Kaya Yorganci

Surgical treatment of hydatid cysts of the liver in the era of percutaneous treatment

BACKGROUND Although surgery is the recommended treatment for liver hydatid disease, percutaneous treatment has been introduced as an alternative to surgery. No previous studies have been reported for patients who have not been suitable for percutaneous treatment and undergone surgery. The aim if this study was therefore to evaluate the patients who have liver hydatid disease and not suitable for percutaneous treatment and to determine the effectiveness of different types of surgical interventions in these patients. PATIENTS AND METHODS Ninety-five patients who underwent operations for liver hydatid disease were retrospectively reviewed. All patients were radiologically evaluated before surgery for possible percutaneous treatment. Besides other related factors, conventional and radical surgical approaches were compared in terms of complication and recurrence rate. RESULTS Overall complication and recurrence rates were 40% and 25%, respectively. Conventional surgical approaches and common bile duct exploration were significantly associated with an increased complication and recurrence rate. CONCLUSIONS Selection of simple liver hydatid cysts for percutaneous treatment had led us to operate more difficult and complicated cases. It seems that routine use of endoscopic retrograde cholangiography in the preoperative period and more efforts to perform radical procedures are two major determinants in the successful treatment of theses complicated cases.

In vitro evaluation of the antibacterial activity of three different central venous catheters against gram-positive bacteria

Abstract.The aim of this study was to evaluate the activity of three different catheters against Staphylococcus aureus ATCC 29213 and the slime-producing Staphylococcus epidermidis ATCC 35984 (RP62A). Three central venous catheters were evaluated: one impregnated with silver sulfadiazine–chlorhexidine, one to which minocycline/rifampin is bonded and a novel one into which silver, platinum and carbon are incorporated. A nonantiseptic catheter was used as the control catheter. One-centimeter trisected pieces of catheter were immersed in phosphate-buffered saline (0.01 mol/l) with 0.25% dextrose and incubated. On days 1, 3, 7, 14 and 21, a 1 ml standardized inoculum was added for 30 min and then replaced with phosphate-buffered saline with 0.25% dextrose. One-third of the samples were immediately sonicated and plated to determine bacterial adherence. The remaining segments were incubated for 4 and 24 h to determine the persistence of bacterial adherence. Bacterial adherence to the catheters impregnated with silver sulfadiazine-chlorhexidine was reduced 91–98% for the first 7 days. Adherence of Staphylococcus aureus to catheters into which silver, platinum and carbon are incorporated was reduced 70% on day 1 and 35% on day 3. Adherence to minocycline/rifampin-bonded catheters was quite variable. There was an 85.6–99.8% reduction in the persistence of bacterial adherence to the three catheters compared to controls. Bacteriostatic and bactericidal studies indicated that the effluents from the catheters impregnated with silver sulfadiazine-chlorhexidine were bactericidal, while effluents from the minocycline/rifampin-bonded catheters were bacteriostatic. The antibacterial activity of the effluents from catheters impregnated with silver sulfadiazine-chlorhexidine dissipated by day 7, while the activity of effluents from the minocycline/rifampin-bonded catheters continued to show activity at day 21. No measurable antibacterial activity was detected in the effluents of the catheters into which silver, platinum and carbon are incorporated. These data suggest that catheters coated with antibiotic/antibacterial agents and the novel catheters that incorporate antiseptic agents have different activities against initial bacterial adherence. All of them, however, effectively prevent bacterial colonization by gram-positive bacteria.

Antibacterial activity of triclosan chitosan coated graft on hernia graft infection model

The use of mesh in hernia repair has become common, because of lower recurrence rate and simple application. Data from the meta-analysis and the multi-central studies support the use of meshes in hernia repair. One of the complications due to the hernia repair with mesh is the infection. The incidence range is between 1 and 10%. Triclosan embedded commercial absorbable suture materials are used to reduce surgical site infection rate. This study was planned on mesh infection model, because of the low incidence rate. The agent isolated from mesh infections was mostly Staphylococcus aureus and thus it was used as the infecting agent in this research. To achieve a better therapeutic efficacy, triclosan was formulated in chitosan gels. Chitosan is an attractive biopolymer because of its biocompatible, biodegradable, bioadhesive properties. Gel formulations using chitosans (low, medium and high molecular weight) were prepared in 1% (v/v) acetic acid solution and in vitro release profiles were evaluated. Gel formulations showed release profile extended up to 7 days and high molecular weight chitosan gel formulation was released higher quantity drug than other formulations. Meshes coated with triclosan loaded chitosan gel were used to reduce bacterial count and to prevent mesh infection in the study. 24h and simultaneous bacteria inoculation was used to model mesh infection. The rats were observed for 8 days by means of surgical site infection. On the eighth day, the animals were sacrificed and the grafts were removed. Tissue squeezers were used to liberate bacterias from removed grafts. The isolated suspensions were cultured on blood agar plates and colony-forming units were counted overnight. Grafts coated with triclosan loaded chitosan gel presented satisfactory preventive effect against graft infection.

