Mustafa Oncel

Risk and Outcome of Bowel Resection in Patients with Incarcerated Groin Hernias: Retrospective Study

The goal of this retrospective study was to evaluate factors that increase the risk of bowel necrosis and document the outcome of bowel resection in patients with strangulated hernias. We identified 102 patients (60 men, 42 women) who underwent surgical treatment for an incarcerated hernia at the Kartal Education and Research Hospital Emergency Unit between April 1997 and April 2001. Patients in group 1 required intestinal resection (n = 16), and patients in group 2 did not (n = 86). The median age of the patients was 53 years (range 3–96). Demographic and surgical data were obtained from the patients’ charts and compared between the two groups. Women required bowel resections more often than men (p < 0.05). Patients older than 65 years and those with femoral or epigastric hernias required resection more often than patients younger than 65 years and those with inguinal, umbilical, or incisional hernias (p < 0.05 for all). Group 1 patients had a longer hospitalization and experienced more overall complications and wound infections than group 2 (p < 0.05 for all). In conclusion, incarcerated hernias are more common in men, but intestinal resection is required more often in women. The risk of intestinal resection is higher for patients with femoral hernias and those older than 65 years. Patients who undergo intestinal resection have a higher overall complication rate related to wound infections but not an increased risk of other complications or mortality.

Comparison of a novel liquid (Adcon-P®) and a sodium hyaluronate and carboxymethylcellulose membrane (Seprafilm) in postsurgical adhesion formation in a murine model

AbstractPURPOSE: Intra-abdominal administration of antiadhesive barriers may reduce the extent and severity of postoperative adhesions. This study aimed to compare the effectiveness of a novel liquid antiadhesive barrier with a conventional sheet (Seprafilm™) antiadhesive barrier in a murine cecal abrasion model. METHODS: One hundred fifty Swiss-Wister mice underwent laparotomy and cecal abrasion and were randomly assigned to receive Adcon-P® (n = 30) or Seprafilm™ (n = 30) or to a control group (n = 90). At postoperative Day 21, the mice underwent relaparotomy and complete adhesiolysis. An investigator who was blinded to the group assignment scored the extent of adhesion formation and the difficulty of adhesiolysis using a 6-point scale that ranged from 0 (no adhesions) to 5 (full-thickness intestinal injury with adhesiolysis). Results are reported as median (range). RESULTS: Median adhesion scores in mice receiving Adcon-P® (0 (range, 0–1)) and Seprafilm™ (1 (range, 0–3)) were lower than in mice in the control group (2 (range, 0–5); P < 0.0001 for both comparisons). In addition, the median adhesion score for the Adcon-P® group was significantly lower than that of the Seprafilm™ group (P = 0.02). CONCLUSION: This study suggests that both Adcon-P® and Seprafilm™ decrease the incidence of postoperative adhesions and the difficulty of adhesiolysis in the murine cecal abrasion model. However, Adcon-P® appeared to be superior to Seprafilm™. This agent is an attractive device that requires additional studies.

Is the Insertion of Drains After Uncomplicated Thyroid Surgery Always Necessary

PurposeWe conducted a prospective, randomized study to evaluate the necessity of drainage after uncomplicated thyroid surgery.MethodsThe subjects were 135 patients who underwent thyroid surgery between September 2002 and February 2004. The patients were randomized into two groups according to whether drains were inserted at the time of surgery. Group 1 consisted of 68 patients with drains and group 2 consisted of 67 patients without drains. The indications for surgery, procedures performed, local complications (such as infection, seroma, and bleeding or hematoma), necessity for reoperation, and hospital stay were recorded.ResultsThere were 110 (81.5%) women and 25 (18.5%) men, with a median age of 46.9 ± 12.5 years. The mean hospital stay was 2.6 ± 1.0 days in group 1 and 1.3 ± 0.7 days in group 2 (P = 0.001). Local complications developed in five (7.3%) patients from group 1, as wound infections in two (2.9%), seroma in one (1.5%), and hemorrhage in two (2.9%); and in two (3%) patients from group 2, as seroma in one (1.5%) and hematoma in one (1.5%). Both of the group 1 patients with postoperative hemorrhage required reoperation within 8 h after initial surgery. The hematoma in the group 2 patient was treated successfully with needle aspiration.ConclusionThese findings suggest that the routine use of drains may be abandoned in uncomplicated thyroid surgery, since serious postoperative bleeding rarely occurs and hematomas can be treated by needle aspiration if drains have not been placed. Furthermore, the use of drains prolongs hospital stay and increases the risk of infection.

