Ömer Faik Ersoy

Comparison of Adhesive Properties of Five Different Prosthetic Materials Used in Hernioplasty

This experimental study was designed to assess and to compare intra-abdominal adhesions following the use of five commercially available prosthetic mesh grafts in the repair if abdominal wall defects. Sixty Wistar albino rats were randomly divided into six groups (n = 10). A 2 × 1 cm defect at abdominal wall was created and defects were closed either primarily or with one of the following prosthetic mesh grafts: monofilament polypropylene, polytetrafluoroethylene, sodium hyaluronate/carboxymethylcellulose-coated polypropylene, polypropylene/polyglactin 910 composite, or resorbable hydrophilic collagen-coated multifiber polyester. The severity of adhesions was graded, tensile strengths of adhesions were measured, and histopathological grades of inflammation and fibrosis were evaluated. Polypropylene mesh resulted in more adhesion formation in comparison to primary repair and other grafts used in this study, except polypropylene/polyglactin 910 composite mesh. In addition, the highest tensile strength of omental adhesions was detected in the polypropylene group (χ2 = 26.249; p =. 0001). Polyester composite mesh caused the least adhesion formation among the groups. Sodium hyaluronate/carboxymethylcellulose-coated polypropylene and polyester composite meshes revealed the highest fibrosis scores (χ2 = 50.776; p =. 0001). The highest inflammatory activity was detected in the polytetrafluoroethylene mesh group (χ2 = 16.564; p =. 005). Thus, sodium hyaluronate/carboxymethylcellulose-coated polypropylene and polytetrafluoroethylene meshes following polyester composite mesh were the minimal adhesion-forming grafts in this study. Disadvantages of the polytetrafluoroethylene mesh were lower fibrotic activity and higher inflammatory reaction to the graft.

COMPARISON OF DIFFERENT SURGICAL OPTIONS IN THE TREATMENT OF PILONIDAL DISEASE: RETROSPECTIVE ANALYSIS OF 175 PATIENTS

Pilonidal sinus disease is a benign disorder with an unidentified etiology and is observed mainly in young adults. It is an important health problem because it causes work loss. Although various nonsurgical treatment options have been tried up to date, there is a consensus on surgical intervention to treat the disease today. The optimal surgical method should be simple, associated with short hospital stay and low recurrence rates. In this study, patients who have undergone different surgical treatment methods due to pilonidal disease were retrospectively analyzed. The medical records of 175 patients who were operated on between 2002 and 2005 at the General Surgery Departments of Gaziosmanpasa University Medical School and Bartin State Hospital for pilonidal disease were reviewed for treatment option, postoperative complications, hospitalization time, work‐off periods, and recurrence rates. The patients consisted of 150 (85.3%) males with a mean age of 26.47 ± 7.78 years. Marsupialization was applied to 82 (46.9%), unroofing to 20 (14.7%), primary closure to 29 (16.6%), and Limberg flap to 44 (25.1%) patients. The longest hospitalization period of 3.61 ± 1.08 days was observed in the Limberg flap group. The longest return to work period (20.12 ± 5.1 days) was observed in the marsupialization group. Both differences were significant. The highest complication rate was observed among the primary closure group (31%) followed by the patients treated by Limberg flap technique (15.8%). In the primary closure group, infection was detected in five (17.2%) and wound dehiscence in four (13.8%) individuals. The highest complication rates (31.03%) and recurrences (13.8%) were observed in the primary closure group. Various operative methods utilized in the treatment of pilonidal disease are associated with a number of advantages and disadvantages. Postoperative complication rates of unroofing and marsupialization are low, but require long wound care. In our study, we did not observe any recurrence among the patients treated by unroofing, but experienced a high recurrence ratio among subjects treated by marsupialization. In addition, there were high complication rates in the primary closure and Limberg flap groups. So, the best option is to explain the advantages and disadvantages of the available surgical methods and respect the patients decision.

