Orhan Uzun

The Effect of Rabeprazole on LES Tone in Experimental Rat Model

ABSTRACT Introduction: Despite adequate treatment with proton pump inhibitors (PPIs), symptoms of gastroesophageal reflux disease (GERD) may remain persistent as well as Barretts esophagus may emerge. It may be proposed that the relaxant effect of PPIs on the smooth muscles may lead to resistance of symptoms. The aim of this study is to investigate effects of rabeprazole on the lower esophageal sphincter (LES) pressure with a rat model. Materials and Methods: Sixteen rats were grouped as control and treatment groups. After obtaining LES tissues followed by a 60 min equilibration period for stabilization, contractile response to carbachol was obtained by application of single dose of carbachol to have a final concentration of 10−6 M in the organ bath. After the contractions reached a plateau, concentration-response relationships for rabeprazole were obtained in a cumulative manner in the treatment group. Results: In the carbachol contracted LES preparations; 1.5 × 10−6 and 1.5×10−5 M of rabeprazole caused 6.08% and 11.34% relaxations respectively which were not statistically significant. However, mean integral relaxation value for 4.5 × 10−5 M of rabeprazole was 17.34% and this relaxation was significant compared with controls. Conclusions: In the present study, rabeprazole caused no direct significant change in LES tone in the therapeutic dose range applied to the organ bath. However, rabeprazole at the high dose caused a significant decrease in the LES tone.

Pancreatic extragastrointestinal stromal tumor invading the duodenum

Extragastrointestinal stromal tumors that arise in the pancreas are extremely rare and managing them can be difficult, particularly if located in the head of pancreas. This case report aims to contribute to the existing data in the literature regarding extragastrointestinal stromal tumors with rare and unusual locations. We present a 56-year-old man who presented with recurrent mild right upper quadrant abdominal pain. Abdominal computed tomography and magnetic resonance imaging revealed a mass lesion with a diameter of 10 cm localized in the head of pancreas. Pancreaticoduodenectomy with complete tumor excision was performed. He was discharged on the postoperative day 14. Only 15 extragastrointestinal stromal tumors cases have been reported. Of these 15 cases, tumors were located in the head of pancreas in six cases. Here we report the seventh case of pancreatic extragastrointestinal stromal tumor arising in the head of pancreas and also the largest of these seven tumors.

Closure of non-healing perianal Crohn’s disease with surgery and vacuum-assisted closure (VAC) system

A 35-year-old female patient presented with colon-involved Crohn’s disease for 10 years. She had undergone a seton surgery at the 3rd year of diagnosis when a recto-vaginal fistula developed; she had also undergone a loop ileostomy surgery at the 5th year because of the continuation of her complaints arising from bloody diarrhea, abdominal pain, increase in recto-vaginal efflux, and perineal discomfort. Even though she experienced a partial relief, she underwent a second colonoscopy after her ileostomy surgery. The patient developed colon perforation during the operation and underwent a total colectomy surgery. Following the surgery, fistular efflux increased, but fissures developed in the meantime. Despite changes in medical therapy, recto-vaginal efflux and fissure-related pain increased, and gradually growing wounds appeared in the perinea. The evaluation of the patient at her admission to our clinic 3 years after the appearance of the wound in her perinea (Figure 1) revealed diffuse cellulitis in skin comprising vagina, which extended up to both the gluteus muscles, leading to the posterior intergluteal sulcus deterioration plus serious subcutaneous tissue loss that destructed the internal and external sphincter muscles. The patient was administered an antibiotherapy to prepare for proctectomy surgery; owing to weight loss, she was administered enteral nutrition. By washing the perineal wound in 6 sessions of VAC (Negative Pressure Wound Therapy; Smith & Nephew, London, UK) system under anesthesia in the nutritional back-up period, the purulent efflux of the rectal stump was drained. After the proctectomy surgery, 14 additional sessions of VAC pro-

The Protective Effect of Spironolactone and Role of the Na /K -ATPase Pump on Intestinal Ischemia/Reperfusion Injury

The aim of this study was to evaluate the possible protective effect of spironolactone (SPL) and role of the Na-K ATPase pump on intestinal ischemia/reperfusion injury. In our study, the period of ischemia was established by clamping the mesenteric artery for 45 minunder anesthesia in Wistar albino rats and the animals left for reperfusion at the end of this period were decapitated after one hour. Spironolactone (20 mg kg-1) was administered orally for three days before ischemia, 30 minbefore ischemia. The control group rats were subjected to the Sham operation and administered saline solution. TNF-α and IL-1β levels were measured in the serum samples. Ileal Na+/K+-ATPase, myeloperoxidase (MPO) analysis were performed. Structural injury was assessed histopathologically. Ischemia/reperfusion increased serum TNF-α and IL-1β levels together with MPO activity, whereas these values were maintained at the control group levels through SPL activation. However, ischemia/reperfusion decreased Na+/K+ATPase activity in ileal tissues; however, these parameters were found to be significantly increased with SPL activation. The protective effect of SPL against ischemia/reperfusion injury by different mechanisms, mainly the activity of the Na+/K+-ATPase pump, suggests that this nontoxic agent may constitute a new clinical therapeutic principle.

