Mahir Kirnap

Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis.

BACKGROUND In low-risk patients with acute cholecystitis who did not respond to nonoperative treatment, we prospectively compared treatment with emergency laparoscopic cholecystectomy or percutaneous transhepatic cholecystostomy followed by delayed cholecystectomy. METHODS In 91 patients (American Society of Anesthesiologists class I or II) who had symptoms of acute cholecystitis ≥72 hours at hospital admission and who did not respond to nonoperative treatment (48 hours), 48 patients were treated with emergency laparoscopic cholecystectomy and 43 patients were treated with delayed cholecystectomy at ≥4 weeks after insertion of a percutaneous transhepatic cholecystostomy catheter. After initial treatment, the patients were followed up for 23 months on average (range 7-29). RESULT Compared with the patients who had emergency laparoscopic cholecystectomy, the patients who were treated with percutaneous transhepatic cholecystostomy and delayed cholecystectomy had a lower frequency of conversion to open surgery [19 (40%) vs 8 (19%); P=0.029], a frequency of intraoperative bleeding ≥100 mL [16 (33%) vs 4 (9%); P=0.006], a mean postoperative hospital stay (5.3+/-3.3 vs 3.0+/-2.4 days; P=0.001), and a frequency of complications [17 (35%) vs 4 (9%); P=0.003]. CONCLUSION In patients with acute cholecystitis who presented to the hospital ≥72 hours after symptom onset and did not respond to nonoperative treatment for 48 hours, percutaneous transhepatic cholecystostomy with delayed laparoscopic cholecystectomy produced better outcomes and fewer complications than emergency laparoscopic cholecystectomy.

Biliary Complications After Pediatric Liver Transplantation

OBJECTIVES After liver transplantation, biliary complications are more prevalent in pediatric patients, with reported rates varying between 15% and 30%. METHODS We retrospectively analyzed biliary complications observed in 84 pediatric liver transplantation patients between July 2006 and September 2012. Biliary reconstruction was accomplished via a duct-to-duct anastomosis in 5 (83.3%) of the 6 patients receiving whole liver grafts and in 44 (56.4%) of the 78 patients who received a segmental live donor graft. For the remaining 34 patients with living donor and 1 patient with whole liver graft, Roux-en-Y hepaticojejunostomy was the preferred method. RESULTS Post-transplantation biliary complications were encountered in 26 patients (30.1%). The biliary complication rate was 38% in 49 duct-to-duct anastomosis, whereas it was 20% in the hepaticojejunostomy group consisting of 35 recipients. Thirteen of the 18 biliary leaks were from duct-to-duct anastomoses and the remaining 5 were from the hepaticojejunostomies and 6 of the 8 biliary strictures were observed in recipients with duct-to-duct anastomosis. In 19 of the 26 patients, the biliary complications were successfully treated with interventional radiologic procedures and 1 was treated with stent placement during endoscopic retrograde cholangiopancreatography. CONCLUSIONS Percutaneous interventional procedures are valuable, effective, and life-saving therapeutic alternatives for the treatment of bile leaks and strictures after pediatric liver transplantations.

Effect of static magnetic field on experimental dermal wound strength.

Context: An animal model. Aim: We sought to evaluate the effect of static magnetic fields on cutaneous wound healing. Materials and Methods: Male Wistar rats were used. Wounds were created on the backs of all rats. Forty of these animals (M group) had NeFeB magnets placed in contact with the incisions, either parallel (Pa) and perpendicular (Pr) to the incision. The other 40 animals (sham [S] group) had nonmagnetized NeFeB bars placed in the same directions as the implanted animals. Half of the animals in each group were killed and assessed for healing on postoperative day 7 and the other half on postoperative day 14. The following assessments were done: gross healing, mechanical strength, and histopathology. Statistical Analysis Used: Intergroup differences were compared by using the Mann-Whitney U or t test. Values for P less than 0.05 were accepted as significant. Results and Conclusions: There were no differences between the magnetic and sham animals with respect to gross healing parameters. The mechanical strength was different between groups. On postoperative day 14, the MPr14 had significantly higher scores than the other groups. When static, high-power, magnetic fields are placed perpendicular to the wound, increased wound healing occurs in the skin of the experimental model.

