Ilhan Karabicak

The Effect of Silymarin on Mesenteric Ischemia-Reperfusion Injury

Objective: To examine the effect of silymarin (SM), a mixture of flavonoids and polyphenols extracted from Silybum marianum, on mesenteric ischemia-reperfusion (I-R) injury in a rat model. Materials and Methods: Fifty rats were randomly divided into 5 groups (n = 10). Group 1 was sham operated, while groups 2-5 were subjected to mesenteric I-R lasting 1 h. Group 2 received isotonic sodium chloride, group 3 received SM (100 mg/kg/day) for 7 days before I-R, group 4 received SM for 7 days after I-R, and group 5 received SM for 7 days both before and after I-R. The rats were sacrificed by exsanguination in groups 1-3 at the 24th hour and groups 4 and 5 were sacrificed on the 7th day of reperfusion. Blood and intestinal specimens were taken for biochemical and pathological evaluations. Results: Serum superoxide dismutase (SOD) and heat shock protein 70 levels were significantly higher in group 2 (5.24 ± 1.76 U/l and 261.4 ± 16.8 ng/ml) compared to the sham group (2.08 ± 1.76 U/l and 189.9 ± 28.7 ng/ml) (p < 0.001 and p < 0.0001, respectively). However, SOD activity and the extent and severity of the histopathological lesions were significantly less in groups 3 [3.11 ± 1.18 U/l, 1.0 (range 0.0-2.0)], 4 [2.15 ± 0.87 U/l, 1.0 (range 1.0-3.0)], and 5 [1.80 ± 0.61 U/l, 0.5 (range 0.0-2.0)], treated with SM, than in group 2 [5.24 ± 1.76 U/l, 2.0 (range 2.0-3.0)] (p = 0.002, p < 0.001, and p = 0.0001; p < 0.001, p = 0.007, and p = 0.0001, respectively). Also, TNF-α levels were lower in the SM-supplemented groups compared to group 2. Serum thiobarbituric acid-reactive substance concentrations were low in the pre-/posttreatment groups treated with SM compared to group 2. No statistical difference was observed for protein carbonyls between the groups. Conclusion: Our findings suggest that SM therapy may attenuate the oxidative and intestinal damage induced by I-R injuries.

Long-term outcomes of intraoperative and perioperative albendazole treatment in hepatic hydatidosis: single center experience

Purpose The aim of this study was to evaluate long-term outcome of the intraoperative and perioperative albendazole (ALB) treatment on the recurrence and/or secondary hydatidosis. Methods One hundred and one patients with hepatic hydatidosis were treated intraoperatively and perioperatively with ALB, in addition to surgery. Perioperative ALB treatment was given in a dose of 12-15 mg/kg/day. The ALB treatment was started 13.27 ± 14.34 days before the surgery, and it was continued for 4.39 ± 3.11 months postoperatively. A total of 1.7 µg/mL of ALB solution was used as a protoscolidal agent. The follow-up period was 134.55 ± 51.56 months. Results Four patients died, with only one death was secondary to hydatid disease (cerebral eccinococcus). There was only one recurrence (1%) of hepatic hydatidosis. Early and late morbidity rates were 8.91% and 7.92%, respectively. Conclusion Our results suggest that intraoperative and perioperative ALB is effective for the prevention of hepatic hydatidosis recurrence and/or secondary hydatidosis.

A First Report of Synchronous Intracapsular and Extracapsular Hepatic Adenoma

Although the gallbladder is the most common site of ectopic liver, it has been reported in many other organs, such as kidney, adrenal glands, pancreas, omentum, stomach, esophagus, mediastinum, lungs, and heart. Hepatocytes in an ectopic liver behave like normal hepatocytes; furthermore, they can be associated with the same pathological findings as those in the main liver. Ectopic liver in the gallbladder can undergo fatty change, hemosiderosis, cholestasis, cirrhosis, hemangioma, focal nodular hyperplasia, adenoma, and even carcinogenesis. The incidence of extracapsular hepatic adenoma is not known, but only two cases have been reported. Here, we provide the first case report of synchronous multiple intracapsular and extracapsular hepatic adenomas. A 60-year-old woman with multiple hepatic adenomas and one 7 × 5 × 5 cm ectopic hepatic adenoma attached to the gallbladder fundus complicated with abdominal pain is presented.

Is single‐port laparoscopy feasible after liver transplant?