Gastric cancer with situs inversus totalis: does it really create difficulties for surgeons?

Introduction Situs inversus totalis (SIT) is a very rare condition that is seen at a rate of one in about 6000–8000 births. Aim To offer a general view on the coexistence of SIT and gastric cancer, accompanied by a literature review. Material and methods Within the scope of this study, the case of a patient with gastric adenocarcinoma and SIT has been presented. Previous research on gastric cancer cases with SIT was reviewed through a comprehensive search of the PubMed, Medline, and Google Scholar databases. The keywords used to conduct this research were “situs inversus totalis and gastric cancer,” “situs inversus totalis and gastric malignant,” and “situs inversus totalis and gastric resection.” The database search covered English studies published between 2000 and 2016. Results The results of our literature review revealed 20 studies of patients with gastric cancer and SIT, and 21 related cases. Overall, 12 of the patients were male, 9 were female, and their mean age was 61.8 ±10.97 years. The vascular assessment data showed that three out of the 13 mentioned cases had vascular anomalies. Eleven of the patients had laparoscopic resections, and one of the patients that had a surgical procedure exhibiting a postoperative mechanical obstruction. Conclusions The coexistence of SIT and gastric cancer is a very rare condition, and a careful preoperative radiological assessment should be conducted because there can be accompanying vascular anomalies. Laparoscopies and robotic surgeries can be performed for suitable patients at experienced centres, consistent with oncological principles.

Kardiyak nedenlerle hastanede yatan hastalarda spontan rektus kılıf hematomu: Tek merkez deneyimi

BACKGROUND This study presents the relationship between mortality and spontaneous rectus sheath hematoma (RSH) in inpatients receiving anticoagulant and antiaggregant treatment for cardiac pathology at cardiology and cardiovascular surgery clinics. METHODS Within the scope of our study, the cases of 27 patients who were diagnosed with spontaneous RSH between January 2010 and December 2015 at Kartal Kosuyolu High Speciality Training and Research Hospital were retrospectively evaluated. RESULTS Of the 27 patients, 19 (70.4%) were female and 8 (29.6%) were male. The mean age was 63±12 (32-84) years. All the patients had at least one comorbidity that necessitated follow-up. Fourteen patients received only anticoagulant treatment, 8 received only antiaggregant treatment, and the remaining 5 received both types of treatment. Physical examination of all patients revealed painful palpable masses in the lower quadrants of the abdomen. According to the results of computed tomography (CT) scans, which showed the size and localization of the masses, 7 of the cases were classified as Type I, 6 as Type II, and 14 as Type III. Although 23 of the cases received medical treatment, the remaining 4 patients received surgical treatment. Eight (29.6%) patients suffered mortality. CONCLUSION RSH is rare, but its prevalence is increased among patients receiving anticoagulant and antiaggregant treatment for cardiac reasons. The mortality rate markedly increased among patients who contracted RSH during hospitalization for cardiac reasons, had comorbidities, and experienced additional complications due to extended hospitalization.

Emergency cases following elective colonoscopy: Iatrogenic colonic perforation

Objective Our aim in this study was to present the cases of our patients who contracted colonic perforation during elective colonoscopy and became emergency cases; we also discuss treatment modalities along with literature reports on the subject. Material and Methods Cases of patients who contracted iatrogenic colonic perforation following endoscopy of the colorectal system between January 2009 and December 2015 at Kartal Koşuyolu Yüksek İhtisas Training and Research Hospitals Endoscopy Unit were reviewed retrospectively. Results Within the duration of the study, 5.586 patients underwent colonoscopies at our hospital; 7 (0.12%) of these patients contracted iatrogenic colonic perforation. Three (42.8%) of these patients were male, four (57.2%) were female, and their mean age was 69 years (46 to 84). Six (85.7%) patients were diagnosed intraoperationally, while one (14.3%) patient was diagnosed 12 hours after the procedure. The perforation area was the sigmoid colon in six patients and the ascending colon in one patient; all patients underwent surgery. Four patients were discharged with no complications. One of the remaining three patients had enterocutaneous fistula, one had acute renal failure, and one died of sepsis. Conclusion The progress of perforation due to colonoscopy varies according to the underlying diseases, the mechanism of perforation formation, the treatment modality used, and the experience of the physicians treating the patient. Special attention should be paid to senior and comorbid patients receiving therapeutic procedures during colonoscopy.

