Faruk Cavdar

Controversial issues in biliary pancreatitis: when should we perform MRCP and ERCP?

OBJECTIVES The majority of bile duct stones (BDS) that cause acute biliary pancreatitis (ABP) pass spontaneously into the duodenum. If not passed, they worsen the prognosis or cause recurrence. Therefore, they must be treated. The purpose of this study was to assess the number and timing of spontaneous passage of BDS using magnetic resonance cholangiopancreatography (MRCP) and to determine the effect of this approach on endoscopic retrograde cholangiopancreatography (ERCP). METHODS Sixty patients diagnosed with ABP were evaluated prospectively. MRCP was performed between the 1st and 4th days of an acute attack in all the patients. A control MRCP was performed after 7 days in patients with MRCP-identified choledocholithiasis. Patients in whom BDS were visible on imaging or who showed no decrease in bilirubin or cholestasis enzymes underwent ERCP. RESULTS MRCP revealed choledocholithiasis in 20 (33%) of the 60 patients. In the control MRCP imaging, choledocholithiasis was detected in 16 of 20 (80% of those who had stone initially) patients. ERCP was performed in these patients and in 2 patients who did not have BDS on the control MRCP but whose bilirubin values and cholestatic enzyme levels had not decreased. ERCP verified choledocholithiasis in 16 of the 18 patients. The positive predictive value of MRCP was 93.7% (15/16). CONCLUSIONS MRCP performed in the second week in ABP patients with a nonworsening prognosis and a suspicion of choledocholithiasis will give more specific results. This will avoid unnecessary ERCP and the potential morbidity and mortality that can develop with this invasive procedure.

Paraoxonase and arylesterase activities, lipid profile, and oxidative damage in experimental ischemic colitis model.

Objective. In the present study, since PON1 is known as an HDL-associated antioxidant enzyme that inhibits the oxidative modification of LDL and oxidative stress plays a role in the pathogenesis of mesenteric ischemia, we investigated the changes in PON1 activity and lipid profile in an experimental ischemic colitis model. Methods. Forty male Wistar albino rats were divided into two groups: the control group (N = 15) and the experimental group (N = 25). All animals were anesthetized with ether and ketamine anesthesia to undergo a midline laparotomy. Ischemic colitis was induced by marginal vessel ligation in the splenic flexura (devascularization process). A sham laparotomy was performed in the control group. All animals were sacrificed on the seventh postoperative day. Oxidative stress marker (malonyldialdehyde, MDA), lipid profile, and paraoxonase (PON-1) and arylesterase activities were determined. Histopathological evaluation was done under light microscopy, after sectioning and staining with hematoxyline and eosin. Statistical analysis was conducted using Students t-test and Mann-Whitney U test, and P < 0.05 was considered as statistically significant. Results. There was a significant decrease in both serum and tissue PON1 activity in ischemic colitis group (P < 0.01, for each). Similarly, arylesterase levels showed a parallel decrease in both tissue and serum of the experimental group (P < 0.01 and P < 0.001, retrospectively). MDA, an oxidative stress marker, was seen to increase in the experimental group (P < 0.01, tissue; P < 0.05, serum). In experimental group, there was a significant rise in serum total cholesterol and LDL levels (P < 0.001, for each). However, HDL level decreased significantly (P < 0.001). Triglycerides did not show any change between the groups (P > 0.05). Conclusions. PON1 and arylesterase play an important role in the pathophysiology of ischemic colitis.

The Evaluation of a Modified Dufourmentel Flap after S-Type Excision for Pilonidal Sinus Disease

Purpose. The use of an S-type oblique excision with a bilateral gluteus maximus advancement flap has recently been described for the surgical treatment of sacrococcygeal pilonidal sinus (SPS). Its use in wide lesions has been limited due to the need for a full-thickness flap. We describe the use of an S-type oblique incision together with the Dufourmentel flap in wide lesions. Method. Twenty-one patients were treated using a technique including an S-shaped oblique excision of the sinus tract and a broad-pedicled full-thickness flap resembling a Dufourmentel flap to close the defect. Results. Of the 21 patients, 19 (90.5%) were male and 2 (9.5%) were female. Their mean age was 24.0 ± 6.1 (range 15–36) years. The mean follow-up period was 14.0 ± 5.8 (range 6–23) months. The postoperative complication rate was 4.8% (one patient), and recurrence was seen in one patient (4.8%). The mean return-to-work time was 13.5 ± 1.9 (range 10–18) days. None of the patients reported dissatisfaction with the cosmetic results. Conclusions. This new technique achieved low morbidity and recurrence rates. We anticipate that this will become an important technique in the surgical treatment of SPS if the observed success is confirmed by randomized prospective trials.

