.001) were found to influence the increase in mortality.ConclusionsEarly and appropriate surgical intervention with effective preoperative and postoperative care may improve survival in TIP.

Intussusception in Adults

Abstract To review clinical, radiological and histopathological findings of adult intussusception and its management, 18 adult patients who had been treated surgically because of intussusception were reviewed. Of the patients, 5 (27.8%) had idiopathic intussusceptions, while the other 13 (72.2%) had a definable intraluminal pathology. The site of the intussusception was more common in the small bowel (83.3%) than the colon (16.7%). Ultrasonography and computed tomography were successful in demonstrating “target lesion” in 80% and 75% respectively. Patients with idiopathic intussusception were treated with simple reduction, while the others underwent segmental resection because of the possibility of malignant tumour. In contrast to intussusception in childhood, intussusception in adults usually has a definable lead point and resection of the involved bowel, rather than simple reduction, is indicated.

Intrabiliary rupture in liver hydatid cysts: results of 20 years' experience.

Abstract To assess the diagnostic tools and results of treatment of biliary rupture observed in liver cyst hydatids, clinical findings of 562 patients with hepatic hydatid disease were reviewed. Imaging techniques were not very effective to determine intrabiliary ruptures. Rates of rupture sizes determined in the patients were as follows; 22 (%24.7) large, 38 (%42.7) small, and 29 (%32.6) occult. Most frequently utilized procedures for patients with intrabiliary rupture were Roux-en-y cystojejunostomy, tube drainage + omentoplasty, sutured fistula + omentoplasty, and sutured fistula + tube drainage. Of the total 25 external biliary fistulas, 21 closed spontaneously. Of the four fistulas that did not close, one was managed by internal drainage and three by endoscopic sphincterotomy. Preoperative diagnosis of biliary rupture in liver hydatid cyst allows early planning of operation and helps the surgeon design the operative strategy. In the treatment of cases with large rupture, internal drainage may be proposed.

The Protective Effect of Aprotinin and α-Tocopherol on Ischemia-Reperfusion Injury of the Rat Liver

BACKGROUND Liver injury caused by ischemia-reperfusion (I/R) processes is a complication of hepatic resection surgery and transplantation, particularly using grafts from marginal donors. Despite improvements in organ preservation and advances in surgical techniques, I/R injury remains a significant clinical problem. In this study, we investigated whether aprotinin provided protection against the adverse effects of I/R injury in liver tissue. METHODS Forty rats were randomized into four groups (n = 10): group I: (control group) I/R + no medication; group II: sham-operated group + no medication or I/R; group III: I/R + aprotinin; group IV: I/R + alpha-tocopherol. Malondialdehyde (MDA) was measured in the liver tissue and superoxide dismutase (SOD), catalase (CAT), aspartate aminotransferase (AST), alanine aminotransferase (ALT), as well as lactate dehydrogenase (LDH) in rat serum. RESULTS Administration of aprotinin and alpha-tocopherol before I/R resulted in significant reductions of MDA levels compared to the I/R alone group (group I; P = .01 and P < .01, respectively). Administration of aprotinin or alpha-tocopherol prior to I/R resulted in significant increases in SOD and CAT levels compared with the I/R group (P < .05 each). Compared to the I/R group, significant decreases in plasma AST, ALT, and LDH levels were observed both in the aprotinin and in the alpha-tocopherol group (P < .05). Histological evaluation revealed the injury grade to be relatively lower among groups III and IV compared to group I. DISCUSSION In conclusion, rat hepatic structures in aprotinin and alpha-tocopherol administered groups were well protected. Therefore, aprotinin may provide protection against the adverse effects of I/R injury in liver transplantation.