Colonic Surgery in Patients With Juvenile Polyposis Syndrome: A Case Series

PURPOSEJuvenile polyposis syndrome is characterized by multiple hamartomatous polyps in the large intestine. When indicated, the surgical choices in symptomatic juvenile polyposis syndrome patients are colectomy with ileorectal anastomosis or proctocolectomy with pouch. The aim of this study was to evaluate the long-term outcomes of the surgical options in juvenile polyposis syndrome patients who present with symptomatic colonic polyps.METHODSThe charts of all juvenile polyposis syndrome patients who had had at least one colonic operation since 1953 in our institution were reviewed. The following data were abstracted: demographics, the number and site of the polyps, symptoms, the intervals and types of the colonic operation, follow-up, and the patients’ current status.RESULTSThere were 13 patients (6 males) with a median age of 10 years (range, 1–50 years) at the time of diagnosis. Patients had colonic (n = 13), rectal (n = 12), and gastric (n = 6) polyps. Rectal bleeding (n = 11) was the most common presenting symptom. Three patients underwent proctectomy as the initial operation. Although a rectum-preserving operation was initially performed in ten patients, a subsequent proctectomy was required in five of them within a median of 9 years (range, 6–34 years). Therefore, eight patients had their rectum removed during the study period; five had an ileal pouch–anal anastomosis, one had a Koch pouch as a restorative surgery, and two had an end ileostomy. No relation was observed between the number of colonic and rectal polyps and the type of surgery or the need for proctectomy. Patients were followed up a median of 3 years (range, 2–24 years) after their ultimate operations. During this period, one patient (20 percent) who underwent restorative proctectomy and 4 patients (80 percent) whose rectums were preserved required multiple endoscopic polypectomies for recurrent polyps in the pouch (first patient) or their rectums (the other four patients). The patient who underwent the Koch procedure required surgery for recurrent polyps in her pouch.CONCLUSIONSOne-half of the patients who initially underwent rectal preservation required subsequent proctectomy. The number of colonic or rectal polyps does not influence the choice of the surgical procedure. Both restorative proctocolectomy and subtotal colectomy with ileorectal anastomosis need endoscopic follow-up because of the high recurrence rates of juvenile polyps in the remnant rectum or pouch.

Transcutaneous electrical nerve stimulation for pain management in patients with uncomplicated minor rib fractures

OBJECTIVE Few non-surgical conditions are more painful than rib fractures. There are a few methods for pain relief in patients with minor rib fractures. METHODS We used a non-steroidal anti-inflammatory drug (NSAID, Naproxen sodium) and transcutaneous electrical nerve stimulator (TENS) to control pain of the patients with uncomplicated minor rib fractures. One hundred consecutive patients admitted to Kartal Education and Research Hospital Emergency Service, were randomized into four groups. The patients were assigned to one of the following pain treatments: NSAID, TENS, NSAID plus inactive TENS or placebo. The patients used NSAIDs and placebo four times a day and TENS twice a day for 3 days. All patients were asked to assess their pain level with a scoring system on days 0, 1 and 3. RESULTS The most effective treatment was TENS on days 1 and 3 (P<0.05). Although NSAID and NSAID plus inactive TENS controlled pain better than placebo on day 1 (P<0.05), this superiority did not continue to day 3 (P>0.05). There was no difference between NSAID and NSAID plus inactive TENS in controlling pain on either days 1 or 3. CONCLUSION We conclude that TENS was more effective than NSAID or placebo in patients with uncomplicated minor rib fractures, because of its prominent and admirable efficacy in reduction of pain.

Benefits of 'clean sweep' in Peutz-Jeghers patients.

Objective  Laparotomy is the treatment of choice in Peutz–Jeghers Syndrome (PJS) patients for endoscopically irretrievable symptomatic polyps and polyp‐related complications. During the last decade, we have operated on majority of the PJS patients with the purpose of removing all the gastrointestinal polyps (clean sweep), when an operation was indicated. The aim of this study is to evaluate the effect of clean sweep technique on the need for repeated surgery compared to a problem focused approach.

Excision and marsupialization versus sinus excision for the treatment of limited chronic pilonidal disease: a prospective, randomized trial

Abstract. The treatment techniques for pilonidal disease are either associated with high recurrence rates or complex procedures. This prospective randomized study compared the outcome of excision and marsupialization technique with sinus excision technique. A total of 40 consecutive patients with limited, chronic pilonidal sinus disease were operated with either excision and marsupialization technique (Group 1, n=20) or sinus excision technique (Group 2, n=20). The demographics, perioperative data, complications and recurrences were recorded. Patient satisfaction was evaluated with a specific questionnaire 16–18 weeks after surgery. Demographic data, preoperative symptoms and the acute disease history were similar between the groups. Operation time, hospital stay and work-off periods were significantly shorter and the number of out-patient procedures was significantly more in Group 2. Although satisfaction scores were similar between the groups, the patients who had no complaint, were “completely satisfied” or would “absolutely recommend the operative technique to other patients” were significantly more in Group 2. In conclusion, the sinus excision technique requires a shorter operation time, hospital stay and work-off period than excision and marsupialization in the treatment of limited, chronic pilonidal disease. The sinus excision technique can be performed as an out-patient procedure in most cases, and seems to be associated with better patient satisfaction.

