Durkaya Ören

Late Complications of Incisional Hernias Following Prosthetic Mesh Repair

Abstract Background: Incisional hernias still continue to be a serious problem for surgeons. In this study, we aimed to investigate the effects of polypropylene mesh and mersilene mesh, which are frequently employed in incisional hernias, as well as the effects of their application techniques on late complications. Methods: Two-hundred-sixty-four open abdominal hernia repairs were performed between 1986–2000, using prosthetic materials: polypropylene mesh and mersilene mesh were used in hernia repair. Mesh was placed as onlay, underlay and sandwich techniques. Follow-up data were obtained from medical records. Results: Comparisons were made with respect to surgical techniques and to late complications such as recurrence, ente-rocutaneous fistula, intestinal obstruction, and infections. Enterocutaneous fistulas developed in two patients. Recurrence occurred in 6.4 per cent. Chronic infection and wound sinus formation occurred in 5 per cent. The causes of recurrence included smoking, cellulitis, chronic infection/sinus tract, upper abdominal localization, and obstruction. Fistula formation occurred in patients with no peritoneal prevention, which was statistically significant (p=0.012). Chronic infection/sinus tract was high in patients for whom mersilene mesh was used, and enterocutaneous fistula occurred in 2 patients. Conclusion: To prevent late complications, it is necessary to avoid the contact of mesh with bowel.

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.

Intra-Abdominal Extrahepatic Echinococcosis

Abstract Twenty-seven patients who were treated surgically because of extrahepatic abdominal hydatid disease between 1981 and 1999 were retrospectively reviewed. Nineteen patients had coexistent hepatic cysts while 8 patients had only peritoneal cysts. The cysts were located in the spleen, pancreas, adrenal gland, mesentery of the intestines, ovaries, retroperitoneum, omentum, abdominal wall, rectovesical region, and the psoas muscle. Due to organ destruction because of large cysts in 8 patients, the involved organ had to be sacrificed. The other 19 patients were treated by a pericystectomy. No postoperative mortality or severe morbidity was seen. In conclusion, symptomatic or large cysts should be surgically treated. In cases suspected of having peritoneal spillage, antihelminthic drugs should be administered. In addition, small asymptomatic cysts may also be effectively treated with antihelminthics.

Ileosigmoid knotting in Turkey

PURPOSE: The high mortality associated with ileosigmoid knotting prompted us to review the collected experiences of three university hospitals in order to establish a more rational approach to the problem. METHOD: The clinical records of 68 patients with ileosigmoid knotting from 1970 to 1990 were reviewed with respect to incidence, etiopathogenesis, clinical features, treatment, and clinical outcome. RESULTS: The most common type of ileosigmoid knotting was Type IA (48.5 percent), in which the active ileum encircled the passive sigmoid in a clockwise manner. Fifty (73.5 percent) patients developed a gangrenous bowel whereas 18 patients did not show any definite evidence of impairment of bowel viability.En blocremoval of gangrenous knot and reestablishment of intestinal continuity by enteroenteric or enterocolic anastomosis combined with the Hartmann procedure, which was employed in 20 (42.6 percent) cases, constituted the most frequently preferred operation. The mortality rate in this series was 30.9 percent (21/68) and toxic shock, which ultimately resulted in multiple organ failure, was the major cause of death. It was remarkable to note that there was an inverse correlation between the duration of symptoms and the mortality rate reflecting the dramatic rapidity and severity of symptoms due to tightness of the knot which led to early and extensive gangrene, thus inevitably urged the patients to seek medical help without delay. CONCLUSION: The performance of prompt, individualized surgical treatment in conjunction with the use of advanced measures of critical care to combat the disastrous consequences of multiple organ failure would contribute greatly to improve survival rate in victims of this dreadful entity.

Bacterial Translocation in Experimental Intestinal Obstruction

In this study, bacterial translocation to the mesenteric lymph nodes (MLN), liver and spleen and the histopathological changes in the intestine MLN, liver and spleen were investigated in Wistar Albino rats with intestinal obstruction. The subjects were divided into three main groups: the control group, simple obstruction group and loop obstruction group. Each group was further subdivided into two subgroups: those who underwent repeat laparotomy at 12 h or at 24 h. No bacterial translocation was observed in the control group. The incidences of bacterial translocation to the MLN, livers and spleens of the rats with loop obstruction who underwent repeat laparotomy at 24 h were the highest. According to the cultured bacteria growth results, Escherichia coli was most abundant (48%). Most histopathological changes were observed in the MLN, livers, spleens and intestines of the rats with loop obstruction who underwent second laparotomy at 24 h.

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.

