Gokhan Moray

Endovascular stent placement in the treatment of upper extremity central venous obstruction in hemodialysis patients.

OBJECTIVE To evaluate the efficacy of stent placement for treating upper extremity central venous obstruction in chronic hemodialysis patients. METHODS AND MATERIAL Between January 1999 and October 2001, we inserted metallic stents into the upper extremity central veins of 14 patients with shunt dysfunction and/or arm swelling. The indications for stent placement were stenosis or occlusion of the central vein in the upper extremity used for dialysis. Six of the individuals were diagnosed with subclavian vein stenosis, and 5 with brachiocephalic vein stenosis. Of the remaining 3 patients, 2 had subclavian vein occlusion, and 1 had left brachiocephalic vein occlusion. RESULTS All the stent placement procedures were technically successful, and there were no major complications. Follow-up ranged from 2 weeks to 29 months. The 1-, 3-, 6- and 12-month primary stent patency rates were 92.8, 85.7, 50 and 14.3%, respectively. Repeat interventions, including percutaneous transluminal angioplasty and additional stent placement, were required in 9 patients. The 3-, 6-, 12-month, and 2-year assisted primary stent patency rates were 100, 88.8, 55.5 and 33.3%, respectively. CONCLUSION Endovascular stent placement is an effective alternative to surgery in patients with shunt dysfunction due to obstruction of an upper extremity central vein. Repeated interventions are usually required to prolong stent patency.

Retained surgical sponge (gossypiboma) after intraabdominal or retroperitoneal surgery: 14 cases treated at a single center

Background and aimsThe objective of this study was to present the etiology, clinical presentation, diagnosis, and management for 14 cases of gossypiboma [retained surgical sponge (RSS)] treated at a single center and to emphasize the importance of this potential complication.MethodsData for 14 cases of RSS treated between January 1999 and December 2004 were retrospectively assessed. The details of preoperative evaluation, demographic features, and operative findings were recorded. Use of, and findings from, abdominal x-ray, ultrasonography, computed tomography, magnetic resonance imaging, and upper-gastrointestinal endoscopy were also noted.ResultsIn all cases, the RSS was surgically removed. Thirteen of the 14 patients were symptomatic, and the most frequent finding was nonspecific abdominal pain and intestinal obstruction. Four patients required urgent surgery because the sponges were causing intestinal obstruction or intraabdominal sepsis. Based on history, physical examination findings, and diagnostic imaging, RSS was diagnosed preoperatively in five of the patients. Postoperative complications, including surgical site infection and evisceration, occurred in five cases.ConclusionRSS can lead to significant medical and legal problems between the patient and the doctor. RSS may be incorrectly diagnosed preoperatively, which can lead to unnecessary invasive diagnostic procedures and operations. Strict measures must be taken to prevent this complication.

Epidemiology of pediatric burn injuries in southern Turkey.

The aim of this study was to identify the epidemiological features of pediatric burn injuries in southern part of Turkey. In this retrospective study, 137 hospitalized pediatric patients (85 men and 52 women) who were admitted to our burn unit during a period of 3 years were analyzed. Pediatric patients were categorized into three groups: the infants and toddlers (0-2 years), early childhood (3-6 years), and late childhood (7-15 years). Epidemiological data included age, sex, location, the cause and type, and place of burn. In the first two groups, scalding (95.1% and 86.7%, respectively) was the predominant cause of burn whereas in late childhood electric burns (51.4%) were a more common occurrence. No differences were found between the groups with respect to mean TBSA and full-thickness burns. A total of 15 (10.1%) patients died during the study period. A total of 74.4% of burn injuries occurred at home, and almost all were preventable, with 16 % of the burns occurring in the autumn; however, 42% occurred in the summer. These findings will be used as a basis for developing targeted preventive programs to protect children from burns. We also consider it is necessary to educate children and their parents about the prevention of burn injuries.

