Ilker Turan

The modified sequential treatment regimen containing levofloxacin for Helicobacter pylori eradication in Turkey.

Background:  Eradication rates of Helicobacter pylori have declined to unacceptable levels in recent years. New and effective treatment options are warranted both as a first and second line treatment.

Swallow-Induced Syncope in a Patient with Achalasia

A 48-year-old man was referred for the evaluation of dysphagia and syncope. He suffered from both dysphagia and transient loss of consciousness when eating solid food, especially bread. An upper gastrointestinal barium examination and esophageal manometry suggested achalasia. Ambulatory ECG revealed marked sinus bradycardia when experiencing a syncopal episode following the ingestion of a solid meal. A permanent pacemaker was implanted and the patient’s syncopal attacks were relieved following this procedure. However, the dysphagia and cardiac arrhythmia completely disappeared only following a successful pneumatic balloon dilatation for achalasia. This observation suggests that swallowing-induced sinus bradycardia and syncope might occur in the course of achalasia and these rhythm abnormalities could be relieved by successful treatment of the achalasia.

Effects of a kefir supplement on symptoms, colonic transit, and bowel satisfaction score in patients with chronic constipation: A pilot study

BACKGROUND/AIMS Although probiotics have been extensively studied in irritable bowel syndrome, data on the impact of probiotics on chronic constipation are scarce. We aimed to evaluate the effects of kefir, which is a probiotic fermented milk product, on the symptoms, colonic transit, and bowel satisfaction scores of patients with chronic constipation. MATERIALS AND METHODS Twenty consecutive patients with functional constipation according to the Rome II criteria were divided into two groups based on their colon transit studies: 1. The normal transit (NT) group (n=10); and 2. The slow transit (ST) group (n=10). After a baseline period, 500 mL/day of a probiotic kefir beverage was administered to all patients for 4 weeks. Defecation parameters (stool frequency, stool consistency, degree of straining, laxative consumption) were recorded in diaries daily by the patients. Bowel satisfaction scores were assessed using a visual analog scale. The colon transit study was repeated in the ST group at the end of the study. RESULTS At the end of the study, the patients showed an increased stool frequency (p<0.001), improved stool consistency (p=0.014), and decreased laxative consumption (p=0.031). The degree of straining during evacuation showed a tendency to improve after kefir administration; however, this was not statistically significant (p=0.18). A repeat transit study showed an acceleration of colonic transit in the ST group (p=0.013). Bowel satisfaction scores also improved (p<0.001). CONCLUSION This pilot study shows that kefir has positive effects on the symptoms of constipation. Our results also suggest that kefir improves bowel satisfaction scores and accelerates colonic transit. Controlled trials are warranted to confirm these findings.

A Cerebrovascular Event After Single-Dose Administration of Recombinant Factor VIIa in a Patient with Esophageal Variceal Bleeding

Upper gastrointestinal bleeding (UGIB) is a life-threatening complication of cirrhosis that develops from esophageal varices in almost 70% of patients. The mortality rate from the bleeding episodes is reported to be 30% [1–4]. Standard management of UGIB of cirrhotic patients is vasoactive therapy combined with endoscopic procedures such as endoscopic sclerotherapy and band ligation [5]. Currently, it is reported that recombinant activated fVIIa (Novoseven, NovoNordisc) can correct the prothrombin time in decompensated cirrhotic patients and also can be used safely in Childs B and C cirrhotic patients with UGIB [6–8]. Herein, we describe the first case report in the literature of a cerebrovascular event after the administration of a single dose of fVIIa in a cirrhotic patient with esophageal variceal bleeding.

Magnetic compression anastomosis for patients with a disconnected bile duct after living-donor related liver transplantation: a pilot study.

BACKGROUND AND STUDY AIM We present the use of the magnetic compression anastomosis (MCA) technique for treatment of disconnected bile duct after living-donor related liver transplantation (LDLT) using the recently introduced through-the-scope magnet. PATIENTS AND METHODS The MCA technique was used in patients with disconnected bile duct who could not be treated with either percutaneous or endoscopic procedures. All patients already had a percutaneous external biliary drainage catheter before the procedure. The magnet was placed percutaneously into the proximal side of the obstruction by pushing a 5-Fr catheter over a guidewire. Concurrently, endoscopic retrograde cholangiopancreatography (ERCP) including endoscopic papillary sphincterotomy was performed. The sister magnet was then carefully advanced to the opposite side of the obstruction with a 5-Fr catheter over a guidewire. After the confirmation of biliary recanalization, a guidewire was passed through the stricture and a percutaneous dilation of the stricture was performed with a balloon-tipped catheter. Endoscopic balloon dilation of the stricture, insertion of two plastic stents and the removal of the internal drainage catheter were performed during the first ERCP session. Stent exchange and multiple side-by-side stent placements were planned at regular intervals (3 monthly) for all patients. RESULTS A total of six LDLT patients with disconnected bile duct (aged 37 - 68, four men) underwent the MCA technique between September 2014 and July 2015. Biliary recanalization was achieved 13 - 42 days after the magnet placement procedure. The success rate of the procedure was 100 %. CONCLUSIONS The MCA technique using a small magnet (diameter 2.4 mm) is effective and useful in LDLT patients with disconnected bile duct.