An Experimental Study of the Adhesive Potential of Different Meshes

OBJECTIVE To assess the adhesive potential and incidence of incisional hernia with three meshes. DESIGN Open experimental study. SETTING Surgical Research Laboratory, Turkey. ANIMALS 75 Wistar albino rats INTERVENTIONS Abdominal walls were excised, and defects closed primarily or with polyglactin 910, polypropylene, or dura mater. Adhesions were graded and hydroxyproline concentrations measured on days 14 and 180. On day 180, the incidence of incisional hernia, and the grades of inflammation and fibrosis were also recorded. RESULTS The polyglactin 910 group had a higher adhesion grading than the control and dura mater groups on day 14, whereas the polypropylene group had higher adhesion grading than controls. Both polypropylene and polyglactin 910 groups had significantly higher concentration of hydroxyproline than the control and dura mater groups. On day 180, the polypropylene group had a higher adhesion grading than the controls. There were no differences in hydroxyproline concentrations, incidence of hernias, or grading of fibrosis levels among the groups. CONCLUSION Polyglactin 910 induced more fibrotic adhesions in the early postoperative period whereas polypropylene did in both the early and late postoperative periods.

Endotoxin Challenge Causes a Proinflammatory State in Obstructive Jaundice

The aim of this study was to investigate the relationship between the obstructive jaundice-induced cellular immune suppression and endotoxin challenge with respect to the levels of tumor necrosis factor (TNF), interleukin-10 (IL-10), and interleukin-2 (IL-2). Rats underwent either bile duct ligation or sham operation. At 21 days, all rats were challenged either with lipopolysaccharide (LPS) or saline. In the sham-operated group LPS injection significantly increased TNF levels at 90 min. The common bile duct ligated group showed a significant increase in TNF levels compared with all other groups, including the sham-operated, LPS-injected group, at 90 min. At 180 min following LPS challenge, TNF levels decreased, and there was no difference between any of the LPS-challenged groups at 180 min and any of the saline groups at either 90 or 180 min. In the sham-operated group, LPS injection significantly increased IL-10 levels at both 90 and 180 min. In the bile duct ligated group, LPS injection significantly increased IL-10 levels compared with saline injection at both 90 and 180 min. On the other hand, bile duct ligated animals had significantly less increase in IL-10 levels following LPS challenge at 90 min but not at 180 min. In common bile duct ligated rats, LPS challenge induced a significantly greater increase in IL-2 levels compared with all other groups. In conclusion, in the presence of obstructive jaundice, endotoxemia primes a more vigorous inflammatory response despite cellular immune depression.

Visualizing multiple organ failure: a method for analyzing temporal and dynamic relations between failing systems and interventions.

Multiple organ failure is the common clinical course of critical patients who have prolonged stay in the

Detrimental Effects of Nitric Oxide on Mesenteric Circulation during Endotoxaemia and its Reversal by Aminoguanidine

OBJECTIVE To investigate the effect of endotoxaemia on rat mesenteric vascular bed and plasma nitrite concentrations, the possible beneficial effect of aminoguanidine (the selective inducible nitric oxide synthase inhibitor) compared with N(G)-nitro-L-arginine methyl ester (L-NAME) (non-selective nitric oxide synthase inhibitor). DESIGN Randomised experiment. SETTING University surgical research laboratory, Turkey. SUBJECTS 75 Wistar rats. INTERVENTIONS Rats were divided into control (n = 30) and endotoxaemia (n = 42) groups. Endotoxaemia was produced by intraperitoneal injection of lipopolysaccharide 20 mg/kg. Subgroups were given either aminoguanidine or L-NAME. MAIN OUTCOME MEASURES After 4 hours, isolated perfused mesenteric preparations were obtained and pressor responses to phenylephrine and vasodilatation responses to acetylcholine were evaluated, and plasma nitrite concentrations measured. RESULTS Pressor response to phenylephrine did not alter but vasodilatation in response to acetylcholine was significantly reduced during endotoxaemia. Pretreatment with aminoguanidine prevented the impairment of the response to acetylcholine. However, L-NAME was ineffective. In the control group, aminoguanidine and L-NAME did not alter the vascular reactivity. The baseline plasma nitrite concentrations in the control group were increased 5-fold during endotoxaemia. This increase was significantly reduced with aminoguanidine but not with L-NAME. CONCLUSION The protection achieved by aminoguanidine but not L-NAME suggested that nitric oxide produced by inducible nitric oxide synthase had a role in the impairment of endothelial response during endotoxaemia, and confirmed the importance of selective inducible nitric oxide synthase inhibition to achieve beneficial effects in endotoxaemia.