Analysis of Vascular Complications After Renal Transplantation

PURPOSE Despite medical and surgical advances, vascular complications remain common after renal transplant, occurring among 3%-15% of patients. These complications may compromise graft function. This study sought to evaluate the frequency and management of vascular complications after renal transplant. MATERIALS AND METHODS We retrospectively analyzed the 1843 transplantations performed at 2 centers by our team since November 1975. The 1349 male and 494 female patients had an overall mean age of 31.5±11.2 years; (range, 3-66). Grafts were obtained from a living-related donor in 1406 (76.29%) or a deceased donor in the remaining 437 (23.71%). The mean donor age was 40.7±13.7 years (range, 2-76). Of 1843 transplants, multiple vascular anastomoses were performed in 155 cases (8.4%), including 130 involving renal arteries and 25 renal veins. RESULTS Forty-seven vascular complications (2.55%) were observed in 43 procedures (2.33%), most frequently renal artery stenosis (n=14). It was followed by allograft renal artery kinking (n=7), renal vein kinking (n=7), renal artery thrombosis (n=5), renal vein laceration (n=4), renal artery laceration (n=3), renal vein thrombosis (n=2), renal artery disruption (n=2), renal and iliac vein obstructions owing to pressure from a lymphocele (n=1), renal artery and vein obstruction owing to pressure from a hematoma (n=1), or an arteriovenous fistula after percutaneous graft biopsy (n=1). Fifteen of these 47 complications were treated by interventional radiologic procedures. CONCLUSION The vascular complication rates in our patients were somewhat lower than those reported in the literature. A thorough understanding of how complications impair allograft function and survival is essential for adequate treatment. Interventional radiology is invaluable in the postoperative management of transplant-related complications.

Prospective randomized controlled trial comparing V–Y advancement flap with primary suture methods in pilonidal disease

BACKGROUND An ideal treatment method for the widely prevalent pilonidal sinus disease is not yet available. The most commonly practiced technique is simple closure following resection of the effected tissue. However, high recurrence rates in some series have led to the search for other methods. One of these methods is the V-Y advancement flap (VYAF), which in theory results in the flattening of the natal cleft without tension in the suture line. METHODS In this prospective randomized controlled study, the VYAF method was compared to 2 simple primary closure techniques. In 238 patients, following resection, in the AL (all layers) group, all layers were closed with polypropylene sutures. In the SS (subcutaneous suture) group, polyglactin subcutaneous sutures were used to approximate the wound edges. Skin was closed separately in the SS group. In addition, demographic variables, past history, physical examination findings, defect dimensions, and wound tension were recorded. RESULTS Surgical site infection was observed in 23.9%, 17.4%, and 10.2% of the patients in AL, SS, and VYAF groups, respectively (P = .129). Early wound dehiscence without infection was detected in 11.9%, 7.4%, and 10.2% of the patients in groups AL, SS, and VYAF, respectively (P = .665). Mean follow-up was 29.7 +/- 15.6 months. Survival (time without recurrence) was not significantly different between groups (P = .648). In the whole group, independent predictors of recurrence according to logistic regression analysis were younger age, recurrent disease, presence of discharge on physical examination, and development of postoperative surgical site infection. CONCLUSIONS VYAF is not superior to simple primary closure techniques in terms of postoperative complications, recurrence, and patient satisfaction. For most cases, simple primary closure would suffice. Patients should be informed of the increased risk of recurrence if any of the independent predictors (being a recurrent case, presence of discharge, development of postoperative infection) are present.

Acute necrotizing pancreatitis as a rare complication of extracorporeal shock wave lithotripsy.

Abstract  Extracorporeal shock wave lithotripsy (ESWL) is considered the standard treatment for most renal and upper ureteral stones. Some centers use ESWL to treat bile duct stones and pancreatic calculi. Although ESWL is generally considered safe and effective, major complications, including acute pancreatitis, perirenal hematoma, urosepsis, venous thrombosis, biliary obstruction, bowel perforation, lung injury, rupture of an aortic aneurysm and intracranial hemorrhage, have been reported to occur in less than 1% of patients. Here, we present an extremely rare case of acute necrotizing pancreatitis occurring after ESWL for a right‐sided urinary stone, which was treated by non‐operative percutaneous interventions.

Delayed graft function: predictive factors and impact on outcome in living-related kidney transplantations

The aim of this study was to determine the incidence and possible causes of delayed graft function (DGF) and its impact on outcome in living-related kidney transplantations. We analyzed 158 consecutive living-related kidney transplant recipients. DGF is described as the failure of serum creatinine to fall below pretransplant levels within 1 week of the operation, regardless of urine output. Of the 158 patients studied, 14 (8.8%) fit this criterion. Donor and recipient factors such as age, gender, body weight, recipient/donor weight ratio, HLA match, cyclosporine level, blood group, and anastomosis time of patients with DGF were compared to those of patients without DGF. Apart from donor gender, body weight, and recipient/donor body weight ratio, these parameters were similar in the two groups. In the DGF group the majority of the donors were female (11/14), whereas this was not the case in the controls (64/144; p < 0.02). Mean donor weight in patients experiencing DGF (59.6 +/- 9.2 kg) was significantly lower than in those without DGF (67.8 +/- 10.4 kg; p < 0.05). The mean recipient/donor weight ratio for the DGF group (1.26) was significantly higher than that of the control group (1.03, p < 0.02). The 5-year graft survival rates for patients with and without DGF were 74% and 77%, respectively (NS). On the other hand, the 5-year graft survival rate for patients with DGF complicated by an acute rejection episode (n = 6, 61%) was significantly lower than that of control group patients who experienced acute rejection (n = 43, 74%; p < 0.02). These results indicate that female donor gender and higher recipient/donor weight ratio are major predictive factors in the development of DGF following living-related kidney transplantation. Although DGF alone did not affect the outcome, long-term graft survival was significantly reduced when DGF was associated with acute rejection episodes.

