Mehmet Fatih Can

Multicenter prospective randomized trial comparing modified Limberg flap transposition and Karydakis flap reconstruction in patients with sacrococcygeal pilonidal disease

BACKGROUND There is still no consensus as to the optimal treatment for sacrococcygeal pilonidal disease (SPD). Many recommend off-midline closure, if any excisional procedure is to be selected. METHODS The authors prospectively studied 145 patients with SPD who presented at 3 hospitals. Patients were randomly assigned to undergo either modified Limberg flap (MLF) transposition (n = 72) or Karydakis flap reconstruction (n = 73). Surgical findings, complications, recurrence rates, and degree of patient satisfaction, evaluated via a standardized telephone interview, were compared. RESULTS Operation time was longer in the MLF group. There were no significant differences between the two groups in terms of complication rate, length of stay, or recurrence rate. Patients in the Karydakis group reported feeling completely healed more quickly postoperatively. The two groups reported similar rates of satisfaction. Mandatory patient withdrawal from a given study arm because of the orifice straying from the midline occurred more frequently in the Karydakis group. CONCLUSIONS The MLF technique and the Karydakis procedure appear to generate comparable outcomes. With laterally situated orifices, however, the applicability of the Karydakis method may be limited.

Preoperative administration of oral carbohydrate-rich solutions: Comparison of glucometabolic responses and tolerability between patients with and without insulin resistance

OBJECTIVE Preoperative carbohydrate loading with clear fluids is thought to reduce surgery-related insulin resistance (IR). However, IR per se is already present in some patients scheduled for elective surgery. Data on the safety of preoperative oral carbohydrate loading in patients with IR undergoing surgery is lacking. We aimed to evaluate the effects of preoperative carbohydrate loading on the glucometabolic state and gastric content of patients with and without IR. METHODS Thirty-four non-diabetics received 800 mL of a special carbohydrate-containing drink on the evening before the operation and then 400 mL 2 h before surgery. Blood samples for glucose, insulin, and cortisol levels were taken immediately before the second dose, at 40 and 90 min after intake of the drink, and at the onset of surgery. Patients with a homeostasis model assessment IR score >2.5 were considered to have IR. The differences between patients with and without IR were then evaluated. RESULTS Eight of the 34 patients had IR and the remaining 26 did not. Glucose levels in the IR group were higher than those in the non-IR group, but the differences did not reach significance. The initially elevated insulin concentrations then tended to decrease to the corresponding levels detected in the non-IR group. The cortisol concentrations were similar in both groups. CONCLUSION Patients with IR receiving a carbohydrate-rich drink before surgery appear not to be affected adversely by the beverage. Furthermore, they also obtain the probable beneficial effects related to these drinks and, like patients without IR, can undergo surgery safely.

Systematic Review of Studies Investigating Sentinel Node Navigation Surgery and Lymphatic Mapping for Gastric Cancer

Evolutions in minimally invasive surgical techniques and advances in sentinel node navigation surgery (SNNS) have had considerable impact on current insights into surgical treatment of gastric cancer. Extensive data on this method of surgical application have accumulated but have been principally derived from single-institute studies. Isosulfan blue and patent blue violet have been the most frequently used dye tracers in the past; however, indocyanine green has now is increasingly popular. The double-tracer method, where dye and radioisotope tracers are used together, seems to be more effective than any single tracer. Among newly emerging adjunct techniques and promising alternative in particular are infrared ray electronic endoscopy, florescence imaging, nanoparticles, and near-infrared technology. Hematoxylin and eosin (H&E) staining is still the method of choice for the detection of sentinel lymph node (SLN) metastases. Immunohistochemical staining can be used to support H&E findings, but the equipment costs of ultrarapid processing systems are currently slowing down their worldwide spread. We believe minimally invasive function-preserving resection of the stomach, together with lymphatic basin dissection navigated by SLNs, can represent the ideal approach for SNNS to detect clinically node-negative early gastric cancer, although this remains to be elucidated. Patients with cT3 or more advanced disease should still be treated by means of standard D2 dissection.

Sentinel lymph node biopsy for gastric cancer: Where do we stand?

Development of sentinel node navigation surgery (SNNS) and advances in minimally invasive surgical techniques have greatly shaped the modern day approach to gastric cancer surgery. An extensive body of knowledge now exists on this type of clinical application but is principally composed of single institute studies. Certain dye tracers, such as isosulfan blue or patent blue violet, have been widely utilized with a notable amount of success; however, indocyanine green is gaining popularity. The double tracer method, a synchronized use of dye and radio-isotope tracers, appears to be superior to any of the dyes alone. In the meantime, the concepts of infrared ray electronic endoscopy, florescence imaging, nanoparticles and near-infrared technology are emerging as particularly promising alternative techniques. Hematoxylin and eosin staining remains the main method for the detection of sentinel lymph node (SLN) metastases. Several specialized centers have begun to employ immunohistochemical staining for this type of clinical analysis but the equipment costs involving the associated ultra-rapid processing systems is limiting its widespread application. Laparoscopic function-preserving resection of primary tumor from the stomach in conjunction with lymphatic basin dissection navigated by SLN identification represents the current paramount of SNNS for early gastric cancer. Patients with cT3 stage or higher still require standard D(2) dissection.

