Gokhan Yagci

Results of Surgical, Laparoscopic, and Percutaneous Treatment for Hydatid Disease of the Liver: 10 Years Experience with 355 Patients

Selection of the most appropriate treatment to obtain the best results with the lowest rate of recurrence and minimal morbidity and mortality is mandatory for the management of hepatic hydatid disease. The surgical approach is the mainstay of treatment, and there has been a tendency toward laparoscopic surgery and, more recently, percutaneous treatment (PT), which has become increasingly popular with revolutions in techniques. We aimed to evaluate the results of current therapeutic methods in the context of a 10-year single-institution experience. Between 1992 and 2003, 355 patients with 510 hydatid cysts of the liver were treated by open operation, laparoscopic surgery, or PT. The series included 128 females and 227 males ranging in age from 10 years to 73 years. Preferred treatment modalities, perioperative complications, interventions, recurrences, and length of hospital stay were retrospectively analyzed. There were two postoperative deaths (1.08%) in the open surgery group. Biliary leakage was observed in 28 patients treated with open surgery, in 10 patients after PT, and in 2 after laparoscopic treatment. Recurrence rates were 16.2%, 3.3%, and 3.5% after open surgery, laparoscopic surgery, and percutaneous treatment, respectively. Characteristics of the cyst, presence of cystobiliary communications, and the availability of a multidisciplinary team are the factors that we believe directly affect the results. Radical surgery can be done safely for suitable cases; conventional procedures are associated with greater morbidity. Laparoscopic surgery seems effective and safe, with low morbidity and recurrence rates for type I–III cysts in accessible localizations. Our experience with PAIR (puncture, aspiration, injection, and reaspiration) and catheterization provides evidence that the procedure is an effective and safe option.

Multicenter prospective randomized trial comparing modified Limberg flap transposition and Karydakis flap reconstruction in patients with sacrococcygeal pilonidal disease

BACKGROUND There is still no consensus as to the optimal treatment for sacrococcygeal pilonidal disease (SPD). Many recommend off-midline closure, if any excisional procedure is to be selected. METHODS The authors prospectively studied 145 patients with SPD who presented at 3 hospitals. Patients were randomly assigned to undergo either modified Limberg flap (MLF) transposition (n = 72) or Karydakis flap reconstruction (n = 73). Surgical findings, complications, recurrence rates, and degree of patient satisfaction, evaluated via a standardized telephone interview, were compared. RESULTS Operation time was longer in the MLF group. There were no significant differences between the two groups in terms of complication rate, length of stay, or recurrence rate. Patients in the Karydakis group reported feeling completely healed more quickly postoperatively. The two groups reported similar rates of satisfaction. Mandatory patient withdrawal from a given study arm because of the orifice straying from the midline occurred more frequently in the Karydakis group. CONCLUSIONS The MLF technique and the Karydakis procedure appear to generate comparable outcomes. With laterally situated orifices, however, the applicability of the Karydakis method may be limited.

Treatment of pilonidal sinus by phenol application and factors affecting the recurrence.

BackgroundPhenol injection, a less invasive method, has become more popular for the treatment of sinus pilonidalis. Recurrence rates after the use of phenol have been reported to be less than those after other surgical methods.MethodsIn this study, we applied 80% phenol to 143 patients with sinus pilonidalis. Patients were reevaluated at 1, 3, 6, 12 and 24 months after the phenolization procedure to search for any recurrences. Age, sex, skin color, occupation, hair distribution, complaints, macroscopic characteristics of the lesion, pouch volume, microbiological yield, complications of phenol injection, healing time, and recurrences were determined.ResultsThe mean follow-up period was 24 months and the recurrence rate was 8.3% (12 of 143 patients). Volume of the sinus tract and number of sinus orifices were determined to be the factors significantly affecting recurrences (p<0.05).ConclusionsInjection of 80% phenol is an ideal approach for the conservative treatment of sinus pilonidalis. This study confirms that this is an effective and costless method with low recurrence rates.

