Cengiz Erenoglu

COLOR: A Randomized Clinical Trial Comparing Laparoscopic and Open Resection for Colon Cancer

Background: Laparoscopic surgery has proven to be safe and effective. However, the value of laparoscopic resection for malignancy in terms of cancer outcome can only be assessed by large prospective randomized clinical trials with sufficient follow-up. Methods: COLOR (COlon carcinoma Laparoscopic or Open Resection) is a European multicenter randomized trial which has started in September 1997. In 24 hospitals in Sweden, The Netherlands, Germany, France, Italy and Spain, 1,200 patients will be included. The primary end point of the study is cancer-free survival after 3 years. Results: Within <2 years, more than 540 patients have been randomized for right hemicolectomy (45%), left hemicolectomy (10%) and sigmoidectomy (45%). 33 patients (6%) were excluded after randomization. The accrual rate is approximately 25 patients/month. Current survival rates for the whole study group are: stage I: 95%, stage II: 98%, stage III: 93%, stage IV: 64%. For all patients with stage I disease, the mortality was not cancer related. Conclusions: Although laparoscopic surgery appears of value in colorectal malignancy, results of randomized trials have to be awaited to determine the definitive place of laparoscopy in colorectal cancer. Considering the current accrual rate, the COLOR study will be completed in 2002.

Angiogenesis predicts poor prognosis in gastric carcinoma.

Background/Aims: New prognostic factors in gastric carcinoma to determine the prognosis of the disease or to identify patients who will benefit from adjuvant therapy are being researched. The aim of this study is to investigate the correlation between microvessel count (MVC) and various clinicopathologic features in gastric carcinoma in order to evaluate the role of angiogenesis on the prognosis of gastric cancer. Methods: Fifty-seven patients who underwent surgical intervention for gastric carcinoma between 1993 and 1997 were reviewed retrospectively. The relationship between MVC and various clinicopathological features was assessed. The effect of angiogenesis on overall survival and the role of MVC and other prognostic factors on distant metastases were assessed by multivariate analysis. Microvessels were outlined by anti-factor VIII, which is a specific monoclonal antibody to factor VIII in vessel endothelial cells, using the streptavidin-biotin method and counted under light microscopy ×200 magnification. Results: There was no correlation between MVC and age or sex of the patient, duration of symptoms or tumor size. Proximally located, undifferentiated, diffuse type, serosal invasion positive, lymph node invasion positive, advanced stage, or distantly metastasized tumors had higher MVCs. Higher MVCs affected the overall survival adversely. Lymph node metastasis, serosal invasion and MVC were found as independent prognostic factors affecting distant metastases. MVC was the sole factor affecting recurrent liver metastasis. Conclusion: It is concluded that MVC in gastric carcinoma may be a valuable prognostic factor to predict patients at high-risk for possible recurrences and to decide on postoperative adjuvant therapy.

Necrotizing fasciitis: A life-threatening clinical disorder in uncontrolled type 2 diabetic patients.

We presented 23 patients with necrotizing fasciitis (NF), 15 of whom had uncontrolled diabetes mellitus (DM), for risk factors, clinical signs, laboratory findings and prognosis during the period 1998 and 2006 in Istanbul. A hospital incidence of NF was 14.2/100,000 admissions. Other risk factors were obesity in 9 and recent surgical trauma in 10 patients. The mean age of the patients with DM was higher than that of the patients with non-DM (58.6+/-12.8 vs 43.0+/-17.2 years, p=0.028). The most frequently isolated microorganisms from tissue cultures were Escherichia coli, Klebsiella pneumoniae and Group A streptococci. Of the 23 patients, 9 (39%), of whom 8 had DM, died between 2 and 29 days after admission. The mortality rate and length of hospitalization were longer in diabetic patients than in others (p=0.02 and p=0.286, respectively). The mean blood glucose levels and HbA1C were higher in non-survival group than in survival group (195.6+/-41.5 vs 133.7+/-22.1 and 10.6 vs 7.4) (p=0.04, r=0.39 and p=0.03, r=0.50, respectively). In the univariate analysis, the hospitalization time (r=0.72), white blood cell count (r=0.52) and surgical debridement count (r=0.47) were found to be prognostic risk factors. Our results showed that NF is a very serious life-threatening disorder in especially diabetic patients with bad metabolic control.