The predictive value of resistive index obtained by Doppler ultrasonography early after renal transplantation on long‐term allograft function

DUSG is a useful diagnostic tool for the follow‐up of renal transplant recipients. The measurement of intrarenal arterial RI by DUSG has been proven to predict short‐term AF. The aim of the study was to evaluate the predictive value of DUSG performed during the early after RTx on long‐term AF. Seventy patients were enrolled into study. DUSG was performed at third and seventh days after RTx. Patients were divided into two groups according to rate of recovery of graft function as patients with normal graft function and abnormal graft function. Although the RI values were correlated with the AF early after transplantation, they were not correlated with long‐term AF. However, the rate of recovery of graft function at early period after RTx was correlated with creatinine level at first year and with glomerular filtration rate at first year and last visit. Although the RI has no predictive value for long‐term AF, the rate of recovery of graft function at early post‐transplantation period has predictive value for long‐term AF; patients with higher RI values early after RTx should be followed carefully for the development of chronic allograft injury.

Cervical Carcinoma in a Renal Transplant Recipient: A Case Report.

A range of cancer types, at increased rates, is described in renal transplant recipients receiving immunosuppression. Aside from immunodeficiency, heightened medical surveillance for cancer, lifestyle, and other risk factors all play a role. Although the relation between cancer risk and degree of immunodeficiency might not be linear, and might be different for a wide range of cancer subtypes, human papillomavirus-related cancers in long-term transplant recipients may suggest the role of even modest immunosuppression, when present long enough. High-risk human papillomavirus types are recognized as the cause of cancer of the cervix. We report a 49-year-old female renal transplant recipient diagnosed with cervical squamous cell carcinoma, 5 years after the transplant. Based on this patient, we highlight difficulties in surgical approach and the importance of close clinical follow-up including regular gynecologic screening for cervical premalignant and malignant lesions.

Surgical Treatment for Ureteral Obstruction After Kidney Transplantation

Introduction Ureteral obstruction occurs in 2% to 10% of renal transplant patients postoperatively, usually presenting within the first few weeks or the first year. Ureteric ischemia is the most common cause, accounting for around 90% of occurrences. The first option for treatment is interventional radiological methods. Percutaneous therapy of ureteral strictures consists of balloon dilatation with or without temporary stenting. If all of these methods are unsuccessful, surgical treatment should be applied. We evaluate the outcomes of 5 patients who treated with surgical teqniques for ureteral obstruction. Materials and Methods Since November 1975, we performed 2646 RT procedures at two different centers by the same transplantation team. At our institution, we perform ureteral anastomoses by means of a corner saving technique. We performed 7 surgical procedures for ureteral obstructions. All patients with ureteral occlusion had recurrent urinary tract infection before surgical treatment and interventional radiological procedures were performed prior to surgery. Results Four of the patients were living donor kidney transplantation and 3 of them were deceased donor transplantation. Four of them were female. For 4 patients, the old ureteroneocystostomy was terminated and new ureteroneocystostomy was performed. In 1 patient, we performed native nephrectomy and end-to-side anastomosis between the native ureter and graft’s renal pelvis. In 2 patients, we performed ureteroureterostomy and side-to-side anastomosis between the native and graft ureters. During the surgical procedure, double J stent was placed in to the anastomosis and removed in the first month. After reconstruction procedure urinary tract infection did not occur. During the follow up period graft functions are normal. Conclusions Ureteral strictures are rare complications that can lead to graft loss. Prompt diagnosis and remedial treatment are vital to prevent graft loss. The interventional radiological methods are the first choice for treatment, surgical procedures should be performed in patients who do not benefit from these treatments.