Beneficial effects of N-acetylcysteine on sodium taurocholate-induced pancreatitis in rats

BackgroundAcute pancreatitis (AP) is a complex disease associated with significant complications and a high rate of mortality. Although several mechanisms are put forward, oxidative stress seems the most important early event in the pathophysiology of AP. Therefore, we evaluated the beneficial effects of N-acetylcysteine (NAC), a strong antioxidant, in experimental AP.MethodsForty-nine Sprague-Dawley rats were used. Acute pancreatitis (AP) was induced by the intraductal infusion of sodium taurocholate. Rats were divided into seven groups (each containing seven rats): control, sham-operated (saline-treated, 3.5 and 12 h), non-treated AP (3.5 and 12 h) and NAC-treated AP (3.5 and 12 h). Treated rats received intraperitoneal (i.p.) NAC 1000 mg/kg 24 h before and just before the induction of pancreatitis.ResultsRats with AP had extensive parenchymal and fat necrosis and NAC treatment at 12 h reduced tissue necrosis significantly (P ≪ 0.05). NAC treatment at 12 h reduced leukocytic infiltration significantly (P ≪ 0.05). Edema and hemorrhage were significantly increased in the AP groups when compared to controls (P ≪ 0.001). NAC treatment reduced edema and hemorrhage at both 3.5 and 12 h slightly but not significantly. The total pathological mean score was significantly increased in the AP groups (P ≪ 0.05) and it was reduced by NAC treatment (P ≪ 0.05). NAC treatment decreased plasma amylase and lipase levels significantly (P ≪ 0.05). While glutathione peroxidase (GPx) activity of pancreatic tissue was similar in the NAC-treated and AP groups, hepatic tissue GPx activity was lower in the AP groups, and NAC treatment restored it (P ≪ 0.05). NAC had no effect on pancreatic superoxide dismutase level. In the NAC-treated rats, the serum NO2/NO3 (nitrite/nitrate) level was significantly increased in the 3.5-h group when compared to the respective AP group (P ≪ 0.05). NAC treatment also significantly reduced the serum concentration of the lipid peroxidation product, malondialdehyde, at 12 h (P ≪ 0.05).ConclusionsNAC treatment had beneficial effects in sodium taurocholate-induced AP in rats. It reduced pancreatic tissue necrosis and lipid peroxidation. In our study, the mechanism underlying the beneficial effects of NAC seemed to be its antioxidant activity, either by increasing hepatic GPx activity, or by a direct scavenging effect on free radicals, thus enhancing the production of and/or inhibiting the degradation of nitric oxide.

The effects of gingko biloba extract (EGb 761) on experimental acute pancreatitis

BACKGROUND AND OBJECTIVE Acute pancreatitis is an important and fatal disease with high mortality and morbidity. Although the pathogenesis of acute pancreatitis is poorly understood, there are many studies that suggest the role for oxygen free radicals (OFRs) in the development of pancreatitis and its complications and show beneficial effects of scavenger treatment. In the present study, we aimed to investigate whether Egb761, the standardized extract of gingko biloba, restrains the generation of OFRs and ameliorates the histopathologic findings of acute pancreatitis. MATERIALS AND METHODS Sixty male Sprague Dawley rats were randomly assigned to one of the following experimental groups. In early and late pancreatitis and treatment groups, acute pancreatitis was induced by retrograde infusion of 3% sodium taurocholate. In treatment groups, 100 mg/kg Egb 761 was given intraperitoneally (IP) 24 h and immediately before induction of pancreatitis. Sham-operated rats received isotonic saline instead of sodium taurocholate. After observation times of 3.5 and 12 h, the pancreas was removed for light microscopy and determination of malondialdehyde (MDA) levels as a marker for OFRs-induced lipid peroxidation. Serum samples also were obtained for amylase and lipase levels. RESULTS There was no significant difference in control and sham-operated groups in terms of histopathologic findings and serum enzyme levels. The tissue concentrations of MDA and serum enzyme levels were significantly elevated in early and late treatment groups as compared with the control group. The treatment with Egb 761 caused significant decrease in serum amylase and lipase levels and histopathologic scores as compared with early and late pancreatitis groups. CONCLUSIONS Prophylactic application of Egb761 exerts highly beneficial influence on the course of acute pancreatitis, and this seems to be related to the oxygen radical scavenger effect of Egb761.

Preoperative and postoperative administration of hyperbaric oxygen improves biochemical and mechanical parameters on ischemic and normal colonic anastomoses.