Ileosigmoidal Knotting in Children: A Review of 9 Cases

BackgroundThe purpose of this study was to review nine pediatric cases of ileosigmoidal knotting (ISK), which is an unusual form of intestinal obstruction common in adults, characterized by double-loop obstruction.MethodsA retrospective analysis was designed to examine preoperative, operative, and postoperative findings of the nine children with ISK who were surgically treated in a university hospital throughout a 38.5-year period..ResultsThe mean age was 10.6 years (range: 7–16 years). Seven patients (77.8 %) were male. The most common symptoms were abdominal pain, distention, obstipation, and vomiting, and the most common signs were abdominal tenderness and distention. The most common form was type 1A in 4 patients (44.4%) in whom the active ileum encircled the passive sigmoid colon in clockwise direction. There was a gangrene in both ileum and sigmoid colon in 7 patients (77.8%), one patient (11.1%) had gangrene in only the sigmoid colon, and the bowels were viable in 1 patient (11.1%). In the gangrenous cases, nonviable small bowel segments were resected, and anastomosis was performed, while gangrenous sigmoid colon was resected and Hartmann procedure or primary anastomosis was used. In the nongangrenous case, detorsion was performed and sigmoidopexy was added. One patient in this series (11.1%) died.ConclusionsIleosigmoidal knotting is a rare disease in children. Its preoperative diagnosis is not easy. It is generally misdiagnosed as an obstructive emergency. Aggressive preoperative resuscitation, effective and prompt surgery, and postoperative support are the basic principles of treatment. Although resection with primary anastomosis is advised in gangrenous cases, stomas may be lifesaving in unstable patients. In nongangrenous cases, definitive surgical procedures are generally used.

Stereological evaluation of liver volume in living donor liver transplantation using MDCT via the Cavalieri method.

In living donor liver transplantation (LDLT), obtaining the precise volume of the graft is very important to decrease volume‐related postoperative complications, especially in cases with suspected small‐for size grafts. We used stereology based on the Cavalieri method (CM), a new method to measure liver graft volume, and compared the results with those obtained through intraoperative measurement (IOM) and through multidetector computed tomography (MDCT) measurement. Liver volumes estimated using the 3 methods were well‐correlated with each other (r2 = 0.94 and P < 0.001 for IOM and CM; r2 = 0.91 and P < 0.001 for IOM and MDCT, and r2 = 0.95 and P < 0.001 for CM and MDCT); however, they were different from each other (in descending order, 908 ± 124 cm2, 861 ± 121 cm2, and 777 ± 168 cm2 for MDCT, CM, and IOM, respectively). Although MDCT and CM overestimated the volumes, the results of CM were almost similar to those obtained via IOM. In conclusion, our results suggest that CM measured the liver graft volume more reliably. Thus, its use, particularly in cases with suspected small‐for‐size graft, may prove useful. Liver Transpl 13:693–698, 2007.

Giant Mesenteric Cyst

Mesenteric cysts (MCs) are defined as cystic masses located in the mesentery. These are commonly located at the ileal mesentery, but they also can be found anywhere at the mesentery from the duodenum to the rectum [1]. The incidence of mesenteric cysts has been estimated to be 1:100,000 in the adult population, with a male:female ratio of 1:1 [2]. The etiopathogenesis of the disease remains unknown, and many pathologic processes have been reported, including benign proliferation of ectopic lymphatics, obstructions of the lymphatics, abdominal traumas and local degeneration of some lymph nodes [2, 3]. Most MCs remain asymptomatic [4]. A total of 40% are diagnosed incidentally during surgery. Abdominal pain, nausea and vomiting are the most frequent symptoms [1]. We present a case with an unknown abdominal mass, diagnosed as giant ileal MC and treated surgically.

Hepatobiliary and pancreatic: Alveolar hydatid disease

What abnormalities are seen on the contrast-enhanced computed tomography scan shown in Figure 1? There is a large semisolid mass in the right lobe of the liver with features consistent with central necrosis. On other images, there was patchy calcification and the possibility of invasion of the portal vein and inferior vena cava. The differential diagnosis should include primary and secondary neoplasms, a large adenoma or cavernous hemangioma and perhaps a pyogenic or amebic liver abscess. A tru-cut biopsy was performed with ultrasound guidance and revealed larval membranes (Fig. 2). The diagnosis was that of alveolar hydatid disease (Echinococcus multilocularis). The patient was a 50-year-old woman who was investigated because of a 3-month history of dyspepsia and back pain. She had tenderness over the upper abdomen and changes in liver function tests. As the lesion was judged to be too large for surgical resection, she was treated with albendazole. E. multilocularis is a rare disorder that appears to be restricted to the Northern Hemisphere. The definitive hosts include foxes, dogs and wolves while the intermediate hosts are small rodents and humans. Primary infections mostly occur in the liver and invade the surrounding parenchyma as scolices are released from daughter cysts that bud on the outside of the germinal membrane. There is no cyst wall. The infection may spread through the blood stream and result in secondary foci in other organs, usually the lungs or brain. The treatment of choice is operative resection of the larval mass but this can only be achieved in a minority of patients. Patients with unresectable disease have a mortality of approximately 90% at 10 years although in some, survival can be prolonged by treatment with mebendazole or albendazole. Medical treatment may halt the progression of disease but does not appear to kill the parasite.