Baskent University Expanded Criteria for Hepatocellular Carcinoma: The Importance of the Histopathological Features as a Part of the Evaluation Criteria for Liver Transplantation

Introduction Hepatocellular carcinoma (HCC) is the most common primary malignant tumor of the liver and is responsible for up to 90% of all liver tumors. Liver transplantation remains the best option for patients with HCC. This study aimed to determine the impact of the histopathological features of the primary tumor to the long-term outcome of liver transplants for HCC. Materials and Methods Among 554 liver transplants performed between 1988 and 2016, only 61 was for the treatment of HCC. All histopathological prognostic criteria such as tumor grade, tumor size, the number of tumor nodules, the presence of lymphovascular invasion (LVI), and tumor necrosis were reevaluated. Patients classified into 2 groups; Group 1: patients who underwent LT within Milan criteria, and Group 2: patients who underwent LT beyond Milan criteria. Also, we divided Group 2 patients into 2 subgroups; Group 2a: tumors with favorable histologic features, Group 2b: tumors with unfavorable histologic characteristics. The mean follow-up time was 89.7±47 months. Results The histopathological mean tumor diameter was found 3.2 ±2.1 cm (1-9 cm) in 61 (M/F: 52/9) patients. Total 24 recipients died because of HCC at a mean time of 38.8 ±25 months posttransplant. The disease-free survival found to decrease with the increasing degree of grade and tumor size (p<.01). A tumor size >5 cm showed significant correlation with tumor recurrence and lower survival (p<.05).Patients who had LVI and also tumor necrosis tended to show lower survival (p<.01). The mean survival of Group 1 and Group 2 were 111.4±42 and 72.5±43.7 months, respectively. Overall 10-year survival was 76% and 43% for Group 1 and Group 2, respectively (p<.05). Overall 10-year survival was 75% and 28% for Group 2a and Group 2b, respectively (p<.01). Overall 10-year survival rates of Group 1 and Group 2a were similar to each other (p>.05).Whereas patients in Group 2b with unfavorable histology showed poorer prognosis compared to patients who did not have these histopathological parameters (p<.01). Discussion Based on our results; we propose an algorithm to evaluate HCC for the decision of transplant. If HCC radiologically classified as “within Milan”, transplantation could be the treatment modality. If HCC classified as “beyond Milan”, a liver biopsy should be performed. If the histopathological characteristics were favorable, the treatment modality should be the same as tumors classified “within Milan”. If the tumor has unfavorable histologic characteristics, transplantation option could be still beneficial and curative for at least 50% of the patients in 5 years and 28% of the patients in 10 years. Conclusion Tumor biology is the most critical parameter that predicts the survival of patients with HCC and the histopathological parameters must take part in the selection criteria of the patients for LT.

Improvement of Cardiac Functions After Renal Transplantation in Patients with Severe Cardiac Risk: Long Term Follow-Up

Introduction Chronic kidney disease (CKD) has increased risk for cardiovascular morbidity and mortality. CKD evokes structural and functional cardiac changes such as left ventricular hypertrophy (LVH), LV dilatation, LV systolic and diastolic dysfunction. Increased blood pressure, volume overload and in particular the uremic milieu with its toxins contribute to these alterations. Restoration of renal function after renal transplantation (RT) disrupts the negative cardiorenal interplay and may reverse some of the cardiac changes seen with CKD. The surgical procedure is risky in these patients but RTX reduces cardiac mortality and the risk for development of chronic heart failure compared with long-term dialysis. We presented the patients with high cardiovascular risk and the success of renal transplantation on the cardiac functions. Materials and Methods Thirteen RT patients who had severe cardiac risk were evaluated by echocardiography before and after RT. Left ventricular diastolic diameter, systolic diameter, and ejection fraction (%) were assessed by echocardiographic standard parameters. Results Mean transplantation age was 12.4±4.2 years and mean follow-up period 28.2±15.3months after transplantation of thirteen patients (F/M:7/6). There was a statistically significant improvement (p<.01) in all cardiac parameters. Preoperative mean ejection fraction (EF) significantly increased after RT within six months (34.4±9.1%, 68.4±7.6% respectively, p<.01). Preoperative mean left ventricular diastolic diameter (LVDD) and mean systolic diameter (SD) were significantly decreased, after RT within six months (53.8±8.8 vs 40.6±8.5 and 44.7±8.6, vs 25.5±7.4 respectively, p<.01). There were 11 patients (90.9%) received multiple antihypertensive treatment before transplantation. Only 2 patients (15.3%) needed antihypertensive treatment after transplantation. After RT, serum creatinine level was 0.56±0.11 (0.5-1.06) mg/dl and glomerular filtration rate was 102.38±23.29 (51-126) ml/min/1.73 m2 in the sixth month. Conclusions Cardiac functions improve markedly and rapidly in ESRD patients with severe cardiac risk after renal transplantation. We suggest that although the surgical procedure is risky, RT should be considered the treatment of choice for these patients, because longer duration of dialysis in these patients may result in progressive and ultimately irreversible myocardial dysfunction.

