Nusret Akyürek

Management of acute calculous cholecystitis in high-risk patients: percutaneous cholecystotomy followed by early laparoscopic cholecystectomy.

Emergency cholecystectomy for acute cholecystitis is associated with high morbidity and mortality rates in patients with significant comorbidities and high-risk surgery. The aim of this study was to evaluate the effectiveness, possible advantages, and complications of percutaneous cholecystostomy (PC) followed by an early laparoscopic cholecystectomy (LC) in relation to conservative treatment followed by a delayed LC in high-surgical risk patients. Between 2002 and 2004, patients were randomly classified into 2 groups: the first group consisted of patients who had PC followed by an early LC (PCLC group, n = 31) and the second group consisted of patients who had conservative treatment followed by a delayed LC (DLC group, n = 30). The groups were statistically compared regarding their demographic, comorbidity, hospital stay, conversion, and complication rates. PC was technically successful in 31 patients with no attributable mortality or major complications. No difference had been found in regarding demographic, comorbidity, and complication rates. In PCLC group, all the patients experienced symptom relief within 24 hours, and early LC was attempted in 31 patients once their clinical condition was sufficiently stable, this was successfully accomplished in 29 (93.5%). In the DLC group, delayed LC was attempted in 30 patients, and this was successfully accomplished in 26 (86.6%). The hospital stay was shorter and cost was in the PCLC group was lower than in the DLC group. PC allows resolution of sepsis in patients at high surgical risk. Early LC could be safely performed once sepsis and acute infection resolved in these patients.

Urgent Laparoscopic Cholecystectomy Is the Best Management for Biliary Colic

Background/Aim: Delay of laparoscopic cholecystectomy after the diagnosis of biliary colic may increase the probability of recurrent emergency admission while awaiting elective cholecystectomy. The aim of this study was to compare the possible advantages and safety of urgent laparoscopic cholecystectomy (ULC) with elective laparoscopic cholecystectomy (ELC) in patients with biliary colic. Patients and Methods: Between 2001 and 2003, 75 patients with biliary colic were included in this study. The patients were classified into following two groups: patients who had ULC in 24 h were in group I (n = 28) and patients who had ELC (mean interval 4.22 ± 1.42 months) were in group II (n = 35). Conversion to open cholecystectomy, operative time, postoperative hospital stay, costs, and complications were evaluated. Results: In group II, 9 patients made a total of 13 return visits to the emergency department with recurrent attacks of biliary colic or complications of gallstone disease. Mean operative time increased from 35.1 ± 6.74 min for urgent laparascopic cholecystectomy to 49.9 ± 6.12 min for ELC (p > 0.05) and hospital stay time increased from 1.06 ± 0.4 to 2.31 ± 2.36 days (p < 0.05). Conversion to open cholecystectomy increased from 0% in group I to 17.2% in group II (p < 0.05). Discussion: ULC for biliary colic may be the most medically efficacious and cost-effective treatment.

Probiotic Agent Saccharomyces boulardii Reduces the Incidence of Lung Injury in Acute Necrotizing Pancreatitis Induced Rats

BACKGROUND Acute necrotizing pancreatitis is a severe acute inflammatory disease of the pancreas that can lead to extrapancreatic organ involvement. Supervening lung injury is an important clinical entity determining the prognosis of the patient. Probiotics are dietary supplements known to reduce or alter inflammation and inflammatory cytokines. In the present study, we hypothesize that probiotics may reduce lung injury by reducing bacterial translocation, which results in reduced infection, inflammation, and generation of proinflammatory cytokines in an experimental model of acute necrotizing pancreatitis. METHODS Pancreatitis was induced by concomitant intravenous infusion of cerulein and glycodeoxycholic acid infusion into the biliopancreatic duct. Saccharomyces boulardii was used as the probiotic agent. Rats were divided into three groups: sham, pancreatitis-saline, which received saline via gavage at 6 and 24 h following the pancreatitis, pancreatitis-probiotics, which received probiotics via gavage method at 6 and 24 h following the pancreatitis. The rats were sacrificed at 48 h, venous blood, mesenteric lymph node, pancreatic and lung tissue samples were obtained for analysis. RESULTS Serum pancreatic amylase, lactate dehydrogenase, secretory phospholipase A(2), and IL-6 were found to be increased in pancreatitis-saline group compared with the other groups (P < 0.05). Histological analyses revealed that edema, inflammation, and vacuolization as well as polymorphonuclear leukocyte infiltration in the lung tissue was significantly reduced in the probiotic treated group. Bacterial translocation was significantly reduced in the probiotic treated group compared with the other groups (P < 0.05). CONCLUSION These results suggest that Saccharomyces boulardii reduce the bacterial translocation. As a result of this, reduced proinflammatory cytokines and systemic inflammatory response was observed, which may be the reason underlying reduced lung injury in acute necrotizing pancreatitis.

The Effect of Platelet Activating Factor Antagonist BN 52021 on Bacterial Translocation and ICAM-I Expression in Experimental Obstructive Jaundice

Expression of intracellular adhesion molecule-1 (ICAM-1) in an obstructive jaundice model and the potential protective role of platelet activating factor antagonist over small intestine and liver together with its effects on bacterial translocation are examined in this study. Forty-eight male Wistar albino rats were assigned into four equal groups of 12. In groups I and II, animals were sham operated. In groups III and IV, common bile duct ligation and division were performed. In group I and group III, 0.5 ml/day normal saline was applied intraperitoneally daily from day 2 to 6 of the study; in group II and group IV, 1 mg/kg/day BN 52021 was applied intraperitoneally daily from day 2 to 6 of the study. All animals were sacrificed on postoperative day 7. ICAM-1 expression (CD54 positivity) was analyzed in the liver and ileum tissue by immunohistochemical method. Samples from blood, liver mesenteric lymph nodes, and spleen were cultured under aerobic conditions. It is revealed that ICAM-1 expression was statistically higher in group III, with highest bacterial translocation and liver and spleen injury when compared to other groups. Serum alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP), gamma-glutamyltranspeptidase (GGT), bilirubin, tumor necrosis factor α (TNFα), and interleukin 1β(IL-1β) values were at the highest level in group III, and there was a statistical decrease in group IV compared to group III. The administration of BN52021 in experimental obstructive jaundice is a useful way to reduce liver and intestinal mucosal villi damage by inhibiting bacterial translocation and systemic inflammatory response.

Combined proper hepatic artery and common hepatic duct injury in open cholecystectomy : Case report and review of the literature

A 24-y-old male patient underwent elective open cholecystectomy at another center. On the third postoperative day, he developed fever and jaundice, for which he underwent reoperation at the same center on the seventh postoperative day. During the second surgery, massive bleeding was encountered, suture ligations were applied, and T-tube drainage was performed. After the surgery was completed, the patient developed hepatic microabscess, and sepsis ensued. The patient presented at this hospital for further evaluation. To rule out vascular injury, which was suspected in this patient, celiac angiography was performed; it showed that the hepatic artery was occluded near the eminence of the gastroduodenal artery, and the liver was supplied by many collaterals. After the patient’s condition had stabilized and the sepsis had resolved, Roux-N-Y hepati-cojejunostomy was performed on the 59th d after admission.