Ileosigmoidal Knotting: Outcome in 63 Patients

PURPOSE:This study was designed to review the outcomes of 63 patients with ileosigmoidal knotting.METHODS:Sixty-three, surgically treated patients (47 males; 74.6 percent) were reviewed retrospectively. The mean age was 45.6 (range, 7–75) years. The most common symptoms were abdominal pain and obstipation, and the most common signs were abdominal tenderness and distention. The preoperative diagnosis was obstructive emergencies in 49 patients (77.8 percent) and nonobstructive emergencies in 14 (22.2 percent).RESULTS:All patients underwent emergency laparotomy. The most common type of ileosigmoidal knotting was Type 1A in 30 patients (47.6 percent), in which the active ileum encircled the passive sigmoid colon in a clockwise direction. Fifty patients (79.4 percent) developed gangrenous bowel. Resection of gangrenous segments and enteroenteric or enterocolic anastomosis combined with the Hartmann procedure was the most preferred operation, used in 34 patients (54 percent). The mortality rate was 15.9 percent (10 patients), and toxic shock was the most frequent cause of death.CONCLUSIONS:Ileosigmoidal knotting is a rare but serious form of intestinal obstruction. Its preoperative diagnosis is difficult and may present as an obstructive or nonobstructive emergency. Early and effective resuscitation, prompt surgical intervention selected on the basis of clinical and operative findings, and effective postoperative intensive care are the basis of treatment.

Dehydroepiandrosterone prevents oxidative injury in obstructive jaundice in rats.

We investigated the effect of dehydroepiandrosterone (DHEA) on oxidative injury in obstructive jaundice using three groups of rats: sham-operated group; common bile duct (CBD) group — the CBD was ligated; and DHEA group — DHEA administration followed CBD ligation. Liver function tests were performed using blood samples, and malondialdehyde concentration (MDA), superoxide dismutase activities (SOD), glutathione peroxidase (GPx), and total glutathione (tGSH) concentrations were measured in liver tissue. Serum alkaline phosphatase, γ-glutamyltransferase and alanine aminotransferase activity were significantly elevated in the CBD group compared with the other groups. Serum aspartate aminotransferase and total bilirubin were highest in the CBD group; the MDA concentration was higher in the CBD group than the sham group. There were no significant differences in GPx activity among the groups. SOD activity and tGSH concentration were significantly lower in the CBD group than the other groups. DHEA may protect hepatic tissue against oxidative injury in obstructive jaundice by decreasing MDA concentration and increasing SOD activity and tGSH concentration.

Glutathione and Nitric Oxide Concentrations in Glutamine-Infused Rabbits with Intestinal Ischaemia/Reperfusion

Intestinal ischaemia/reperfusion causes formation of reactive oxygen intermediates which lead to mucosal cell injury. Glutathione, a scavenger of reactive oxygen intermediates, protects tissues from reactive oxygen intermediate-mediated cell injury. Nitric oxide is a lipophilic gas and its synthesis is stimulated by ischaemic conditions. In this experimental study, we aimed to investigate the role of i. v. L-glutamine infusion on mucosal tissue glutathione and serum nitric oxide concentrations in intestinal ischaemia/reperfusion. External jugular vein of albino rabbits was cannulated with catheter and infused with normal saline at 4 ml/h. After 3 days, they were randomly divided into two main groups. Group 1 (n = 30) received i. v. normal saline alone, group 2 (n = 30) received normal saline + 205 mmol/l glutamine at 4 ml/h for 24 hours. Next, mucosal glutathione and serum nitric oxide concentrations were measured after 0, 30, 60 min of ischaemia/60 min of reperfusion. Basal glutathione concentrations were similar in normal saline alone and normal saline + 205 mmol/l glutamine infusion groups (p > 0.05). At 30 and 60 min of ischaemia/60 min of reperfusion, glutathione concentrations were significantly lower in normal saline-infused rabbits compared to the normal saline + 205 mmol/l glutamine-infused rabbits (p < 0.05). In addition, serum nitric oxide concentrations were found to be significantly increased in rabbits 30 and 60 min after ischaemia/reperfusion when compared to mean basal nitric oxide concentrations obtained from control animals. However, the normal saline + 205 mmol/l glutamine group had lower serum nitric oxide concentrations than did the normal saline alone group. In conclusion, this study revealed that intestinal mucosal glutathione concentrations were significantly higher in glutamine-receiving rabbits than in non-receiving ones. Additionally, it was shown that nitric oxide concentrations increased in ischaemia both in normal saline alone and normal saline + 205 mmol/l glutamine receiving groups, while this increase in nitric oxide was more prominent in the normal saline alone group (p < 0.01). These findings show that glutamine supplementation may protect the small intestine from ischaemia/reperfusion injury and may play a regulatory role in the biosynthesis of nitric oxide.

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.