Kaan Karayalcin

Direct trocar insertion versus veress needle insertion in laparoscopic cholecystectomy

BACKGROUND Direct insertion of the trocar is an alternative method to Veress needle insertion for the creation of pneumoperitoneum. The safety of direct disposable shielded trocar insertion for the creation of pneumoperitoneum was assessed by comparing with Veress needle insertion during laparoscopic cholecystectomy (LC). METHODS One thousand five hundred patients undergoing LC with pneumoperitoneum were included in this study. In 470 patients the Veress needle insertion technique was used, and in 1,030 patients direct trocar insertion technique was used. Patients having indications for open trocar insertion were excluded from the study. RESULTS Complication rate was significantly higher in the Veress needle group (14% versus 0.9%; P <0.01), and the two major complications, gastric perforation and iliac artery laceration, were also encountered in this group. CONCLUSIONS Our results suggest that with a lower complication rate, direct insertion of the disposable trocar is a safe alternative to Veress needle insertion technique for the creation of pneumoperitoneum. Such an approach has further advantages such as less cost/instrumentation and rapid creation of pneumoperitoneum.

Chlorhexidine Gluconate: An Ideal Scolicidal Agent in the Treatment of Intraperitoneal Hydatidosis?

Hydatid disease is a parasitic disease that is treated primarily by surgery. The most important complication of surgical treatment is spillage of the contents of the cyst, leading to secondary dissemination. In this study, the effect of chlorhexidine gluconate (Chx-Glu) was investigated in the treatment of experimental intraperitoneal hydatidosis (IPH). IPH was reproduced in 100 Wistar albino rats by inoculation with 1 ml of a suspension contained approximately 1500 viable protoscolices of Echinococcus granulosus following determination of scolicidal activity of chlorhexidine gluconate in vitro. Five minutes after protoscolex inoculation, 5 ml of the scolicidal solution was instilled into the peritoneal cavity: 0.9% NaCl (control group), 4.0% Chx-Glu, 0.4% Chx-Glu, and 0.04% Chx-Glu. After 6 months of follow-up, the rats were sacrificed, and the number of isolated cysts, peroperative and postoperative deaths, and toxicity were evaluated. Cyst formation did not occur in any of the Chx-Glu groups compared to the control group (p < 0.05), whereas it was detected in all of the control rats. In addition, to 4.0% Chx-Glu was found to be more toxic and to cause a high mortality rate compared to the 0.4% and 0.04% Chx-Glu groups and the control group (p < 0.05). Chx-Glu 0.04% was found to be the most potent, nontoxic agent; it is easily available, inexpensive, and highly potent in a short period of time at the low concentration. Chx-Glu 0.04% can be used safely in the treatment of intraperitoneal hydatidosis and hydatid cyst.

Recipient-derived hepatocytes in sex-mismatched liver allografts after liver transplantation: Early versus late transplant biopsies

Background. The presence of microchimerism in transplanted tissues is well defined; however, the timeframe of appearance and disappearance of engraftment in liver allograft is unknown. The aims of this study were to analyze for the presence of “recipient-derived cells” in sex-mismatched individuals after liver transplantation, comparing the frequency of “recipient-derived cell repopulation” in early versus late transplant biopsies and to evaluate the relationship between “recipient-derived cell repopulation” and the severity of graft injury. Methods. Paraffin-embedded liver biopsy samples of 18 recipients were reviewed. Sixteen of them were obtained from recipients with sex-mismatched donors. The remaining two were obtained from recipients with sex-matched donors and were used as controls. Immunohistochemistry and fluorescence in situ hybridization double-labeling method were performed on pretreated slides using anti-human hepatocyte antibody to identify hepatocytes, a mouse anti-human cytokeratin-7 to identify ductal epithelial cells, and using CEPX/Y DNA probes for visualizing X and Y chromosomes. The double-labeled slides were examined systematically using an image analyzer system. Results. The mean time from transplantation to biopsy was 8.1 months. Eleven of the 16 samples obtained from recipients with sex-mismatched grafts demonstrated “recipient-derived hepatocyte repopulation,” comprising a mean of 2.1% of the hepatocytes. In the control biopsies, none of the cells demonstrated different nuclear signals from the donor’s sex origin. The presence and proportion of “recipient-derived hepatocyte repopulation” rate were significantly higher in early transplant biopsies than in late transplant biopsies (P<0.05). Conclusion. Some hepatocytes of sex-mismatched liver grafts were replaced by “recipient-derived cells” during injury. Such repopulation is more common in the early liver-graft biopsies. The severity of acute cellular rejection appears to have no effect on the rate of recipient-derived repopulation.

