Murat Aksoy

Vascular Reconstruction in Buerger's Disease : Is it Feasible?

Abstract.Purpose: Thromboangiitis obliterans (Buergers disease) is a clinical syndrome characterized by segmental occlusions of the distal vessels. Although a cessation of using nicotine products usually helps, nevertheless a surgical revascularization may be needed in cases of stage III and IV limbs. Because of the distal and segmental nature of the disease, these procedures are rarely feasible. This article focuses on the feasibility of performing a vascular reconstruction in thromboangiitis obliterans. Methods: Thirty-six of 94 patients (38.3%) who were followed by the Peripheral Vascular Unit of Istanbul Medical Faculty were selected for revascularization and 27 of 36 (81%) patients underwent revascularization procedures. Results: During a 36-month follow-up, the patency rates at the 12th, 24th, and 36th months were 59.2%, 48%, and 33.3%, respectively. The limb salvage rate was 92.5%. Conclusions: Since patients affected by Buergers disease consist a group of young population who are still in their productive stages, every effort should be taken to obtain a limb salvage in the ischemic period. Although the patency rates do not seem promising, the limb salvation rate was quite satisfactory.

Major retroperitoneal vascular injuries during laparoscopic cholecystectomy and appendectomy.

BACKGROUND Serious complications may occur during laparoscopic surgery, as in any surgical procedure. Injuries of major retroperitoneal vascular structures are uncommon but important complications of laparoscopy. METHODS We report on 9 major vascular injuries in 8 patients in the course of 8 laparoscopic procedures between 1994 and 2002. RESULTS The primary operations were cholecystectomy in 7 patients and appendectomy in one patient. Six vascular injuries occurred during placement of the first umbilical trocar, two in the course of the insertion of a Veress needle, and one during the insertion of the second trocar. A laparotomy was performed immediately in all cases. Left common iliac arteries were injured in two patients, aorta in three patients, right common iliac vein in one patient, both right common iliac artery and vein in one patient, and inferior vena cava in one patient. Polytetrafluoroethylene (PTFE) graft interposition was employed in two common iliac arteries and a tubular PTFE graft in one aortic injury, and Dacron patchplasty in one common iliac artery injury. Two aortic, two common iliac vein, and an inferior vena cava injury were repaired primarily. There were also four visceral organ injuries, which were repaired primarily. The major retroperitoneal vascular complication rate was 0.07%. An average of 3.5 units of whole blood were transfused in each case and the average stay in hospital was 6.8 days. There was no mortality. CONCLUSIONS The surgeons experience and knowledge are the essential factors for prevention of major vascular injuries during laparoscopic procedures. In case of an injury, immediate laparotomy must be performed to achieve hemostasis and a surgeon who is familiar with vascular surgery should employ the definitive treatment.

Traumatic injuries to the subclavian and axillary arteries : A 13-year review

PurposeBy reviewing our experience, we evaluated the presentation, management, and long-term outcome of patients with subclavian and axillary artery injuries resulting from trauma.MethodsWe retrospectively reviewed the data of 38 patients who received treatment for subclavian or axillary artery injuries in the Emergency and Trauma Department of Medical Faculty of Istanbul, Istanbul University between January 1989 and July 2002.ResultsArterial injuries were repaired with an end-to-end anastomosis in 10 (26.3%) patients, primary repair in 6 (15.7%), autologous vein graft interposition in 16 (42%), ligation in 5 (13.1%), and a proximal subclavian-brachial artery bypass in 1 (2.6%). One (2.6%) of the arterial reconstructions failed in the perioperative period. Fourteen (36%) patients presented with a neurological deficit, which recovered after the intervention in 2 (5.2%) patients. A wound infection developed in 8 (21%) patients and 2 (5.2%) patients died of concomitant injuries. Thirteen (36.1%) of the remaining 36 patients were followed up for a mean period of 7 months.ConclusionSuccessful management of subclavian and axillary artery injuries requires prompt diagnosis because the occult nature of these injuries necessitates a high index of suspicion. Although revascularization procedures are often successful, it is the associated neurological, orthopedic, and soft tissue injuries that affect the functional outcome of the limb.

Vacuum assisted closure improves the quality of life in patients with diabetic foot.

