Cem Ibis

The Amount of Comorbidities as a Single Parameter Has No Effect in Predicting the Outcome in Appendicitis Patients Older than 60 Years

Background: Retrospective analysis of acute appendicitis patients older than 60 and statistical evaluation of the association between the accompanying illnesses, severity of peritonitis, morbidity, and mortality rates. Introduction: Although acute appendicitis is not frequent among aged populations, accompanying comorbidities of the geriatric patients are always fear factors before an emergency abdominal surgery even for acute appendicitis. Methods: The data of the 27 patients older than 60 years who underwent appendectomy were retrospectively analyzed. The patients were grouped according to the total number of their comorbidities, Mannheim peritonitis index scores, and the period between the onset of abdominal pain and the admission to the hospital. Results: The mean age of the patients was 73 years. The morbidity and mortality rates were statistically significantly higher in perforated cases. The comparison of patients with ≤1 comorbidity with patients with ≥2 comorbidities did not show any statistical difference in morbidity and mortality. The sensitivity, specificity, positive predictive value, and negative predictive values for mortality in geriatric acute appendicitis patients with Mannheim peritonitis index scores greater than 26 were found to be 75%, 86%, 50%, and 95%, respectively. Discussion: Retrospective evaluation of geriatric patients with acute appendicitis, according to the total number of their comorbidities, surprisingly revealed no statistical difference between groups. We thought that a high Mannheim peritonitis index score is a more reliable criteria than the total number of comorbidities in predicting the prognosis of patients with acute appendicitis in the geriatric population.

Protective effect of Urtica dioica on liver damage induced by biliary obstruction in rats

The aim of this study was to evaluate the possible protective effects of Urtica dioica (UD) against liver damage in the common bile duct-ligated rats. A total of 24 male Sprague Dawley rats were divided into three groups, namely, control, bile duct ligation (BDL) and BDL + received UD groups, containing eight animals in each group. The rats in UD-treated groups were given UD oils (2 ml/kg) once a day intraperitoneally for 2 weeks starting 3 days prior to BDL operation. The change demonstrating the bile duct proliferation and fibrosis in expanded portal tracts includes the extension of proliferated bile ducts into the lobules; inflammatory cell infiltration into the widened portal areas were observed in BDL group. Treatment of BDL with UD attenuated alterations in liver histology. The α-smooth muscle actin, cytokeratin-positive ductular proliferation and the activity of terminal deoxynucleotidyl transferase dUTP nick end labeling in the BDL were observed to be reduced with the UD treatment. The data indicate that UD attenuates BDL-induced cholestatic liver injury, bile duct proliferation and fibrosis.

Primary hydatid disease of pancreas mimicking cystic neoplasm.

Primary hydatid disease of the pancreas is very rare. We report a 33-year-old female who was admitted to the hospital with abdominal discomfort due to the pancreatic mass. A diagnosis of a pancreatic cystic mass was established through abdominal ultrasonography and computed tomography scan. Hydatid disease as well as a cystic neoplasm of the pancreas were both thought in the differential diagnosis. Distal pancreatectomy with splenectomy was performed. The histopathologic evaluation of the specimen revealed a hydatid cyst affecting the tail of the pancreas. Hydatid disease should be considered in the differential diagnosis of all cystic masses of the pancreas, especially in endemic regions.

Acute Abdomen Caused by Brucellar Hepatic Abscess

Brucellosis is a zoonotic infection that is transmitted from animals to humans by ingestion of infected food products, direct contact with an infected animal, or aerosol inhalation. The disease is endemic in many countries, including the Mediterranean basin, the Middle East, India, Mexico, Central and South America and, central and southwest Asia. Human brucellosis is a systemic infection with a wide clinical spectrum. Although hepatic involvement is very common during the course of chronic brucellosis, hepatic abscess is a very rare complication of Brucella infection. We present a case of hepatic abscess caused by Brucella, which resembled the clinical presentation of surgical acute abdomen.