Colonic anastomotic leaks are a major postoperative complication, causing increased mortality and morbidity. Tissue ischemia is one of the most important factors that disrupt anastomotic healing. It is possible to reverse inadequate tissue oxygenation by using increased atmospheric pressure and hyperoxia, which are obtained from hyperbaric oxygen treatment (HBO). Our aim was to investigate the effects of preoperative and postoperative HBO treatment on normal and ischemic colonic anastomoses in rats. Eighty male Wistar Albino rats, weighing between 180 and 240 g, were divided into 8 equal groups. A 1-cm segment of left colon was resected 3 cm proximal to the peritoneal reflection in all groups and colonic anastomosis was performed. In groups 2, 4, 6 and 8, colonic ischemia was established by ligating 2 cm of mesocolon on either side of the anastomosis. Control groups (1 and 2) received no HBO. HBO treatment was given preoperatively in groups 3 and 4, postoperatively in groups 5 and 6, and both preoperatively and postoperatively in groups 7 and 8. HBO treatment was applied for 2 days in the preoperative period and 4 days in the postoperative period. Relaparotomy was performed on postoperative day 5 and a perianastomotic colon segment 2 cm in length was excised for detection of biochemical and mechanical parameters of anastomotic healing and histopathological evaluation. HBO treatment increased tissue hydroxyproline levels in all groups, and this difference was significant in normal anastomosis groups receiving preoperative HBO compared to controls (p =. 013 for group 1 vs. group 3; p =. 023 for group 1 vs. group 5). This improvement was more evident in ischemic and normal groups treated by administration of combined pre- and postoperative HBO (p =. 021 and p =. 013). HBO treatment also increased the mean bursting pressure values in all groups, and again, a statistically significant increase was noted in the ischemic groups compared to controls (p =. 002 for group 2 vs. group 6; p =. 001 for group 2 vs. group 8). Histopathological evaluation of anastomotic line fibrosis was not found to show significant differences between the groups. Adequate tissue oxygenation is the main factor in wound and anastomosis healing. HBO treatment has a positive effect on biochemical and mechanical parameters of ischemic and normal colon anastomoses in rats. It is possible to see this effect more clearly with combined HBO treatment applied before and after ischemic anastomosis.

Increased intra-abdominal pressure causes bacterial translocation in rabbits

Background: Abdominal compartment syndrome (ACS) is defined as intra‐abdominal hypertension associated with organ dysfunction. Subsequently, increased intra‐abdominal pressure (IAP) adversely affects the pulmonary, cardiovascular, renal, musculoskeletal/integumentary and central nervous systems. Bacterial translocation (BT), which is defined as the movement of viable enteric bacteria to the mesenteric lymph nodes, liver and spleen, occurs after various types of stress and results in splanchnic ischemia. In this experimental study, we aimed to investigate the effects of various levels of increased IAP on BT in rabbits; IAP was increased by the intra‐abdominal balloon‐insufflation method, thus simulating noncompliant abdominal‐wall closure under tension. Methods: Fifty rabbits were randomly assigned to 1 of 5 groups, with each group comprising 10 animals. In group I (control group), an intra‐abdominal balloon was placed without inflation. In groups II, III, IV and V, IAPs of 10, 15, 20 and 25 mmHg, respectively, were established via inflation of the intra‐abdominal balloon. All groups underwent laparotomy after 12 hours. Multiple biopsies were taken from ileocecal lymph nodes, the spleen and liver. Results: BT was observed to some degree in all 4 experimental groups. A gradual increase in the phenomenon was noted as IAP increased from 10 to 15 mmHg; and BT was overt at 20 mmHg, and significant at 25 mmHg. Klebsiella pneumoniae, Serratia marcescens, and Escherichia coli were the predominant pathogens identified by culture. Conclusion: We propose that an intravesical pressure (IVP) of 15 mmHg is the critical point for BT in patients with increased IAP. In this experimental study, BT occurred when IVP reached 20 mmHg. We suggest that IVP monitoring is desirable in the management of patients with ACS, and that decompressive laparotomy should be performed in patients with IVP > 20 mmHg.