Telbivudine in liver transplant recipients: Renal protection does not overcome the risk of polyneuropathy and myopathy

The recently reported benefit of telbivudine for renal function has not been systematically studied in long‐term liver transplantation (LT) recipients who are at high risk for renal impairment. We aimed to examine whether switching lamivudine therapy to telbivudine could improve renal function in LT recipients who have impaired renal function. This single‐center, prospective cohort study enrolled LT recipients who were on lamivudine for hepatitis B virus (HBV) prophylaxis and who had renal impairment for at least 1 year. Lamivudine was switched to telbivudine. The primary outcome was to evaluate the change in renal function at weeks 12, 24, 36, and 48. The secondary outcomes were to assess the efficacy of telbivudine for HBV prophylaxis and the safety profile of telbivudine in the posttransplant setting. After 45 patients were enrolled, the study was terminated early because of increased rates of polyneuropathy/myopathy. During telbivudine treatment (median, 64 weeks), estimated glomerular filtration rate (eGFR) increased in 34 patients (76%). The improvement in renal function was prominent after 24 weeks of telbivudine treatment. Telbivudine was effective as prophylaxis against HBV recurrence. Twenty‐six patients (58%) developed polyneuropathy and/or myopathy. The 1‐year estimated incidence of polyneuropathy/myopathy was 28%. Diabetes was the strongest predictor of polyneuropathy/myopathy (hazard ratio, 4.13; 95% confidence interval, 1.49‐11.50; P = 0.007). In conclusion, although it seems to have a favorable effect in the improvement of renal function and seems to be effective in the prevention of HBV recurrence, the high risk of polyneuropathy and myopathy hampers the use of telbivudine in LT recipients. Liver Transpl 21:1066‐1075, 2015.

Frontal Skull Metastasis Extending Through the Scalp: Initial Sign of Hepatocellular Carcinoma Recurrence 5 Years After Liver Transplantation

Hepatocellular Carcinoma Recurrence 5 Years After Liver Transplantation To date, only two cases of skull metastasis (temporal bone in one case and parietal region after a trauma in other one) of hepatocellular carcinoma (HCC) after liver transplantation (LT) have been reported in the pertinent literature (1, 2). Herein, we described a patient presenting with frontal skull metastasis extending through the scalp as an initial manifestation of HCC recurrence 5 years after LT. A 70-year-old male patient received living donor LT in August 2006 for hepatitis B virusYrelated liver cirrhosis complicated by HCC. Investigations including thorax and cranial computed tomography (CT) and bone scintigraphy showed no extrahepatic metastasis. No vascular invasion was reported in explanted liver. The initial immunosuppression used was prednisolone and sirolimus. Tacrolimus and mycofenolate mofetil were then added due to clinical rejection in the first month after transplantation. Prednisolone, mycofenolate mofetil, and tacrolimus were ceased after 6 months, 2 years, and 3 years, respectively. The patient’s immunosuppression was maintained at sirolimus 2 mg daily. Lamivudine and short-term hepatitis B immunoglobulin were used for preventing recurrence of hepatitis B virus after LT. However, hepatitis B surface antigen positivity was detected in 2008 and tenofovir was added. Annual ultrasonographic investigation of the liver showed no HCC recurrence for the period until 2010. In July 2011, the patient noticed a 3-cm painless, firm, subcutaneous mass with skin ulceration in the frontal region of the skull (Fig. 1). Cranial CT scan demonstrated the presence of an osteolytic lesion in frontal bone without involvement of the dura mater. A wide local excision was performed and histopathologic analysis revealed the diagnosis of HCC. Moreover, toracoabdominal CT scan revealed the presence of simultaneous 2.5-cm mass in the transplanted liver, metastatic pulmonary micronodules in the right lung, metastatic multiple nodules in both adrenal glands, and bone metastases in the ribs, lumbar vertebrae, and pelvis. A diagnosis of metastatic hepatocellular cancer recurrence was done. His >-fetoprotein was found to be 3.59 ng/mL. Due to the lack of clinical, laboratory, and radiologic manifestations of recurrent cirrhosis, liver biopsy was not performed. Because the histopathologic findings of the skull mass were also relevant with the radiologic signs of metastatic HCC, systemic sorafenib therapy (400 mg, twice daily, orally) was initiated and external radiotherapy was administered for bone metastases. A CT scan obtained after 6 months of therapy showed progression of the mass in the liver to 3 cm in diameter, without regression of metastatic nodules in the lung and adrenal glands. Therefore, sorafenib was discontinued and no further treatment was considered because of multiple intractable metastatic lesions. His clinical course was marked by refractory gastrointestinal bleeding due to tumoral infiltration of gastroduodenal artery followed by death 11 months after initial diagnosis of HCC recurrence. Treatment of HCC using hepatic resection and LT achieves the best outcome in well-selected candidates, but 10% to 30% of patients still experience tumor recurrence after LT even if the restrictive criteria are employed (3). The most frequent site of extrahepatic metastasis after LT is the lung followed by bone and others (lymph nodes and adrenal glands). Bone metastasis has been reported ranging from 6% to 33% (3), the most common sites are the vertebrae followed by pelvis and ribs (4). Considering the lack of signs of liver cirrhosis, bone and soft tissue involvement of HCC may suggest de novo