Hyperbaric Oxygen Ameliorates Bacterial Translocation in Rats with Mechanical Intestinal Obstruction

AbstractPURPOSE: The aim of this study was to demonstrate bacterial translocation after experimentally induced intestinal obstruction as well as investigate the preventive effects of hyperbaric oxygen on obstruction-induced bacterial translocation in rats. METHODS: Forty Wistar-albino male and female rats were used. Although no procedure was done in the control group (n = 8), hyperbaric oxygen treatment under 2.5 atm absolute for 90 minutes daily was applied for two days in the hyperbaric oxygen group (n = 8). In the sham group (n = 8), after laparotomy the small bowel was only handled gently, and tissue sampling was done 48 hours later. In the obstruction group (n = 8) the ileum was ligated by 5-0 polypropylene just 5 cm proximal to the ileocecal valve. In the obstruction and hyperbaric oxygen group (n = 8), after obstruction hyperbaric oxygen treatment was applied. Forty-eight hours after the procedures, tissue samples from small bowel, mesenteric lymph nodes, spleen, and liver were taken and 1 ml of blood from the portal vein was withdrawn. All samples were cultured for microbiologic examination. RESULTS: Hyperbaric oxygen treatment significantly reduced the endogenous bacterial overgrowth in the small intestine of normal rats. Endogenous bacteria in the small intestine were significantly increased in the obstruction group, and the presence of bacterial overgrowth was proven by bacterial presence on mesenteric lymph nodes, spleen, liver, and blood. Hyperbaric oxygen treatment significantly reduced the endogenous bacterial overgrowth in the small intestine and prevented the bacterial translocation almost completely in obstruction-induced rats. CONCLUSIONS: Intestinal obstruction causes bacterial overgrowth and translocation. Hyperbaric oxygen treatment prevents the bacterial translocation effectively.

Hyperbaric oxygen prevents bacterial translocation in rats with obstructive jaundice.

This study was designed to demonstrate bacterial translocation following bile duct ligation and investigate preventive effects of hyperbaric oxygen on obstructive jaundice-related bacterial translocation in an animal model. Hyperbaric oxygen treatment significantly reduced the endogenous colony counts in distal ileum of normal rats both in the short (two days) and long (seven days) term. Endogenous bacteria in distal ileum significantly increased in bile duct ligated rats in the short and long term, and presence of bacterial translocation was proven by bacterial growth in mesenteric lymph nodes, liver, spleen, and blood. Short- and long-term hyperbaric oxygen treatments significantly reduced the intestinal colony counts and prevented the bacterial translocation almost completely in rats with bile duct ligation. It is concluded that obstructive jaundice causes bacterial overgrowth and translocation, and hyperbaric oxygen treatment can prevent both bacterial overgrowth and translocation effectively.

Tamoxifen and Gallstone Formation in Postmenopausal Breast Cancer Patients: Retrospective Cohort Study

Tamoxifen is being used successfully in breast cancer patients as adjuvant hormonal therapy. The aim of this retrospective cohort study is to evaluate the impact of tamoxifen on gallstone formation in postmenopausal breast cancer patients. A total of 3165 patients who were treated for invasive breast cancer between 1990 and 1997 were reviewed. The data were collected from four university hospitals in a population-based registry. Among these patients, 2462 were excluded from the study owing to improper follow-up and other reasons. Premenopausal patients were also excluded. Of the 703 patients included in the study, 457 had received adjuvant therapy including tamoxifen, and the other 246 had not. Gallstone formation was assessed by annual abdominal ultrasonography. The mean follow-up period was 4.6 years (range 1–7 years). There were no significant differences between the groups of breast cancer patients treated with or without tamoxifen regarding the age of the patients at the time of breast cancer diagnosis, the age at menopause, the duration between the onset of menopause and the time the breast cancer was diagnosed, the presence of diabetes, and the body mass index. At the end of 5 years the incidence of gallstone formation in tamoxifen-treated patients was 37.4%, whereas it was 2.0% in patients who did not receive tamoxifen (p < 0.0001). The incidences of gallstones being detected in 171 tamoxifen-treated patients were 0.4%, 3.7%, 24.4%, 33.1%, and 37.4% cumulatively during the first, second, third, fourth, and fifth years, respectively. Hence adjuvant tamoxifen therapy leads to gallstone formation in postmenopausal breast cancer patients and is most apparent after 3 years of treatment.