Effects of Aminoguanidine and N ω -nitro-L-arginine Methyl Ester on Vascular Hyporeactivity Induced by Endotoxaemia

OBJECTIVE To investigate the effects of endotoxaemia on the reactivity of the aortic bed in rats, and to compare the effects of the nitric oxide (NO) synthase inhibitors aminoguanidine and N(omega)-nitro-L-arginine methyl ester (L-NAME), on endotoxaemia-induced changes in vascular reactivity. DESIGN Randomised experiment. SETTING University laboratory, Turkey. SUBJECTS 54 Wistar rats. INTERVENTIONS Rats were divided into control (n = 24) and endotoxaemia (n = 30) groups and were treated with an intraperitoneal injection of saline (control) and lipopolysaccharide (20 mg/kg), respectively. Subgroups of control and endotoxaemic rats were given either aminoguanidine or L-NAME by the same route. MAIN OUTCOME MEASURES Contractile responses to phenylephrine and relaxation responses to acetylcholine 4 hours after treatment. RESULTS Incubation with aminoguanidine and L-NAME potentiated the phenylephrine-induced contractile response and inhibited acetylcholine-induced relaxation in aortic rings in the control group. The vascular responses to phenylephrine and acetylcholine were less pronounced in the endotoxaemia group, and in vitro incubation with aminoguanidine and L-NAME partially restored the contraction induced by phenylephrine but did not affect the impaired response to acetylcholine. Aminoguanidine given in vivo prevented the impairment of vascular responses to both phenylephrine and acetylcholine whereas L-NAME gave no such protection. CONCLUSION Aminoguanidine acted similarly to L-NAME when incubated with the tissues in vitro, and did not show selectivity to inducible compared with constitutive isoforms of NO synthase. The finding that aminoguanidine but not L-NAME, prevented the endotoxin-induced impairment of vascular reactivity when administrated in vivo, therefore, suggested a role other than inhibition of NO synthase.

Comment on Hamada et al.: Ultrasound assessment of gastric volume in critically ill patients.

Dear Editor, We read with great interest Hamada et al.’s article [1] on ultrasound assessment of gastric volume in critically ill patients. Their study population comprised mostly trauma patients (49 %) and patients with abdominal diseases (9 %). Additionally, patients in whom the gastric volume measurements were performed with ultrasonography (USG) were trauma patients or they had suspected abdominal pathology so they were scheduled to have a computed tomography (CT) scan. In this study by Hamada et al., gastric volume assessment with CT scanning after USG assessment took 23–44 min (mean 31 min). The gastric emptying time for liquids in healthy people is approximately 12 min and for solid food it is approximately 2 h depending on the food contents [2, 3]. Because of the time period between USG assessment and CT scanning, a disparity is expected to occur between the measurements; however, in Hamada et al.’s study there is a consistency between the measurements that can be attributed to the study population being intensive care unit patients with delayed gastric emptying [4, 5]. As was mentioned above, in the study by Hamada et al., the patients who underwent a CT scan were suspected of having an abdominal pathology. Patients were assessed with the simplified acute physiology score II (SAPS II) (IQR 17–57) and injury severity score (ISS) (IQR 11–57). However in the article there is no information about the CT determinations. The abdominal pathology of patients and its severity are not mentioned in the article. We can not estimate how these abdominal pathologies can effect gastric emptying with these SAPS II and ISS scores. In conclusion, Hamada et al.’s study is worthy because of its patient population being intensive care unit patients, especially trauma patients which have not been studied before. In other studies of the gastric volume assessment with USG, healthy volunteers were assessed. If the present pathologies of these intensive care unit patients are classified and the effect of these pathologies on the gastric emptying is assessed, in our opinion the effective use of USG for gastric volume measurement may improve.

Changes in the Frequencies of Abdominal Wall Hernias and the Preferences for Their Repair: A Multicenter National Study From Turkey

Abdominal wall hernias are a common problem in the general population. A Western estimate reveals that the lifetime risk of developing a hernia is about 2%.1–3 As a result, hernia repairs likely comprise the most frequent general surgery operations. More than 20 million hernias are estimated to be repaired every year around the world.4 Numerous repair techniques have been described to date however tension-free mesh repairs are widely used today because of their low hernia recurrence rates. Nevertheless, there are some ongoing debates regarding the ideal approach (open or laparoscopic),5,6 the ideal anesthesia (general, local, or regional),7,8 and the ideal mesh (standard polypropylene or newer meshes).9,10