Results of 1001 liver transplantations in 23 years: Ege University experience

BACKGROUND/AIMS Liver transplantation (LT) is now the standard of care for most end-stage liver diseases. Over the next 30 years, advances in medicine and technology will greatly improve the survival rates of patients after this procedure. The aim of the present study was to analyze retrospectively the results of 1001 patients withLT. MATERIALS AND METHODS Medical reports of 989 patients were analyzed retrospectively. Data were obtained from the patients data chart. Descriptive statistics were used to describe continuous variables (mean, median, and standard deviation). RESULTS A total of 1001 LTs for 989 recipients were performed at Ege University Organ Transplantation and Research Center between 1994 and 2017. Therewere 639 male and 350 female recipients. Among 1001 LTs, there were 438 deceased donors and 563 living donors. The age interval of the patients was 4 months to 71 years old. The median Model for End-Stage Liver Disease score was 20. There were 12 deceased liver donors using the split method. There were 12 cases subject to retransplantation. In living donor LT grafts, 423 right lobes, 46 left lobes, and 94 left lateral sectors were used. In the first monitoring,the total annual mortality rate was 130 cases (13%). The mortality rate in retransplantation was found to be 66%. A 1-year survival rate of 87% was generally stablished. CONCLUSION LThas been improving consistently over the last two decades. Ege University is one of the biggest liver transplant centers in Turkey for both technical and educational perspective.

In vitro fertilization-induced pregnancies predispose to gastroesophageal reflux disease

Background Women conceiving following in vitro fertilization (IVF) likely have a variety of risk factors that predispose them to gastroesophageal reflux disease (GERD) in the future. Objective We aimed to investigate whether pregnancy through IVF may predispose to subsequent GERD compared with pregnancies without IVF. We also evaluate whether twin IVF pregnancies lead to additional risk for having GERD compared with singleton IVF pregnancies. Methods A validated reflux questionnaire was administered to 156 women with singleton (n = 102) or twin (n = 54) IVF birth (IVF group) and 111 women with a naturally conceived singleton birth (control group). All women included in the study were primiparas who had given birth at least 1 year prior to data collection. The diagnosis of GERD was based on the occurrence of typical symptoms (heartburn, regurgitation, or both) at least once a week. Results The prevalence of GERD was 13.5% and 4.5% in IVF and control groups (p = 0.015); in the IVF group, this was slightly higher, but not statistically significant, in women with twin compared with singleton pregnancies (14.8% vs. 12.7%, p = 0.749). Logistic regression analysis showed that IVF was strongly associated with subsequent GERD (OR, 3.30; 95% CI 1.20–9.04; p = 0.02). Conclusion The risk of developing GERD at least 1 year after delivery increased following IVF. Long-term follow-up studies are required to determine whether therapy during pregnancy can prevent this risk.

Fractured esophageal self-expandable metallic stent in a patient with advanced lung cancer: a case report and review of the literature

Self-expandable metallic stents (SEMS) are the currently recommended treatment modality for palliation of dysphagia resulting from unresectable malignant esophageal obstruction. The most common post-SEMS-placement complications are migration, perforation, bleeding, and tumor ingrowth or overgrowth. We report herein a patient with advanced lung cancer invading the esophagus with the very rare late complication of spontaneous stent fracture 8 months after esophageal SEMS placement, together with a comprehensive review of the related literature. To the best of our knowledge, this is the first report describing the spontaneous fracture of an esophageal SEMS inserted for the palliative treatment of malignant esophageal obstruction due to extrinsic invasion by lung cancer.