Is helium insufflation superior to carbon dioxide insufflation in bacteremia and bacterial translocation with peritonitis

PURPOSE To evaluate the effects of CO2 or helium insufflation on bacteremia and bacterial translocation in rats with peritonitis. MATERIALS AND METHODS Forty male Wistar-Albino rats were divided into four groups, each containing 10 rats. The rats in the first group were injected only with E. coli into their peritoneal cavities with no further manipulation. The second group, following E. coli injection, underwent midline laparotomy without manipulation of the viscera for 1 hour. After the injection of E. coli in the third and fourth groups, CO2 and helium pneumoperitoneum, respectively, were maintained for 1 hour under 14 mm Hg pressure. At the end of the sixth hour, tissue samples were taken from the liver, spleen, lung, and mesenteric lymph nodes in order to evaluate bacterial translocation. During the study, blood samples were taken from each rat at 0, 1, 2, 4, and 6 hours to demonstrate bacteremia. RESULTS There was a significant increase in bacteremia in the CO2 pneumoperitoneum group compared with the laparotomy-only and helium groups at 1 and 2 hours. Although all the blood samples at the fourth hour were positive for E. coli in every rat of all groups, helium was associated with a lower incidence of bacteremia at the sixth hour compared with other groups (P < 0.05). The CO2 pneumoperitoneum caused bacterial translocation to all organs from which tissue samples were taken. Although there was an insignificant decrease in translocation to the liver, spleen, and lung with helium compared with CO2 insufflation, helium did not increase bacterial translocation to the spleen compared with laparotomy alone, as did CO2 (P < 0.05). CONCLUSION Helium might be an alternative to CO2 insufflation in patients with peritonitis if these results are confirmed by further experimental and clinical trials.

Hyperbaric Oxygen Prevents Bacterial Translocation in Thermally Injured Rats

This study was designed to evaluate the effects of hyperbaric oxygen (HBO 2 ) on intestinal microflora and bacterial translocation (BT) caused by experimentally induced thermal injury in rats. Rats were separated into four groups, namely, HBO 2 group, thermal injury (TI) group, TI + HBO 2 group, and control group. All groups were further separated into short-term (2 days) and long-term (7 days) treatment or injury groups. Control group was neither exposed to thermal injury nor was given any treatment. Thirty percent second-degree thermal burn was induced on the dorsal body part of the rats in TI groups. In the HBO 2 groups, rats received HBO 2 treatment either without TI or following TI induction, for 2 and 7 days, respectively. Sampling from tissues and portal vein was performed on day 3 in the short-term groups and on day 8 in the long-term groups. Samples were cultured for identification of bacteria and colony counts. HBO 2 treatment significantly reduced the colony counts of endogenous microflora in distal ileum of healthy rats ( p < .05), while TI significantly increased the colony counts of endogenous microflora in distal ileum in short and long-term TI groups ( p < .05). Presence of bacterial translocation was proven by bacterial isolation in mesenteric lymph nodes, liver, spleen and blood. Both short- and long-term HBO 2 treatment following TI significantly reduced the colony counts of intestinal microflora ( p < .05) and prevented bacterial translocation almost completely. It is concluded that thermal injury causes both bacterial overgrowth within intestinal lumen and bacterial translocation across the intestinal wall. HBO 2 administration prevents both bacterial overgrowth and translocation.

Surgical Management Of Hydatid Disease Of The Liver: A Military Experience

Hydatid disease of the liver is highly prevalent in oriental countries including Turkey, in which their population live mostly in rural areas. The outcome of surgical methods used in the management of a cystic cavity in patients with hepatic hydatid disease was evaluated. Three hundred and forty consecutive patients who presented to Department of General Surgery between 1988 and 1996 with hepatic hydatid disease were reviewed retrospectively. In the first group surgical methods without drainage such as cystectomy (n = 11), capitonnage (n = 55), omentoplasty (n = 91) and capitonnage + omentoplasty (n = 53), in the second group surgery with drainage such as external drainage (n = 74), internal drainage (n = 7), and combined methods (n = 21) were applied. Symptoms, physical findings, types of surgical management, complication rate, hospitalisation period, mortality and recurrence rates were evaluated. Complication rate, average hospitalisation period, recurrence and mortality rates were 12.5%, 9.5 days, 9.9% and 0% respectively in patients without drainage and 63.7%, 26.5 days, 12.7% and 0.9% respectively in patients with drainage. It is concluded that surgical treatment of hydatid disease of the liver without drainage decreases postoperative complication rate and average hospitalisation period, and drainage or nondrainage of cystic cavity has no effect on recurrence.

Contents Vol. 17, 2000

421 Postgraduate Course: Common Laparoscopic Procedures from Revolution to Standard of Care Chairpersons: Hunter, J. (USA); Lacy, A. (Spain) Ongoing Clinical Trials Section Editor: S. Galandiuk, MD, Louisville 427 Oncology 431 Inflammatory Bowel Disease 431 Surgical Infection/Sepsis 433 Miscellaneous 435 Questionnaire for Trial Submission 437 EDS News 438 Announcement Review 439 Human Islet Autotransplantation to Prevent Diabetes after Pancreas Resection White, S.A.; Robertson, G.S.M.; London, N.J.M.; Dennison, A.R. (Leicester)