An assessment of the effects of two types of bioresorbable barriers to prevent postoperative intra-abdominal adhesions in rats

PurposeThis study assessed and compared the efficacy of two types of bioresorbable membranes in the prevention of postoperative adhesion under clean contaminated and bacterial peritonitis conditions using a cecal ligation and puncture model in rats.MethodsWistar albino rats (n = 72) were divided into six groups. Bacterial peritonitis was induced using a cecal ligation and puncture model in groups 2, 4, and 6. Groups 1, 3, and 5 served as controls for clean contaminated procedures in the absence of bacterial peritonitis. Groups 1 and 2 were the untreated clean contaminated and bacterial peritonitis groups and served as controls for the effect of the bioresorbable membranes in each condition. In groups 3 and 4, a 1.5 × 3 cm USP glycerol/sodium hyaluronate/carboxymethylcellulose membrane was wrapped around the cecal resection area and a 2 × 4 cm membrane was left under the incision. The oxidized regenerated cellulose membrane was similarly applied in groups 5 and 6. Four weeks later, the adhesions were evaluated. In addition, fibrosis and inflammation were observed histopathologically.ResultsAdhesion development (P = .008), fibrosis (P = .008), and inflammation (P = .0001) differed among the groups. Both materials increased adhesion formation in the bacterial peritonitis condition. Increased fibrotic activity was detected in all material-applied groups under both conditions. In addition, more inflammation was detected in the groups that received the application of a material, especially in the presence of bacterial peritonitis.ConclusionNeither material prevented adhesions in clean contaminated conditions. Moreover, they increased adhesion formation in bacterial peritonitis.

Effect of n-butyl-2-cyanoacrylate on high-risk colonic anastomoses.

We investigated the effect of n‐butyl‐2‐cyanoacrylate (BCA) on colonic anastomosis under clean contaminated procedure (CCP) and bacterial peritonitis (BP) conditions in rats. Male Wistar albino rats (n = 80) were divided into two groups: CCP and BP. In the CCP group, colonic resection and anastomosis were performed. BP was induced by cecal ligation and puncture. BCA was administered to the anastomosis in half of the rats in both groups. Anastomotic assessment was done on postoperative days 3 and 7 by evaluating the burst pressure, and gross anastomotic and histopathologic healing indices. The presence and severity of adhesion formation was also investigated. There were no differences in terms of gross healing parameters on days 3 and 7. Burst pressures were also similar on both days (p = 0.244 and p = 0.101, respectively). In the early phase (day 3), adhesion development (p < 0.001), granulocytic cell infiltration (p = 0.02), inflammation (p = 0.019) and necrosis (p = 0.019) were higher in the BCA groups. Mononuclear cell infiltration (p = 0.659), fibroblastic cell infiltration (p = 0.538) and capillary formation (p = 0.316) were similar. In the late phase (day 7), adhesion development (p < 0.001), necrosis (p = 0.001) and granulocytic cell infiltration (p = 0.034) were higher in the treatment groups. Fibroblastic cell infiltration (p = 0.017) and capillary formation (p = 0.016) were lower in BCA treated rats, particularly in the BP condition. Mononuclear cell infiltration did not differ (p = 0.176). The application of BCA did not provide any benefit under either CCP or BP conditions. Moreover, BCA caused increased inflammatory reactions, necrosis and adhesion formation. During the late phase of healing, the ongoing enhanced inflammation caused a reduction in capillary formation and fibroblastic infiltration, particularly under BP conditions.