Effect of hypertonic saline and alcohol on viability of daughter cysts in hepatic hydatid disease

OBJECTIVE To test the efficacy of hypertonic saline (20%) and absolute alcohol on the integrity of daughter cysts and the viability of the protoscoleces contained in these cysts. DESIGN Experimental study. SETTING Teaching hospital, Turkey. MATERIAL 80 daughter cysts obtained from two patients with Gharbi type III hydatid cysts of the liver. INTERVENTIONS The cysts were divided into two groups, in the first of which cysts were placed into hypertonic saline and in the second into absolute alcohol; they were kept there for 5, 15, 30 or 60 minutes. MAIN OUTCOME MEASURES Integrity of the cyst wall and viability of the contents were evaluated using a vital staining technique with 0.1% eosin. RESULTS Neither hypertonic saline nor absolute alcohol solution had any effect on the integrity of the daughter cysts or the viability of the protoscoleces. CONCLUSION Percutaneous drainage of type III hydatid cysts can lead to high recurrence rates.

Portal venous system Evaluation with contrast-enhanced 3D MR portography

The purpose of this study is to compare contrast-enhanced three-dimensional (3D) magnetic resonance (MR) portograms to Doppler sonography in detection of portal venous abnormalities. Thirty-five consecutive patients, who were suspected of having portal venous system abnormalities, were examined with MR portography and Doppler sonography. Vascular abnormalities were identified in 27 of 35 patients. There was statistically significant agreement between the results of MR portography and Doppler sonography. The major limitation of contrast-enhanced 3D MR portography was its inability to provide objective hemodynamic data regarding flow direction and flow pattern.

The Effects of Cetrimide–Chlorhexidine Combination on the Hepato-Pancreatico-Biliary System

Sclerosing cholangitis is a rare but dreadful complication of liver hydatid surgery. Almost all scolocidal agents are associated clinically or experimentally with this complication. Cetrimide–chlorhexidine combination is the most potent scolocidal agent, and this study was designed to examine its effect on the hepato-pancreatico-biliary system. Forty Wistar-albino rats were divided into two groups. 0.5% cetrimide–0.05% chlorhexidine was injected into the biliary tract of study group animals and 0.9% saline ( NaCl ) into the control group through a 3-mm duodenotomy. The animals were sacrificed after 90 days and histopathological examination of the liver, biliary tract, and pancreas was performed 90 days after the biliary injection. The histopathological examination showed that the lesions ranged from focal necrosis to sclerosing cholangitis to liver cirrhosis. Focal necrosis and eosinophilic inflammation were observed in all rats in the study group. The changes in the liver, biliary tract, and pancreas of the study group animals were significantly more severe than those in the control group (p < 0.05). This experimental study confirms the deleterious effect of another scolocidal agents on the hepato-pancreatico-biliary system. Although it is a very effective scolocidal agent, it should not be used in the presence of a duct biliary–cyst communication.

Effects of Peritoneal Lavage with Scolicidal Agents on Survival and Adhesion Formation in Rats

Intraoperative irrigation of the peritoneal cavity with scolicidal agents is frequently recommended when dealing with traumatic or spontaneous rupture of hydatid cysts. The present experimental study was designed to examine the influence of various scolicidal agents on adhesion formation and survival. A total of 149 rats were randomly allocated to nine groups. Peritoneal lavage through a median laparotomy was performed with the following scolicidal agents. Group 1 (0.9% saline: controls), group 2 (20% hypertonic saline), group 3 (0.04% chlorhexidine gluconate), group 4 (3% hydrogen peroxide), group 5 (0.5% silver nitrate), group 6 (1% polyvinylpyrrolidone-iodine, or PVP-I ), group 7 (5% PVP-I), group 8 (0.5% cetrimide/0.05% chlorhexidine), and group 9 (10% PVP-I). The surviving animals were sacrificed on postoperative day 15. Adhesion formation was macroscopically graded by the Nair criteria. The severity of adhesion formation was evaluated microscopically using the fibrosing scoring criteria and the strain test. Group 9 (10% PVP-I) was excluded from the adhesion evaluation because all of the rats died in this group. The mortality rate was significantly higher in groups 5 and 7 than in groups 1, 2, 3, 4, 6, and 8. Adhesion scores were significantly lower in groups 1, 2, 3, and 4 than in groups 5, 6, 7, and 8. The lowest adhesion score was found in group 3 and the highest in the group 7. These results indicate that 0.04% chlorhexidine gluconate, the most potent scolicidal agent in vitro and in vivo, was associated with the lowest adhesion formation and mortality among various scolicidal agents in this experimental study.