Comparison of Urografin versus standard therapy in postoperative small bowel obstruction.

Water-soluble contrast media (Urografin) cause redistribution of intravascular and extracellular fluid into intestinal lumen due to their hyperosmolarity. As a consequence, these media decrease intestinal wall edema and act as a direct stimulant to intestinal peristalsis. In this prospective study, we aimed to examine objectively the therapeutic role and ability of Urografin in patients with postoperative small bowel obstruction for whom failed to respond to conservative treatment. Three hundred and seventeen patients with postoperative small bowel obstruction due to intraperitoneal adhesions were included prospectively in this study. In the Urografin group, 40 mL Urografin diluted in 40 mL distilled water was administered through the nasogastric tube. No contrast media were administered in the control group, but the patients were decompressed via a nasogastric tube continuously. The number of obstruction episode in 317 patients was 338. In total, 199 patients were in the Urografin group, and 118 patients were in the control group. In the Urografin group, 178 (89.4%) patients responded successfully to the treatment, but 21 (11.6%) patients underwent surgical operation. Intensive intraabdominal adhesions and obstructing fibrous bands were observed and repaired in 15 (71.4%) patients at the operation, while 6 patients underwent segmental small intestine resection in control group, conventional management was successful in only 89 (75.4%) patients, and the remaining 29 (24.6%) patients underwent surgical intervention. In conclusion, it was suggested that in patients with intestinal obstruction due to postoperative intra-abdominal adhesion, water-soluble contrast media such as Urografin may be safely administered via a nasogastric tube or oral route and may decrease the need for surgical operation; furthermore, they may help the physician to operate the patients who needs surgery as early as possible.

Invasive Pulmonary Aspergillosis after Liver Transplantation: Rapid and Complete Response to Combined and Sequential Antifungal Therapy

BACKGROUND Invasive pulmonary aspergillosis is a rare, but severe and potentially fatal, complication after liver transplantation. There is no therapeutic regimen accepted worldwide for both initial and continuation therapy; nevertheless, several options have been proposed. METHODS Case report and review of the pertinent English-language literature. RESULTS In a patient with pulmonary aspergillosis after a liver transplant, combined and sequential therapy with caspofungin and voriconazole with termination of the immunosuppressive regimen and careful management were helpful to control the infection rapidly, possibly because of a positive drug interaction. CONCLUSION In cases of invasive aspergillosis that are refractory to monotherapy, this regimen may be used in an attempt to overcome the infection.

The effects of hyperbaric oxygen therapy on experimental colon anastomosis after preoperative chemoradiotherapy.

The aim of the present study was to investigate the effect of hyperbaric oxygen therapy (HBOT) on colon anastomosis after chemoradiotherapy (CRT). Sixty female Wistar-Albino rats were divided into 5 groups and underwent left colon resection and end-to-end anastomosis. CRT simulation was performed on 2 sham groups before the anastomosis, and 1 of these groups was administered additional postoperative HBOT. Two groups were administered CRT before the anastomosis, and 1 of them received additional postoperative HBOT. On postoperative day 5, all groups underwent relaparotomy; burst pressure was measured and samples were obtained for histopathologic and biochemical analysis. There was a significant weight loss in the CRT groups and postoperative HBOT had an improving effect. Significantly decreased burst pressure values increased up to the levels of the controls after HBOT. Hydroxyproline levels were elevated in all groups compared to the control group. Hydroxyproline levels decreased with HBOT after CRT. No significant difference was observed between the groups regarding fibrosis formation at the anastomosis site. However, regression was observed in fibrosis in the group receiving HBOT after CRT. Preoperative CRT affected anastomosis and wound healing unfavorably. These unfavorable effects were alleviated by postoperative HBOT. HBOT improved the mechanical and biochemical parameters of colon anastomosis in rats.

The effect of using an abdominal binder on postoperative gastrointestinal function, mobilization, pulmonary function, and pain in patients undergoing major abdominal surgery: A randomized controlled trial