Comparison of the effects of troxerutin and heparinoid on flap necrosis

We aimed to assess the effects of local troxerutin and heparinoid (HEP) treatments in a model of flap necrosis. Three groups of Wistar albino rats, each comprising 10 animals were used. A cranially based 6x3-cm full-thickness random-pattern skin flap was raised and sutured to the same area in each model. The control group was treated daily with normal saline, the second with topical HEP and the third with topical troxerutin. The amount of flap necrosis was measured in all groups by the end of the seventh day. Flap tissues were excised for histological analysis and evaluation of the expression of vascular endothelial growth factor (VEGF) levels. Assessment of the blood levels of nitric oxide was also performed in each animal by cardiac puncture. The mean area of flap necrosis was 110.6mm(2) in the control, 39.44 mm(2) in the troxerutin and 47.11 mm(2) in the heparinoid-treated rats. The treatment arms exhibited significant reduction in areas of flap necrosis, compared with the control group (p<0.001), but it was similar among treatment groups (p=0.60). The rates of fibroblast proliferation were decreased in control group as compared to HEP and troxerutin arms (p<0.001). The mean level of collagen density, collagen organisation, granulation tissue and demarcation were similar in all rats. Measurement of VEGF expression did not show any significant difference between the groups (p=0.30). Nitric oxide levels were significantly higher in control rats, as compared to treatment groups (p<0.0001), but were similar in treatment arms (p=0.45). Our results suggest that troxerutin and HEP effectively reduce the flap necrosis and improve flap survival. The observed effects might be due to their anti-oedematogenic, radical-scavenging, antioxidant effects and supportive activities on capillary permeability and transudation.

Intranodal Palisaded Myofibroblastoma; a Case Report and Review of the Literature

Intranodal palisaded myofibroblastoma (IPM) also called as intranodal hemorrhagic spindle cell tumor with amianthoid fibers is a distinctive and rare mesenchymal neoplasm of lymph nodes. This entity generally misdiagnosed as intranodal Kaposi’s sarcoma or schwannoma in past. In contrast to Kaposi’s sarcoma, it behaves in a benign fashion and does not need any further therapy except total surgical resection of the mass. This neoplasm has a great predilection for the inguinal region. The lesion presents typically as a unilateral, painless, solitary mass. To our knowledge, approximately 53 cases of IPM have been reported in the English-language literature. We present a 43-year-old-male patient with IPM and discuss histological, immunohistochemical features and pathogenesis of this rare benign neoplasm.

Effects of Two Different Meshes Used in Hernia Repair on Nerve Transport

BACKGROUND We aimed to investigate the effects of two different types of mesh used in hernia repair on nerve transport and neural injury. STUDY DESIGN Forty-five Wistar-albino rats were randomly allocated to three groups. Basal neural transport on the index of the left sciatic nerve was performed in all groups before surgery. In the control group, only sciatic nerve manipulation was performed. Other groups received a cuff around the index sciatic nerve. The second group received a monofilament polypropylene and the third group received a polytetrafluoroethylene mesh. Effects of entrapment on neural transport were evaluated by electromyography on the 28th day. Tissue samples from sciatic nerves were taken for evaluation of nerve injury. RESULTS There was no significant difference between basal latency and amplitudes (p=0.609 and p=0.152, respectively). But latency was significantly different 4 weeks after the operation (p < 0.0001). At post hoc evaluation, entrapment groups had longer latency times compared with those in the control group (p=0.006 and p < 0.0001, respectively). But the increase in latency between entrapment arms was similar on the 28th day (p=0.601). Both initial and late term amplitudes were similar (p=0.364 and 0.913, respectively). Histologic evaluation by Massons trichrome staining revealed high fibrosis scores and increased collagen deposits, especially in the polypropylene group (p < 0.0001), and increased inflammation in the polytetrafluoroethylene group (p < 0.001). CONCLUSIONS Our results showed that the two most commonly used meshes in tension-free hernia surgery have different effects on nerve physiology and morphology. We concluded that alterations in nerve physiomorphology are from the properties of the mesh and may be the source of postoperative pain in hernia surgery.

Effect of cyanoacrylate on closure of gastric perforation: a comparative study in a rat model.