Endoscopic approach to anastomotic leaks: partially covered self-expandable stents. A single center’s experience

Introduction: Anastomotic leakage is an important and undesirable major complication after upper and lower gastrointestinal surgery. This complication can lead to significant morbidity and mortality and prolonged hospital stay. The objective of this study was to evaluate the safety and technical and clinical outcomes of temporary partially covered self-expandable metallic stent (PCSEMS) placement for treating anastomotic leaks after gastrointestinal tract surgery. Material and methods: Medical records of 9 patients who had undergone partial covered self-expandable esophageal or colonic stenting either for colorectal anastomotic leak or esophageal anastomotic leak in Kartal Kosuyolu Higher Specialty Training and Research Hospital between April 2012 and October 2015 were collected. Living patients were recalled for the policlinic follow-up and recent status was recorded. Results: The mean age was 57 (37–78) years. Six of the patients were male and 3 of them female. Stents were successfully placed in all patients in the fistula localization on the first attempt. Stent migration was encountered in 3 patients and restenting was performed in 2 of these patients. No complications were seen related to the indwelling stents. Stent treatment failure occurred in 2 of the 9 patients. The mean removal time of the stent was 43 (5–70) days and it was not possible to get the stent out in 1 patient. Conclusions: Endoscopic stenting is a minimally invasive and highly effective procedure that gives promise for the treatment of fistula after digestive surgery in the future.

Preoperative immunonutrition regulates tumor infiltrative lymphocytes and increases tumor angiogenesis in gastric cancer patients

Introduction An increased number of tumor infiltrative lymphocytes (TILs) is considered a favorable prognostic factor in various cancers because it is a marker of antitumoral activity of the immune system. In this prospective, non-randomized clinical trial, we evaluated the impact of preoperative immunonutrition on tumor infiltrative lymphocytes and neoangiogenesis in cancerous tissue in patients with locoregional and resectable gastric adenocarcinoma. Material and methods Patients with locoregional and resectable gastric adenocarcinoma were divided non-randomly into two study groups. The first (control) group included patients who had standard nutrition, and the second group included those who had immunonutrition for 7 days before surgery. The biopsy samples taken endoscopically in the preoperative period, as well as the gastrectomy samples, were subjected to immunohistochemical staining for quantitative analysis of CD4, CD8, CD16, CD56, CD31 and CD105 antibodies. Main outcome measures were CD4-to-CD8 ratio and CD105 levels. Results Fifty patients were included in the study between January 2013 and December 2014. Twenty-five patients were assigned to each of the first and second group. The CD4-to-CD8 ratio and CD105 levels determined in endoscopic biopsy samples were similar in both groups. The CD4-to-CD8 ratio in gastrectomy samples was significantly higher in the first group (p = 0.0001). The CD105 levels in gastrectomy samples were significantly lower in the first group (p = 0.01). Conclusions Seven-day preoperative immunonutrition use regulates TILs in gastric cancer patients, but prolonged use increases tumor angiogenesis.

Emergency abdominal surgery in patients with left ventricular assist device: short- and long-term results

Introduction Emergency abdominal surgery (EAS) in patients with long-term mechanical circulatory support and strong anticoagulation is very difficult. Aim To present our experiences regarding the short- and long-term results of patients with a left ventricular assist device (LVAD) who underwent emergency abdominal surgery under general anesthesia at a large tertiary healthcare center. Material and methods The electronic medical records of 7 patients with LVAD who underwent EAS between January 1, 2010 and December 31, 2016 were retrospectively investigated in order to evaluate perioperative management and outcomes. The patients were divided into two groups based on the need for EAS procedures. Results Seven (9.2%) of 76 patients with LVAD underwent EAS an average of 79.1 ±79.4 days after implantation. No statistically significant differences were found between the groups with and without EAS with regard to demographic characteristics, type of device, and rate of perioperative mortality (p > 0.05). The indications for surgery, retroperitoneal hematoma in 2 patients and in 5 other patients; ileus, iatrogenic splenic injury associated with thoracentesis, splenic abscess, acute abdominal pain and rectal cancer surgery was a pelvic abscess in a patient who is connected to the stump. In all cases laparotomy was performed with median incision. The perioperative mortality rate was 28.6% (n = 2). Two patients underwent orthotopic heart transplant during long-term follow-up. Conclusions The EAS is not rare during LVAD treatment but is a rather complex procedure. General surgeons will be increasingly likely to encounter such patients as their numbers rise and their life expectancies are prolonged.