Bilateral brucellar breast abscess in a 48-year-old woman.

To the Editor: Brucellosis is a zoonotic infection transmitted from animals to humans by ingestion of infected food products, direct cont tact with an infected animal, or int halation of aerosols.1 The disease remains endemic in many countries, mainly in the Mediterranean basin, the Middle East, India, Mexico, Central and South America and, currently, central and southwest Asia. Soft tissue involvement is an uncommon occurrence of the dist ease. Breast involvement in animals is common, whereas in humans it is an extremely rare manifestation.2t5 We report a case of bilateral brucelt lar breast abscess, which was succest fully treated through abscess draint age and antibiotic therapy. A 48tyeartold woman was adt mitted to our department with pain, swelling, erythema, and an odorless nipple discharge in both breasts for 10 days. She was involved in stockt breeding on a farm and was suspectt ed of having a history of consumpt tion of unpasteurized cheese. She had also been suffering from night sweats for the previous 2 years. Physical examination revealed a 5×3 cm, indurated, erythematous, and painful mass in the upper left quadrant of the breast on the left side and 3×3 cm periareolar paint ful mass in the right breast. Bilateral abscess formation with cystic and solid components were detected through ultrasonographic examinat tion of both breasts. Needle punct ture of the lesions revealed an obt vious purulent material. Bilateral surgical drainage was performed. Oral antibiotic therapy with cefut roxime axetil was began immedit ately due to a suspected pyogenic abscess. Despite daily wound dresst ing changes of the abscess cavities and scheduled antibiotic therapy, the patient did not improve. Approximately 2 weeks after primary abscess drainage, bactet rial culture of the purulent material revealed Brucella species. Following the positive culture for Brucella, the Wright and RosetBengal tests were also found to be positive, which confirmed the diagnosis of human brucellosis and bilateral brucellar breast abscess. After replacing the ongoing antibiotic therapy with combined regimen of oral doxycyt cline (200 mg/day) and rifampin (600 mg/day), dramatic regression of both of the abscesses and rapid improvement in clinical symptoms were observed, which also cont firmed the diagnosis of human brut cellosis. The 6 month followtup was uneventful. Brucellar infection of the human breast is extremely rare. Clinical symptoms of brucellosis are nont spesifics and include fever, malt aise, sweats, arthralgias, lower back pain, and headache. Based on the series of Andriopoulos et al, the prevalence of human brucellosis as a breast abscess is only 0.7%.6 Our case presented with bilateral breast abscesses first though to be pyogenic. Unfortunately, bilateral surgical abscess drainage followed by broadtspectrum oral antibiotic therapy did not heal the abscesses. The delay in the definitive diagnosis of the causative agent of the breast abscess was the most likely reason for failure of treatment. The clinit cal management of brucellosis is of particular concern because of high initial treatment failure and relapse rates.7 Two weeks after initial treatt ment we were able to replace our initial treatment regimen with apt propriate combined antibiotic thert apy based on the definitive isolation and positive culture for Brucella spet cies as the causative agent in our pat tient. Although the breast abscess is a very rare complication of systemic brucellosis, the physician should be aware of this unusual manifestat tion of human brucellosis. We cont cluded that repeated cultures from purulent material in an unhealing breast abscess, despite the broadt spectrum antibiotic therapy and surgical drainage, may eventually show underlying systemic brucelt losis, especially in endemic areas of the world.