The aim of the study was to compare suture, clip and clip combined with topical N-butyl cyanoacrylate in an experimental model of gastric perforation. Sixty Wistar-Albino rats were divided into three groups. Midline laparotomy was performed and a 4 mm puncture was done on the anterior surface of the stomach. Closure was performed by sutures in the first group, clip in the second group, and clip with topical cyanoacrylate in the third group. Ten rats underwent a re-laparotomy on the 3rd and 7th days, respectively. Intraabdominal adhesions, burst pressures, procedural time, total operation time and histological evaluation were analyzed. In the early phase, clip with topical cyanoacrylate treatment significantly improved burst pressures (p=0.001). In the late phase, burst pressure levels were slightly higher in the third group. Procedural period and total operation times were significantly higher in the suture-treated group and lower in the clip group. Clip with topical cyanoacrylate treatment improved histological healing indices, with significant difference in granulation, chronic inflammation and collagenisation scores, but at the expense of a significantly increased adhesion formation (P=0.001). Our study shows that gastric perforations can be effectively treated by the combination of clip and cyanoacrylate with shorter time and acceptable side-effects in selected cases.

Clinical challenges and images in GI. Intramural intestinal hematoma.

Question: A 75-year-old man was referred with abdominal pain and lower gastrointestinal bleeding. His past medical history consisted of moderate mitral stenosis, and atrial fibrillation treated by oral anticoagulant therapy (coumadin [Eczacibasi, Istanbul, Turkey], 5 mg/d, for 1 year), and right hemicolectomy 5 years ago owing to colon cancer. At admission his International Normalized Ratio (INR) was 12.85 (normal range, 0.85–1.15), hemoglobin level was 11.7 g/dL, and prothrombin time was 30.4 (normal range, 70 –120). During physical examination, a 108-cm abdominal mass located in the left lower quadrant of the abdomen and generalized tenderness were detected. Fresh frozen plasma and parenteral vitamin K replacement were initiated. Annular colonic wall thickening with a maximal size of 2 cm from splenic flexure to sigmoid colon was detected by abdominal ultrasound and thereafter by abdominal computed tomography. The mesocolon was heterogeneous and peritoneal thickening was observed at left lower quadrant in tomography examination, which resembles malignant infiltration or recurrent carcinoma (Figure A). Which diagnostic procedure would you perform next? What is the diagnosis? Look on page 647 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. ALPER CELIK* NAMIK OZKAN* OMER FAIK ERSOY* BERAT ACU HUSEYIN AYHAN KAYAOGLU* *Faculty of Medicine Department of General Surgery Faculty of Medicine Department of Radiology Gaziosmanpasa University Tokat, Turkey

Clinical Challenges and Images in GI

Question: A 75-year-old man was referred with abdominal pain and lower gastrointestinal bleeding. His past medical history consisted of moderate mitral stenosis, and atrial fibrillation treated by oral anticoagulant therapy (coumadin [Eczacibasi, Istanbul, Turkey], 5 mg/d, for 1 year), and right hemicolectomy 5 years ago owing to colon cancer. At admission his International Normalized Ratio (INR) was 12.85 (normal range, 0.85–1.15), hemoglobin level was 11.7 g/dL, and prothrombin time was 30.4 (normal range, 70 –120). During physical examination, a 108-cm abdominal mass located in the left lower quadrant of the abdomen and generalized tenderness were detected. Fresh frozen plasma and parenteral vitamin K replacement were initiated. Annular colonic wall thickening with a maximal size of 2 cm from splenic flexure to sigmoid colon was detected by abdominal ultrasound and thereafter by abdominal computed tomography. The mesocolon was heterogeneous and peritoneal thickening was observed at left lower quadrant in tomography examination, which resembles malignant infiltration or recurrent carcinoma (Figure A). Which diagnostic procedure would you perform next? What is the diagnosis? Look on page 647 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. ALPER CELIK* NAMIK OZKAN* OMER FAIK ERSOY* BERAT ACU HUSEYIN AYHAN KAYAOGLU* *Faculty of Medicine Department of General Surgery Faculty of Medicine Department of Radiology Gaziosmanpasa University Tokat, Turkey