Preoperative administration of oral carbohydrate-rich solutions: Comparison of glucometabolic responses and tolerability between patients with and without insulin resistance

OBJECTIVE Preoperative carbohydrate loading with clear fluids is thought to reduce surgery-related insulin resistance (IR). However, IR per se is already present in some patients scheduled for elective surgery. Data on the safety of preoperative oral carbohydrate loading in patients with IR undergoing surgery is lacking. We aimed to evaluate the effects of preoperative carbohydrate loading on the glucometabolic state and gastric content of patients with and without IR. METHODS Thirty-four non-diabetics received 800 mL of a special carbohydrate-containing drink on the evening before the operation and then 400 mL 2 h before surgery. Blood samples for glucose, insulin, and cortisol levels were taken immediately before the second dose, at 40 and 90 min after intake of the drink, and at the onset of surgery. Patients with a homeostasis model assessment IR score >2.5 were considered to have IR. The differences between patients with and without IR were then evaluated. RESULTS Eight of the 34 patients had IR and the remaining 26 did not. Glucose levels in the IR group were higher than those in the non-IR group, but the differences did not reach significance. The initially elevated insulin concentrations then tended to decrease to the corresponding levels detected in the non-IR group. The cortisol concentrations were similar in both groups. CONCLUSION Patients with IR receiving a carbohydrate-rich drink before surgery appear not to be affected adversely by the beverage. Furthermore, they also obtain the probable beneficial effects related to these drinks and, like patients without IR, can undergo surgery safely.

Hyperbaric oxygen enhances the efficiency of 5-aminosalicylic acid in acetic acid-induced colitis in rats.

The aim of this study was to assess the efficienchyperbaric oxygen alone and in combination with 5-aminosalicylic acid in THE acetic acid–induced colitis model, a well-known experimental model of inflammatory bowel disease in rats. Rats were randomly divided into FIVE groups. In the noncolitis control group, rats were given isotonic saline, while in the other groups rats were treated by intracolonic administration of 4% acetic acid. In group 2, the untreated control group, no additional therapy was applied. In groups 3, 4, and 5 hyperbaric oxygen, 5-aminosalicylic acid. and 5-aminosalicylic acid + hyperbaric oxygen therapies were applied, respectively. Administration of acetic acid caused an inflammatory response in all animals. Histopathologic score was significantly higher in group 2 than in any other group. 5-Aminosalicylic acid and hyperbaric oxygen significantly decreased the histopathologic score (P < 0.05). Myeloperoxidase activity was also reduced significantly by 5-aminosalicylic acid (P < 0.05) but not by hyperbaric oxygen. The most prominent ameliorative effect, however, was seen in group 5 and the histopathologic score and myeloperoxidase activity were significantly lower than in groups 3 (P < 0.05) and 4 (P < 0.001). Hydroxyproline level also increased significantly in group 5, but not in groups 3 and 4 (P < 0.001). These findings indicate that hyperbaric oxygen therapy is effective in reducing the extent of colitis induced by acetic acid, although it is not as potent as 5-aminosalicylic acid. The combination of hyperbaric oxygen and 5-aminosalicylic acid, however, led to a much more prominent reduction in the severitcolitis. Hyperbaric oxygen may have a promising place in the treatment of inflammatory bowel disease.

Systematic Review of Studies Investigating Sentinel Node Navigation Surgery and Lymphatic Mapping for Gastric Cancer

Evolutions in minimally invasive surgical techniques and advances in sentinel node navigation surgery (SNNS) have had considerable impact on current insights into surgical treatment of gastric cancer. Extensive data on this method of surgical application have accumulated but have been principally derived from single-institute studies. Isosulfan blue and patent blue violet have been the most frequently used dye tracers in the past; however, indocyanine green has now is increasingly popular. The double-tracer method, where dye and radioisotope tracers are used together, seems to be more effective than any single tracer. Among newly emerging adjunct techniques and promising alternative in particular are infrared ray electronic endoscopy, florescence imaging, nanoparticles, and near-infrared technology. Hematoxylin and eosin (H&E) staining is still the method of choice for the detection of sentinel lymph node (SLN) metastases. Immunohistochemical staining can be used to support H&E findings, but the equipment costs of ultrarapid processing systems are currently slowing down their worldwide spread. We believe minimally invasive function-preserving resection of the stomach, together with lymphatic basin dissection navigated by SLNs, can represent the ideal approach for SNNS to detect clinically node-negative early gastric cancer, although this remains to be elucidated. Patients with cT3 or more advanced disease should still be treated by means of standard D2 dissection.