Manual Computed Tomography Liver Volumetry: Can It Be Done Faster?

Introduction CT volumetry has been widely used in the preoperative volumetric assessment of the liver for liver transplantation. CT volumetry has been traditionally performed by manual tracing of the hepatic contours and summation of the liver area on each axial section with a slice thickness of 10 mm. Despite the fact that the long calculation time in manual methods, automated and semiautomated methods have been carried out. The aim of this study was to evaluate the efficiency of manual CT volumetry with a slice thickness of 20 mm through the comparison of total liver volume results with a slice thickness of 10 mm and comparison of both techniques with real graft weight. Materials and Methods From 2013-2017, 75 adult liver donors (41 men and 34 women) with a mean age of 33.6 years (range, 19-65 years) underwent CT with a 16-section multidetector row CT scanner after intravenous injection of a contrast material. Two image sets axial section with slice thickness 10 mm and 20 mm were used. An abdominal radiologist reviewed all images on a workstation. The graft volumetric data were examined in 3 groups: right liver lobe, left liver lobe and left lateral liver lobe . There were 16,13 and 43 patients in groups, respectively. 75 total liver volume data from both data sets were compared with Wilcoxon test and graft volumetric data were compared with Friedman test. Results The mean whole liver volumes estimated with CT were 1373 cm3 from 10 mm images, 1364 cm3 from 20 mm images. The difference for total liver volumes calculated from 10 mm and 20 mm were not statistically significant (P >.05). The partial liver volumes of right lobes, left lobes, and lateral segments were evaluated in a similar manner. There were no statistically significant difference in comparison of both technique. In Friedman analysis when both technique compared with the real weight in the results for left lateral lobes, the real weight of the grafts are significantly larger than the volume calculated from 10 mm and 20 mm images (p<.01). Preoperative calculations of total liver and graft volume according to CT volumetry from 20 mm images did not yield statistically significant over- or under-estimations when compared to the CT volumetry from 10 mm images. Conclusion In conclusion, slice thickness of 20 mm in manual CT volumetry can be used as an alternative, time consuming method instead of the thinner slice thickness volumetric data.

Shear Wave Elastography Findings of Achilles Tendons in Patients on Chronic Hemodialysis and Patients with renal Transplantation

Introduction Achilles tendon which was comprised of tendinous parts of gastrocnemius and soleus muscles is the strongest and the largest tendon in the human body. Chronic renal disease is related to reduced physical activity, exercise capacity. Spontaneous rupture of achilles tendon have been reported in patients with chronic renal disease and degeneratif changes, recurrent microtraumas, hypoxia, chronic acidosis are predisposing factors. The aim of the study is to assess the degeneration of achilles tendon by shear wave elastography to compare the elastographic findings of Achilles tendons in patients on chronic hemodialysis, patients with renal transplantation and healthy adults. Materials and Methods Twenty-five patients who were on chronic hemodialysis at least 5 years, twenty-five renal transplant patients and twenty-five healthy controls were included in this study. The thickness and shear wave velocity (SWV) of the middle thirds of the achilles tendons were measured bilaterally. Results The mean SWV of right achilles was 3,67 cm/sn left achilles was 3,64 cm/sn in hemodialysis group. The mean SWV of right achilles was 4,29 cm/sn left achilles was 4,25 cm/sn in renal transplant group. The mean SWV of right achilles was 6,68 cm/sn left achilles was 6,59 cm/sn in control group. There was a statistically significant difference between the SWVs of hemodialysis group, renal transplant group and control group (p<0,005). Conclusion The achilles tendons in patients with chronic renal failure were softer than in patients with renal transplantation and control group. Chronic tendinopathy cause softening and weakening of the tendon. In the renal transplant group stiffness of the achilles tendon was increased with respect to hemodialysis group but still softer than the control group which could be explained by the positive clinical effect of renal transplantation. In conclusion shear wave elastography is an objective, easy, noninvasive, method that can asssess tendinopathy.