Factors Affecting Liver Regeneration in Living Donors After Hepatectomy

Background The safety of living liver donors is the paramount priority of liver transplantation surgeons. The liver has an effective regeneration capacity. The regeneration rate of the liver remnant in living liver donors provides much information useful in liver surgery. The outcome of the remnant liver after hepatectomy can be affected by many different perioperative factors. Material/Methods A total of 46 patients were enrolled in the study. Retrospective clinical data, including preoperative and postoperative early and late computed tomography liver volumetry measurements, estimated resection volumes, resected liver weights, and postoperative laboratory values, were statistically evaluated according to the liver resection type. Results No significant difference was detected in age, sex, calculated and computed tomography estimated total liver volume, intraoperative Hb decrease, postoperative complications, or postoperative portal vein flow rate. Postoperative liver enlargement rates were significant higher in the right hemihepatectomy (RHH) group than in the left lateral sectionectomy (LLS) group. The size of the liver remnant or graft has a major effect on regeneration rate. Postoperative biliary leakage did not have any significant effect on liver regeneration. No post-hepatectomy liver failure was detected among the liver donors. Conclusions Liver hypertrophy depends on the extent of liver resection. The cause of volume decrease in the LLS group after hepatectomy in our series appears to be the gradual atrophy of liver segment 4. RHH and LLS surgeries differ from each other in terms of resected liver volume, as well as inflammatory activity, and the latter appears to affect liver regeneration.

Value of Preoperative Indocyanine Green Clearance Test for Predicting Post-Hepatectomy Liver Failure in Noncirrhotic Patients

Background Liver failure is the most feared complication following hepatectomy. Post-hepatectomy liver failure (PHLF) is closely related to the remnant liver volume, and functional reserve. There are several methods for predicting PHLF prior to liver resection. The indocyanine green (ICG) clearance test was popularized in patients with hepatocellular cancer (HCC). We aim to demonstrate the value of preoperative ICG clearance measurement via pulse spectrophotometer (LIMON®) in prediction of PHLF in noncirrhotic patients prior to liver resection. Material/Methods Fifty-three noncirrhotic patients who underwent liver resection due to different pathologies were included. Retrospectively collected clinical data, including the preoperative ICG clearance measurements and remnant liver volumes of the patients, were statistically evaluated according to the PHLF criteria of the International Study Group of Liver Surgery. Results Four (7.5%) patients with PHLF were observed. There was no significant difference between PHLF and non-PHLF groups regarding ICG clearance measurements with cut-off values of 5% and 9.5%. Conclusions The ICG clearance test does not satisfy our expectations in noncirrhotic patients in predicting PHLF. We believe that the ICG clearance test should be reserved for patients with cirrhosis and/or HCC. This test could be an option for noncirrhotic patients with chronic active hepatitis, advanced-grade fatty livers, or for patients who received long-term preoperative chemotherapy, and also for patients who underwent single or multiple sessions of TACE or TARE prior to liver resection. If the routine selection criteria have been fulfilled, there is no further need to perform the ICG clearance test for living liver donors.

The Value of Intra-abdominal Pressure Measurement in Patients with Acute Abdomen

AIM To find out the potential benefit of bladder pressure (BP) measurement as a diagnostic tool for acute abdomen. BACKGROUND Acute abdomen is one of the most important clinical entities among general surgical clinics. The diagnosis can be achieved by considering the patients history, physical examination, laboratory analysis or by different imaging modalities. Abdominal compartment syndrome (ACS) occurs due to elevated intra-abdominal pressure (IAP), and can be diagnosed by measurement of BP. We observed in our clinical routine elevated IAP levels in patients with acute abdomen. METHODS Two groups were established: one containing 65 consecutive patients diagnosed as having acute abdomen in the emergency room, and the control group of 10 consecutive patients with no acute abdominal complaints elected for laparoscopic operation. IAP measurements were performed before the operations. BP was measured in the supine position with 50 mL of sterile saline instilled into the bladder after the bladder had been emptied. The catheter was connected to a water manometer with the reference point being the symphisis pubis. BP levels greater than 7 cmH2O were accepted as abnormal and interpreted as a diagnostic criteria for acute abdomen. RESULTS Sensitivity, specificity, positive predictive value, negative predictive value and the accuracy are calculated 95.4%, 80%, 96.9%, 72.7%, 93.3%, respectively. CONCLUSION We found elevated IAP may support the physicians diagnosis of acute abdomen with approximately 27.3% false negative rate.

An unusual CT

A 50 year old man was admitted to the emergency room suffering from right upper quadrant pain and vomiting for two days. He had a …