To the Editor, We have read with interest the case reports entitled “Is single-port laparoscopy feasible after liver transplant?” by Zani et al. (1). The article highlights two cases of single-port laparoscopic surgery after liver transplantation. This is the only published article of its kind in PubMed regarding single-port laparoscopic surgery after liver transplantation. In the manuscript, the authors state that “In particular, we believe that SIPES following liver transplant should be reserved to procedures that involve the inframesocolic compartment, where adhesions are more likely to be less important, native anatomy can be preserved and no major structures have to be modified. Conversely, posttransplant SIPES in the supramesocolic compartment should be avoided due to potential hazards, such as the proximity to the transplanted liver graft, the presence of possibly thicker adhesions and the complexity of surgery to the upper abdominal quadrants.” I have several comments to make on this article. Firstly, many types of different single-port laparoscopic procedures are being performed by expert laparoscopic surgeons (2, 3). Secondly, many of the previous contraindications are no longer accepted. Although Zani et al. (1) mention that SIPES should be avoided in the supramesocolic compartment due to the possibility of thicker adhesions and the complexity of surgery to the upper abdominal quadrants, we performed a single-port laparoscopic incisional hernia repair on a liver transplant recipient. The patient underwent a liver transplant two yr ago and developed incisional hernia six months after the procedure. She wanted surgery because she had been experiencing abdominal pain and discomfort. On physical examination, a 9 9 5 defect was identified at the middle of chevron incision and a 4 9 4 defect was discovered at the end of the right extension of the chevron incision. We performed a single-incision laparoscopic ventral hernia repair on the patient. We used two composite meshes, one of which was 15 9 20 cm in diameter and the other 10 9 10 cm in diameter, to fix the two hernia defects. No severe intra-abdominal adhesion was identified, which we contributed to the immunosuppressive therapy. The surgery lasted 70 min with no blood loss. The postoperative course was unevenful, and the patient was discharged on postoperative day 1 without discontinuing any of her medications. Six months after the surgery, no complaints were reported. In the liver transplant patient group, if possible, laparoscopic/single-port laparoscopic surgery should be the preferred course to minimize the operative trauma as these patients are immunosuppressive. Single-port laparoscopic hernia repair is as an ambulatory procedure. Oral immunosuppressive medications, which are crucial for liver transplant recipients, do not need to be discontinued. Another important point about single-port laparoscopic surgery on liver transplant recipients is the location of the SILS port. Great care should be taken not to damage the enlarged veins while placing the trocar. Splenomegaly is another handicap while placing the SILS trocar, especially in the case of incisional hernia repair since the usual, preferred incision for liver transplantation is right-sided subcostal incision. The ideal location for the SILS port is left flank to fix the incisional hernia after liver transplantation. In the case of a massive splenomegaly, the SILS port has to be placed away from the spleen, which can limit the exposure during the surgery. I agree with Zani et al.’s conclusion that diffuse intraperitoneal adhesions should not be considered contraindications. We showed that single-incision laparoscopic liver resection is feasible in patients who had previous colon cancer surgery although they had severe adhesions (3).

Letter to the Editor: Objective Assessment of Surgical Restaging after Concurrent Chemoradiation for Locally Advanced Pancreatic Cancer

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. pISSN 1011-8934 eISSN 1598-6357 http://dx.doi.org/10.3346/jkms.2016.31.9.1503 • J Korean Med Sci 2016; 31: 1503-1504

Cholangiocarcinoma Arising from a Type VI Biliary Cyst: A Case Report and Review of the Literature

Cystic dilatations of the cystic duct which are suggested as type VI biliary cysts are very rare and many of them go unrecognized or are confused with other cysts until the operation although they are obvious on imaging studies. They can present with fusiform or saccular dilatations and can be accompanied by common bile duct dilatations. It is important to identify these cysts as they share the same characteristics as the other biliary cyst types and can be complicated with malignancy. We herein present a very unusual case of a cholangiocarcinoma arising from a type VI biliary cyst in a 58-year-old female patient and review the literature. The patient presented with jaundice, weight loss, and abdominal pain. On imaging, the cystic duct and common bile duct were fusiformly dilated and had a wide communication. There was a mass filling the distal parts of both ducts. The patient was urgently operated on after perforation following ERCP. Histopathology was compatible with a type VI biliary cyst and an associated cholangiocarcinoma.