Abstract Background : Diabetes Mellitus (DM) is the most common endocrine disease worldwide. One of the most important chronic complications of this disease is the development of diabetic foot. The management of diabetic foot wounds is quite important with respect to public health. Aims : To determine the effect of Vacuum Assisted Closure (VAC) therapy on the quality of life in the treatment of diabetic foot ulcers and compare it with standart wound care. Methods : Between May 2007 to December 2008, 67 consecutive patients with diabetic foot ulcers were randomly assigned to VAC therapy (Group1, n: 30) or standart wound care (Group 2, n: 37). The SF-36 questionnaire was administered the day before and in the month following wound healing. Global analyses of the 8 domains and 2 comprehensive indexes of SF-36, Physical Component Summary (PCS) and Mental Component Summary (MCS) were performed. Clinical measures included standard antidiabetic treatment, daily wound care including antiseptic bath, debridement, toe removal for gangrene when necessary, and wound care with conventional methods or VAC. Healing time was calculated as the time from hospital admission to the time of re-epithelization. Results : There were no differences in the mean age, ulcer size and pulse status of the patients in both groups. Healing time in the VAC group was significantly reduced (p < 0.05). All 8 domains of SF-36 and MCS and PCS scores improved remarkably after VAC therapy. Conclusion : Vacuum Assited Closure therapy was found to be effective in the treatment of chronic diabetic ulcers. The improvement of quality of life demonstrates a clear-cut indication in this particular group of patients.

Pathogens Isolated From Deep Soft Tissue and Bone in Patients With Diabetic Foot Infections

BACKGROUND We sought to determine the similarity of pathogens isolated from soft tissue and bone in patients with diabetic foot infections. It is widely believed that soft-tissue cultures are adequate in the determination of causative bacteria in patients with diabetic foot osteomyelitis. The culture results of specimens taken concurrently from soft-tissue and bone infections show that the former does not predict the latter with sufficient reliability. We sought to determine the similarity of pathogens isolated from soft tissue and bone in patients with diabetic foot infections. METHODS Forty-five patients with diabetic foot infections were enrolled in the study. Patients had to have clinically suspected foot lesions of grade 3 or higher on the Wagner classification system. In patients with clinically suspected osteomyelitis, magnetic resonance imaging, scintigraphy, or histopathologic examination were performed. Bone and deep soft tissue specimens were obtained from all patients by open surgical procedures under aseptic conditions during debridement or amputation. The specimens were compared only with the other specimens taken from the same patients. RESULTS The results of bone and soft-tissue cultures were identical in 49% (n = 22) of cases. In 11% (n = 5) of cases there were no common pathogens. In 29% (n = 13) of cases there were more pathogens in the soft-tissue specimens; these microorganisms included microbes isolated from bone cultures. In four patients (9%) with culture-positive soft-tissue specimens, bone culture specimens remained sterile. In one patient (2%) with culture-positive bone specimen, soft-tissue specimen remained sterile. CONCLUSION Culture specimens should be obtained from both the bone and the overlying deep soft tissue in patients with suspected osteomyelitis whose clinical conditions are suitable. The decision to administer antibiotic therapy should depend on these results.

Percutaneous transcatheter embolization in arterial injuries of the lower limbs.

Purpose: To evaluate the efficacy and safety of percutaneous transcatheter arterial embolization (PTE) in lower extremity arterial injuries. Material and Methods: From January 2000 to June 2004, patients who presented with a penetrating trauma of the lower limbs, along with bleeding and with no sign of ischemia or hemodynamic instability, were included in the study. The injuries were embolized by coils and Gelfoam. The efficacy of PTE was defined as its ability to stop bleeding both radiographically and clinically, and its safety was determined by the complication rate. Results: There were 10 embolizations, which consisted of 5 profundal femoral, 3 superior gluteal, and 2 inferior gluteal artery embolizations. PTE was effective in all patients. There were two inguinal hematomas, which did not require any intervention, and there was a temporary renal function alteration. The mean hospital stay of these patients was 2.67±0.91 days. Conclusion: PTE may be an effective and safe method of treatment in certain cases with lower limb arterial injuries. However, patients should be selected meticulously by both the vascular surgeon and the interventional radiologist, and PTE should be undertaken only in experienced hands.

The impact of valvular oxidative stress on the development of venous stasis ulcer valvular oxidative stress and venous ulcers.

Background: It is widely believed that venous ulcers result from venous insufficiency related to venous valve damages. To further investigate the pathogenesis of venous ulcers, we compared the influence of oxidative stress in venous valvular tissue on stasis ulcer formation in patients with venous ulcers secondary to superficial venous reflux disease. Methods: Thirty-nine consecutive patients with superficial venous reflux who underwent saphenectomy were included in the study. Patients were divided into 2 groups: with healed venous ulcers (group 1, n = 15) and without ulcers (group 2, n = 24). All patients were preoperatively evaluated with duplex ultrasound scanning and their blood samples were obtained to examine leukocyte count, interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and C-reactive protein (CRP) levels. All patients underwent standard above-knee saphenectomy. Extracted saphenous vein segments were from the saphenofemoral junction, the first valve along. The biochemical analysis of the valve tissues included matrix metalloproteinase (MMP)-9, MMP-2, IL-6, TNF-α, superoxide dismutase (SOD), malondialdehyde (MDA), and nitric oxide (NO) studies. Results: There was no significant difference between patients in terms of age, gender, hospital stay, and preoperative blood levels of leukocyte, IL-6, TNF-α, and CRP (P > .05). Biochemical examination of valve tissue showed that the levels of MMP-9, MMP-2, IL-6, TNF-α, SOD, MDA, and NO in patients with healing venous ulcer were higher than those of the second group. Conclusion: A higher oxidative stress in the valvular tissue may contribute to venous stasis ulcer formation.