The importance of multifocal/multicentric tumor on the disease-free survival of breast cancer patients: single center experience.

Objectives:Multifocal/multicentric breast cancers have been comprehensively studied and their outcomes have been compared with unifocal tumors. We evaluated the impact of multifocality and multicentricity on the disease-free survival (DFS) and overall survival of breast cancer patients and tried to analyze the correlation between multifocality/multicentricity (M/M) and other prognostic factors. Material and Methods:Between 1994 and 2009, we analyzed retrospectively 697 breast cancer patients. Multicentric and multifocal breast cancer were defined as the presence of 2 or more invasive tumor foci within the different quadrants of the same breast or within a same quadrant of the breast, respectively. M/M and other prognostic factors were evaluated using univariate and multivariate analyses. Results:Multifocal/multicentric tumors were seen in 107 (15.4%) of the 697 breast cancer patients. pT and pN stage were related with the presence of multifocal/multicentric tumors. As tumor size increased and the number of axillary lymph nodes metastasis increased, the incidence of M/M increased significantly (P=0.003 vs. P=0.02, respectively). Overall, the median DFS time of patients with multifocal/multicentric tumors was significantly worse than that of the unifocal tumors (55 vs. 137 mo, P<0.001). Multivariate analysis showed that the presence of M/M was the most important prognostic factor for DFS (P=0.001, hazard ratio (HR): 0.33; 95% confidence interval (CI), 0.18-0.58), as were pN stage and extracapsular extension of the tumor (P=0.01, HR: 1.74; 95% CI, 1.13-2.69) (P=0.03, HR: 1.9; 95% CI, 1.04-3.47, respectively). M/M were not also statistically significant prognostic factors in breast cancer for overall survival (P=0.06). Conclusions:M/M imparts an unfavorable prognosis on the DFS of breast cancer patients in comparison to unifocal tumors and the presence of multifocal/multicentric tumors were associated with advanced pT and pN stages.

Spontaneous and Traumatic Intra-Peritoneal Perforations of Hepatic Hydatid Cysts ☆: A Case Series

Little is known about the presentation, management, outcome, and recurrence of hydatid cyst perforations. We reviewed the charts of all patients admitted to our emergency service for 7 years to identify patients who were surgically treated for intra-peritoneal hydatid cyst perforations. Twelve hydatid cysts were identified in 7 patients (5 males; median age 22 yr; range 8–67). The perforations occurred spontaneously in 5 patients, and were the result of mild trauma in 2 patients. Diagnostic tools included ultrasound (US, n = 4), computed tomography (CT, n = 3), and diagnostic peritoneal lavage (DPL, n = 1). The cysts were treated with radical (n = 3) or conservative (n = 9) operative techniques. Intra-cavitary and intra-abdominal spaces were washed in 6 and 5 patients, respectively. The median follow-up time was 41 months (range 3–58). Indirect hemagglutination test was positive in 3 patients, but CT confirmed cyst recurrence in only 2 of these patients. Both had had large cysts and had undergone conservative therapy (endocystectomy and external drainage). An intra-abdominal recurrence was observed in a patient whose abdomen had not been washed during surgery. In conclusion, patients with hydatid cyst perforations in our study generally presented with severe abdominal findings. US, CT, and DPL may be helpful for the diagnosis. Recurrence may be related to operative technique, location of the cyst, and abdominal wash during the surgery. Alimentary Tract, Inc.

Intra-Abdominal Use of Taurolidine or Heparin as Alternative Products to an Antiadhesive Barrier (Seprafilm®) in Adhesion Prevention: An Experimental Study on Mice

PurposeSeprafilm® (Genzyme Biosurgery, Cambridge, MA) remains a widely used product in postoperative adhesion prevention. This study was designed to compare the antiadhesive effects of taurolidine, heparin, and Seprafilm® in a murine cecal abrasion model.MethodsSixty male Balb/c mice underwent a cecal abrasion procedure and were randomized into four groups (n = 15 in each). Groups T, H, and S animals intraperitoneally received taurolidine, heparin, and Seprafilm®, respectively, and Group C animals were reserved as control. Animals were killed on Day 21, and the severity of adhesions was evaluated with a scoring system ranging between 0 to 5. In addition, the localizations of the adhesions were questioned.ResultsFive (1 in Group S and 4 in Group H) animals died before they were killed. The deaths were related to intra-abdominal bleeding, and mortality rate was significantly higher in Group H than those in other groups (P < 0.05 for each comparison). The severity of adhesions was significantly less in the study groups than Group C, and in Group H than Groups T and S (P < 0.05 for each comparison). In addition, adhesions located cecum over itself were significantly less in the study groups than the control group, and those between small bowel and cecum were significantly lower in Groups T and S than the control group (P < 0.05 for each comparison).ConclusionsAll products are effective in adhesion prevention. Heparin use provides the best results but may be associated with a higher mortality rate related to intra-abdominal bleeding. Taurolidine may be an alternative product to Seprafilm®, but further studies are required.