Surgical treatment of liver hydatid cysts

BACKGROUND The surgical treatment technique for liver hydatic cyst (LHC) cannot be standardized, and the surgical technique should be tailored according to the extent of the cyst and any adjunct complications of hydatid disease. PATIENTS AND METHODS All patients were treated with albendazole (10 mg/kg/day) for 15 days preoperatively. Total pericystectomy was performed in three patients (7%). Partial cystectomy and its modifications were performed in the remaining 41 patients (93%). RESULTS A total of 44 patients were operated on for LHC between December 1998 and October 2004 in our center. Patients were evaluated with ultrasonography and computed tomography scan to determine the extent of the disease and preoperative staging. Twenty-four (53%) of these patients were women and 20 were men (median age, 52.5 years; range, 19-81 years). The majority of patients (n=27) had 1 cyst, and the remaining 17 patients had multiple cysts. In four patients (9.1%), daughter cysts were found in the biliary system, and abscesses were present in three patients (7%). Biliary fistula was the most frequent complication (n=5). Three patients had wound infections. Follow-up was complete for 33 patients (75%). The mean postoperative follow-up was 11.9+/-10.8 months; there were four recurrences during this time. DISCUSSION The aim should be to provide complete drainage and obliteration of the cavity. Bile leak and biliary obstruction may complicate the postoperative course if bile leakage into the peritoneal cavity and obstruction in the biliary system are missed.

Liver transplantation in management of alveolar echinococcosis: two case reports.

Hepatic alveolar echinococcosis is an infectious disease caused by the larval stage of Echinococcus multilocularis, which grows primarily in the liver of an infected person and develops as a tumorlike lesion. In advanced cases, the organisms infiltrate every organ neighboring the liver and spread hematogenously to distant organs such as lungs and brain. Surgical resection and liver transplantation are accepted treatment options for early and advanced disease, respectively. Herein, we present case reports of 2 patients with advanced alveolar echinococcal disease that invaded both lobes of the liver and neighboring vital structures including the inferior vena cava. Despite the technical difficulty of the surgery, both patients were successfully treated with living donor liver transplantation. Liver transplantation should be accepted as a life-saving treatment of choice in patients with alveolar echinococcosis for whom there is no other medical or surgical treatment options.

Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis.

BACKGROUND In low-risk patients with acute cholecystitis who did not respond to nonoperative treatment, we prospectively compared treatment with emergency laparoscopic cholecystectomy or percutaneous transhepatic cholecystostomy followed by delayed cholecystectomy. METHODS In 91 patients (American Society of Anesthesiologists class I or II) who had symptoms of acute cholecystitis ≥72 hours at hospital admission and who did not respond to nonoperative treatment (48 hours), 48 patients were treated with emergency laparoscopic cholecystectomy and 43 patients were treated with delayed cholecystectomy at ≥4 weeks after insertion of a percutaneous transhepatic cholecystostomy catheter. After initial treatment, the patients were followed up for 23 months on average (range 7-29). RESULT Compared with the patients who had emergency laparoscopic cholecystectomy, the patients who were treated with percutaneous transhepatic cholecystostomy and delayed cholecystectomy had a lower frequency of conversion to open surgery [19 (40%) vs 8 (19%); P=0.029], a frequency of intraoperative bleeding ≥100 mL [16 (33%) vs 4 (9%); P=0.006], a mean postoperative hospital stay (5.3+/-3.3 vs 3.0+/-2.4 days; P=0.001), and a frequency of complications [17 (35%) vs 4 (9%); P=0.003]. CONCLUSION In patients with acute cholecystitis who presented to the hospital ≥72 hours after symptom onset and did not respond to nonoperative treatment for 48 hours, percutaneous transhepatic cholecystostomy with delayed laparoscopic cholecystectomy produced better outcomes and fewer complications than emergency laparoscopic cholecystectomy.