Outcomes of laparoscopic versus open splenectomy

Purpose Laparoscopic techniques have gained wide clinical acceptance in surgical practice today. The laparoscopic approach has been established as the technique of choice for elective splenectomies performed on normal sized spleens. The purpose of this study was to evaluate the outcome of patients undergoing laparoscopic splenectomy (LS) at the TOBB University of Economics and Technology (ETU) Hospital and Kecioren Training and Research Hospital. Methods One hundred and thirty-five patients underwent splenectomy between January 2000 and July 2010. For comparison, the records of 130 patients undergoing splenectomy were evaluated for age, gender, hospital stay, time to start of diet, conversion rate, operation time and wound infection. Results Mean operation time means the time interval between surgeon commencing operation to end of operation. Mean operation time in patients treated by LS was 132 minutes and 121 minutes in open splenectomy (OS). Mean hospital stay was 5.65 days in patients undergoing LS and starting of diet was 1.21 days. In patients treated by OS, mean hospital stay was 9.17 days, starting of diet was 2.37 days. Four patients were converted to open surgery. Conversion rate was 6.4 percent. In the early post operative period (within 10 days of surgery) 9.2%, LS group had lower incidences of wound infection rate after surgery than OS group (4.8%, 7.4%, respectively; P = 0.06). Conclusion LS is a safe and effective alternative to OS for treatment of splenic diseases in patients of all ages.

Living-Donor Hepatectomy

BACKGROUND Organ transplantation from deceased donors is still far below the need. Because of this deficiency, liver transplantations are performed mostly from live donors in many transplant centers in our country. Living-donor liver transplantation (LDLT) has evolved dramatically over the past decade. The aim of this study was to present our clinical experience with living-donor hepatectomy. METHODS We retrospectively analyzed all patients who underwent donor hepatectomy between March 2000 and September 2010. We reviewed demographic data, operation type, operation and cold ischemia times, duration of hospital stay, and postoperative complications. RESULTS During the study period, 140 living donors underwent operations for liver transplantation. We performed 108 right hepatectomies, 17 left hepatectomies, and 15 left lateral hepatectomies. The mean age of the donors was 30.8 years. There was no operative or postoperative mortality. Overall morbidity rate was 13.57% (n = 19). Nine patients had biliary leakages, 4 biliomas; 2 urinary tract infections, and 1 each inferior vena caval injury, pneumonia, portal vein thrombosis, and acute tubular necrosis. Reoperation was not required in any of these patients. CONCLUSIONS Living-donor liver transplantation is a valuable alternative for patients awaiting a cadaver organ. Live-donor hepatectomy can be performed with low morbidity. The greatest disadvantage of this procedure is the risk of the surgical operation for the individual who will experience no medical benefit from this procedure.

Could the use of interposition grafts for arterial reconstruction be avoided by more caudate graft placement in living donor liver transplantation

One of the major challenges in living donor liver transplantation (LDLT) is short and small vessels (particularly the hepatic artery), particularly in segmental liver grafts from living donors. In the present study we report an alternative surgical technique that avoids interpositional vessel grafts or tension on the connection by anastomizing the allograft hepatic vein to the recipient inferior vena cava in a more caudate location. From March 2000 to January 2003, 28 patients (11 women/17 men) underwent 28 LDLT. Until June 2001, the preferred technique for hepatic vein anastomosis was end-to-end anastomosis between the allograft hepatic vein and the recipient hepatic vein (HV-HV) (n = 10). Thereafter an end-to-side anastomosis was performed between allograft hepatic vein and recipient inferior vena cava (HV-IVC) (n = 18). The level of venotomy on the recipient vena cava was decided according to the pre-anastomotic placement of the allograft in the recipient hepatectomy site with sufficient width to have an hepatic artery anastomosis without tension or need for an interposition graft during hepatic artery and portal vein anastomoses. Except the right lobe allograft with anterior and posterior portal branches, all portal and hepatic artery anastomoses were constructed without an interposition graft or tension in the HV-IVC group. Only one hepatic artery thrombosis developed in the HV-IVC group. As a result, this technique may avoid both hepatic artery thrombosis and the use of interposition grafts in living donor liver transplantation.