BACKGROUND Evidence on the effectiveness of using a binder following abdominal surgery and its effect on gastrointestinal function, mobilization, pulmonary function, and pain is currently unclear. OBJECTIVE The purpose of this study is to determine the effect of abdominal binder usage on gastrointestinal function, mobilization, pulmonary function, and postoperative pain in patients undergoing major abdominal surgery. DESIGN This research was conducted as a randomized controlled trial. SETTINGS The study was conducted at the Department of General Surgery at a military education and research hospital in Ankara, Turkey, between September 2013 and April 2014. PARTICIPANTS 104 patients were assessed for eligibility. The study was conducted on 84 eligible patients. METHODS The study sample consisted of 84 patients who underwent effective major abdominal surgery. The patients were randomized into two groups, the intervention group, which used an abdominal binder and the control group, which did not. Gastrointestinal function, mobilization, pulmonary function, and the pain status of both groups were evaluated on the first, fourth, and seventh days before and after surgery, and the intergroup results were compared. RESULTS No significant difference was found between the two groups in terms of gastrointestinal and pulmonary function on the first, fourth, and seventh days following surgery (p>0.05). A comparative assessment of mobility by walking distance showed that patients in the intervention group were able to walk further on the fourth [mean (SD); 221.19 (69.08) m] and seventh [227.85 (60.02) m] days after surgery (p=0.003, p<0.001). There were differences in the acute pain status between patients in both groups (p<0.05). On the first [mean (SD); 8.80 (5.03)], fourth [4.83 (2.78)], and seventh [3.09 (3.17)] days after surgery, the sensory sub-scale pain scores were higher in the control group (p<0.001). On the first [mean (SD); 10.16 (6.14)], fourth [5.28 (3.52)], and seventh [3.30 (3.51)] days after surgery the total pain scores were higher in the control group (p<0.001). The visual analogue scale scores were also higher in the control group on the first [mean (SD) 6.26 (1.86)], fourth [4.50 (2.10)], and seventh [3.04 (2.43)] days after surgery (p<0.001). CONCLUSION The studys findings reveal that the use of an abdominal binder does not have any effect on postoperative gastrointestinal and pulmonary function. However, an abdominal binder increases patient mobility soon after surgery. There was also a measurable effect on pain, with lower scores reported by patients who used an abdominal binder after any exercise or activity. These results indicate that the use of a routine abdominal binder is helpful for patients undergoing major abdominal surgery.

The Effect of Gained Experience on Postoperative Complications and Mortality in Cadaveric Liver Transplantation: A Single-Center Experience

AIM Liver transplantation (OLT) has become the treatment of choice for end-stage liver failure, as well as for selected cases of malignancies and metabolic disorders. Decreased postoperative complications and mortality rates are expected to correlate with improvements in the interdisciplinary team approach, the perioperative anesthesiologic and intensive care management, and careful follow-up after transplantation. In this study, we have evaluated the effect of gained experience on postoperative complications and mortality in cadaveric OLT performed in our institution. MATERIALS AND METHODS Data from cadaveric OLT patients (n = 34) since 2003 were retrospectively evaluated. Patients were divided into 2 groups: Early (2003-2006; n = 15) and late (2007-2010; n = 19). Age, gender, cold and warm ischemia times, intraoperative transfusion rates, infectious complications, biliary and vascular complication rates, and early and late postoperative mortality rates were compared in the 2 groups. RESULTS The age and gender distribution was similar among both groups. Mean cold and warm ischemia times, intraoperative transfusion rates, and operative times were significantly lower in the late period group (P = .004, .012, and 0.008, respectively; CI=%95). T-tube usage was also significantly lower in the late period group (P < .001). There was no significant change for postoperative intensive care period (P = .404), but the overall length of stay in hospital was shorter for the patients in the late period group (P = .019). The nonsurgical early postoperative complication rate was lower (P = .001) and early postoperative mortality was nearly significant (P = .06) in patients who comprised the late period group. There was no difference in terms of biliary and vascular complication rates and overall survival rates between patients in the early and late groups (P = .664, .264, and .107, respectively). CONCLUSION Our results indicate that the institutional improvements toward an interdisciplinary team approach in cadaveric OLT correlate with better results in ischemia and operative times and lower intraoperative transfusion rates and hospital stays. Early postoperative complication and mortality rates were found to decline in parallel to the team experience.

Does the type of resuscitative fluid affect healing of colonic anastomosis in experimentally induced hemorrhagic shock in rats

Objective: The aim of the study was to investigate the effects of different resuscitative fluids on the healing of intestinal anastomosis in a hemorrhagic-shock rat model. Materials and Methods: Closed-colony Wistar male rats (n = 40; 8 rats per group) were subjected to volume-controlled hemorrhagic shock, followed by a 30-min shock phase. The animals were then resuscitated with one of the following fluids (which also corresponds to their respective groups): lactated Ringer’s solution (LR), hydroxyethyl starch (HES), 7.5% hypertonic saline (HS) and autologous blood (AB). There was also a control group (CL), which did not experience hemorrhagic shock or receive any resuscitative fluids. All rats underwent laparotomy, segmental resection and anastomosis of the left colon. Five days later, a 2nd laparotomy was performed and the anastomotic bursting pressure was measured in vivo. Thereafter, the anastomosed segment was resected to measure the tissue hydroxyproline level and the grade of anastomotic fibrosis. Results: All experimental groups (LR, HES, HS and AB) exhibited lower anastomotic bursting pressures than the CL group; however, nointergroup differences achieved statistical significance. The mean tissue hydroxyproline level and fibrosis grade also were similar across all 5 groups. Conclusion: In traumatic hemorrhagic shock, anastomosis safety does not appear to be affected by the type of fluid used for resuscitation. Moreover, LR, HES and HS all seemed to reinforce healing as effectively as transfused blood.