Expression of bcl-2 in Papillary Thyroid Cancers and its Prognostic Value

Abstract Purpose: Papillary thyroid cancer has a good prognosis. This favourable prognosis may be attributed to the apoptotic tendency of the cancer cells. This study aims to evaluate the expression of bcl-2, which is an antidote of apoptosis, and aims to evaluate the value of bcl-2 as a prognostic marker in papillary thyroid cancer. Material-Methods : Bcl-2 expression in the archival materials of 31 patients with papillary thyroid cancer was examined with immunohistochemical methods using bcl-2 and p-53 stains. The results were compared with 31 normal thyroid tissue specimens, which consisted of the contralateral lobes of these patients. The results were then analyzed in accordance with the clinical features of the patients. Results : Thirty (96.7%) patients of the control group were positive for bcl-2 whilst one (3.3%) was negative. The staining for bcl-2 was positive in 12 (%75) patients with microcarcinomas (p < 0.05) and 13 (86.6%) with papillary cancers (p > 0.05). Two cases of the papillary cancer group were admitted to the hospital with local recurrence (6.4%) and both were positive for bcl-2 (p > 0.05). All cases (4/31), whose MACIS scores were higher than 7 were positive for bcl-2. Twenty-one of 27 cases whose MACIS scores were lower than 7 (77.7%) were positive for bcl-2 (p > 0.05). All tumours of this series were negative for p-53 immunstaining. Conclusion : The rate of bcl-2 expression in microcarcinomas of papillary thyroid cancer decreases when compared to normal thyroid tissue. This may be an early sign of oncogenesis, and a reason for the favourable prognosis in microcarcinomas. However, bcl-2 cannot be used as a prognostic marker.

Cyanoacrylate for wound closure in prosthetic vascular graft surgery to prevent infections through contamination

PurposeProsthetic vascular graft infection (PVGI) still occurs at an unacceptably high rate, despite the many measures that have proven effective against infection. The major cause of PVGI is perioperative contamination, which usually occurs before a histological barrier is completed and may threaten graft viability. We assessed the efficacy of cyanoacrylate as a tissue adhesive and barrier against early contamination through the skin.MethodA 1 × 0.5-cm Dacron graft was placed subcutaneously under sterile conditions in 16 Sprague-Dawley rats. The skin was closed with polypropylene sutures in eight rats (group A) and with N-butyl 2-cyanoacrylate in eight rats (group B). The closed incisions were then contaminated with 75 × 106 cfu/ml methicillin-sensitive Staphylococcus aureus. Microbiological and histopathological assessments were done 7 days later, after the rats were killed.ResultsAll of the graft cultures from group A (8/8) were positive for S. aureus whereas all of those from group B (0/8) were negative. This difference was significant (p < 0.001). Histological examination revealed denser inflammatory cell infiltration in group A than in group B.ConclusionsMaintaining skin integrity after closure is of the utmost importance because contamination during the first hours of the procedure may cause PVGI. Cyanoacrylate seems to be a promising molecule not only because of its bacteriostatic effects, but also because it seals the barrier effectively and immediately.

What really affects the incidence of central venous catheter-related infections for short-term catheterization?

Abstract Central venous catheterization is one of the important sepsis reasons in surgical patients. In this randomized controlled study, the effect of the frequency and type of catheter site care, as well as age, coexisting malignancy or diabetes mellitus, total parenteral nutrition administration and antibiotics use, on central venous catheter infection was investigated. Seventy-two single-lumen polyurethane catheters were included. In group I (n: 33), a transparent occlusive dressing was applied to the insertion site and not removed for 7 days unless there were signs of local infection. In group II (n: 39), daily site care was done with povidone-iodine 10% solution and a new sterile gauze was applied. Chi-square, linear correlation and multiple regression tests were used for statistical analysis. Mean duration of catheters was 8 ±4 days. There was no catheter-related sepsis. Ten (13.9%) patients had positive catheter tip cultures of whom three had site infection as well. The incidence of site and tip infections were not significantly different in group I and II (p > 0.05). Site infection and age younger than 60 years significantly increased the rate of tip infection (p: 0.004 and p: 0.02 respectively). Total parenteral nutrition administration was associated with higher rate of tip infection (p: 0.06). Coexisting malignancy or diabetes mellitus, duration of catheter and antibiotics use did not have any significant effect on the rate of central venous catheter infections (p > 0.05). In conclusion, we observed that the frequency of insertion site care and the type of dressing applied to the site had no significant effect on the rate of CVC infection. Insertion site infection was the most significant factor increasing the incidence of catheter tip infection. The use of the CVC for total parenteral nutrition facilitated tip infection as well.