Does protocatechuic acid, a natural antioxidant, reduce renal ischemia reperfusion injury in rats?

BACKGROUND Protocatechuic acid (PCA), which has antioxidant property, is a simple phenolic compound commonly found in many plants, vegetables, and fruits, notably in green tea and almonds. Present study was an investigation of the effects of PCA on rat kidney with ischemia/reperfusion (IR) injury. METHODS Sprague-Dawley rats were randomly divided into 4 groups: (1) Sham, (2) Renal IR, (3) Renal IR+Vehicle, and (4) Renal IR+PCA. Renal reperfusion injury was induced by clamping renal pedicle for 45 minutes after right nephrectomy was performed, followed by reperfusion for 3 hours. Dose of 80 mg/kg PCA was intraperitoneally administered to 1 group immediately before renal ischemia; 33% polyethylene glycol was used as vehicle. Total antioxidant status (TAS), malondialdehyde (MDA), superoxide dismutase (SOD), tumor necrosis factor alpha (TNF-α), and interleukin-6 levels were measured in blood and kidney tissue samples taken from sacrificed rats. Kidney tissue samples were examined and scored histopathologically. Terminal deoxynucleotidyltransferase-mediated dUTP digoxigenin nick end labeling assay method was used to detect apoptotic cells. RESULTS It was found that PCA significantly reduced serum MDA, TNF-α, and kidney MDA levels, while it increased serum and kidney TAS and SOD levels. Histopathological scores were significantly higher for the group given PCA. CONCLUSION PCA reduced oxidative stress and can be used as an effective agent in treatment of renal IR injury.

A new approach in bowel preparation before colonoscopy in patients with constipation: A prospective, randomized, investigator-blinded trial

OBJECTIVE Enema administration in the morning of routine colonoscopy is known to be useless. However, the potential bowel cleansing effects of distal colon emptying with enema prior to purgatives are not known. The aim of this study is to investigate the effects of enema use before purgatives in preparation for colonoscopy. MATERIAL AND METHODS Two hundred twenty-seven patients were randomly assigned into three groups; enema before purgative use, enema after purgative use, and no enema. Patients were compared in terms of age, sex, BMI, Rome III constipation criteria, history of abdominal surgery, tolerance to the preparation procedure, complications during preparation such as nausea, vomiting, headache and dizziness, cecal insertion time, total duration of colonoscopy, polyp determination rate and colonic cleansing based on the Boston Bowel Preparation Scale. RESULTS One hundred two (44.9%) patients were male and 125 (55.1%) female. The mean age and BMI was 55.4±11.8 years and 28.8±4.7, respectively. No difference was observed between the groups in terms of sex, age, or BMI. The number of fulfilled Rome criteria and of previous abdominal surgeries were significantly higher in females than in men. Right colon Boston Bowel Preparation Scale score was higher in the group using enemas before purgatives than the scores of other groups. This improvement was statistically significant in the female patient group with higher constipation rate. CONCLUSIONS Use of enemas before purgatives in patients with constipation significantly improves adequacy of right colon cleansing.

An Unusual Cause of Right Lower Quadrant Pain: The Caecum Diverticulitis

Purpose. In the study presented, preoperative examinations and surgical methods were discussed along with literature, regarding two cases who were operated with the prediagnosis of acute appendicitis and for whom caecum diverticulitis was determined. Case 1. 21 years old male patient who had applied to hospital with complaint of abdominal pain, underwent an operation with a prediagnosis of acute appendicitis. Right hemicolectomy was performed with mass perioperatively determined in caecum. Histopathological examination revealed necrosis and inflammation in diverticulum wall. Case 2. 36 years old female patient applied to emergency department with abdominal pain and underwent an operation with a prediagnosis of acute appendicitis. Appendectomy and diverticulectomy were performed for whom inflame diverticula in caecum was determined perioperatively. Histopathological examination was revealed acute inflammation in diverticulum wall. Conclusion. Although solitary caecum diverticulitis is a rarely encountered disease, it must be considered in the differential diagnosis of right lower abdomen pain.