Sedat Belli

Preoperative therapeutic plasma exchange in patients with thyrotoxicosis

The purpose of this report was to determine the effectiveness of therapeutic plasma exchange (TPE) in preoperative preparation of patients with thyrotoxicosis scheduled for either thyroid or nonthyroid surgery. We retrospectively reviewed 11 patients with thyrotoxicosis and those who prepared surgery with plasmapheresis between 1999 and 2008 at our institution. Ten patients underwent thyroid surgery and one patient was operated for femur fracture during antithyroid drug treatment. The indications for plasmapheresis in all patients with severe thyrotoxicosis were poor response to medical treatment (seven patients), agronulocytosis due to antithyroid drugs (three patients), iodine‐induced thyrotoxicosis (Jodd Basedow effect in one patient), and rapid preparation for urgent orthopedic operation (one patient). After TPE, we observed a marked decrease in free thyroxin (FT3) and free triiodothyronin (FT4) levels; however, the decline in the biochemical values were not statically significant (P > 0.62, P > 0.15). Although both FT3 and FT4 levels remained above the normal limits in two of 11 patients, the signs and symptoms of thyrotoxicosis improved in all patients and no thyroid storm observed during the perioperative period. TPE can be considered a safe and effective alternative to prepare patients with thyrotoxicosis for surgery when drug treatment fails or is contraindicated and when emergency surgery is required. J. Clin. Apheresis, 2009.

Prospective randomized controlled trial comparing V–Y advancement flap with primary suture methods in pilonidal disease

BACKGROUND An ideal treatment method for the widely prevalent pilonidal sinus disease is not yet available. The most commonly practiced technique is simple closure following resection of the effected tissue. However, high recurrence rates in some series have led to the search for other methods. One of these methods is the V-Y advancement flap (VYAF), which in theory results in the flattening of the natal cleft without tension in the suture line. METHODS In this prospective randomized controlled study, the VYAF method was compared to 2 simple primary closure techniques. In 238 patients, following resection, in the AL (all layers) group, all layers were closed with polypropylene sutures. In the SS (subcutaneous suture) group, polyglactin subcutaneous sutures were used to approximate the wound edges. Skin was closed separately in the SS group. In addition, demographic variables, past history, physical examination findings, defect dimensions, and wound tension were recorded. RESULTS Surgical site infection was observed in 23.9%, 17.4%, and 10.2% of the patients in AL, SS, and VYAF groups, respectively (P = .129). Early wound dehiscence without infection was detected in 11.9%, 7.4%, and 10.2% of the patients in groups AL, SS, and VYAF, respectively (P = .665). Mean follow-up was 29.7 +/- 15.6 months. Survival (time without recurrence) was not significantly different between groups (P = .648). In the whole group, independent predictors of recurrence according to logistic regression analysis were younger age, recurrent disease, presence of discharge on physical examination, and development of postoperative surgical site infection. CONCLUSIONS VYAF is not superior to simple primary closure techniques in terms of postoperative complications, recurrence, and patient satisfaction. For most cases, simple primary closure would suffice. Patients should be informed of the increased risk of recurrence if any of the independent predictors (being a recurrent case, presence of discharge, development of postoperative infection) are present.

Protective Role of Simvastatin on Lung Damage Caused by Burn and Cotton Smoke Inhalation in Rats

BACKGROUND Smoke inhalation injury is a major comorbid factor in patients with thermal injury and occurs in about 30% of patients with major burns. In addition, inhalation injury reportedly accounts for 20%-84% of the mortality in burned individuals and is associated with higher mortality rates for every age and burn size category. The aim of the present study was to investigate the effects of simvastatin on lung damage with burn and cotton smoke inhalation. METHODS Wistar rats were randomly assigned to three groups: saline treated control group, via an orogastric route (group 1, n = 6), burn (30%) and cotton smoke inhalated group (group 2, n = 6), and simvastatin treated (25 mg/kg/d, via an orogastric route) burn (30%) and cotton smoke inhalated group (group 3, n = 6). Rats were sacrificed at 48 h of the treatments and the trachea and lungs were removed completely. Tissue samples were taken for histopathologic, immunohistopathologic, and biochemical analyses. Univariate analysis of variance coupled with Duncans post-hoc test was performed for statistical evaluation. RESULTS Lung parenchymal and tracheoepithelial damage was confirmed in group 2 by histopathologic examination. Lung malonedialdehyde (MDA) levels were significantly decreased (P < 0.001), while glutathione (GSH) concentration did not alter in group 2 compared with group 1. Also, immunopathologic data revealed that epithelial iNOS level was elevated, while no modulation was detected in the level of myeloperoxidase (MPO). Simvastatin administration resulted in decreasing the lung parenchymal and tracheoepithelial damage. Tissue MDA levels were decreased significantly (P < 0.001), whereas GSH concentrations were elevated in group 3 compared with group 1 and group 2 (P < 0.001). Simvastatin treatment caused a decrease in epithelial iNOS levels, while MPO levels were not modulated. In addition, simvastatin significantly reduced pulmonary apoptosis in lung injury. CONCLUSIONS Our results have indicated that simvastatin administration seems to play beneficial role in lung injury of rats promoted by combined burn and smoke inhalation. Thus, simvastatin may represent a potential approach to prevent smoke inhalation-associated lung dysfunction. However, the significant decrease in basal oxidant production may cause impairment in cellular signalling processes.

A Comparative Study of Conservative versus Surgical Treatment Protocols for 77 Patients with Idiopathic Granulomatous Mastitis

The purpose of this study was to analyze the clinical features and demographic data of patients with idiopathic granulomatous mastitis (IGM) and to compare the results of conservative versus surgical treatment protocols. The demographic data, clinical findings, microbiological and pathologic features, scanning and treatment methods, recurrence, and recovery rates of 77 patients were analyzed retrospectively. The patients were divided into two groups based on the type of treatment received. Core biopsies were used to diagnose 37 patients: 26 using incisional biopsies and 14 using excisional biopsies. Of the patient population with IGM, 31 were treated with surgical excision, one with a simple mastectomy, and one with a subcutaneous mastectomy combined with a breast implant, whereas 44 were treated with steroids. The recovery rates of the 44 patients who were treated conservatively were 6 (1–15) months while for the 33 patients who were treated surgically, it was 1 (1–5) month (p = 0.001). Nine patients from the conservative treatment group experienced a recurrence while there were no recurrences in the surgically treated group (p = 0.009). Among all patients, the recurrence rate was 11.7% (9/77) while the average follow‐up period was 16.57 ± 18.57 months. As a comparative study between conservative treatment protocols and surgical ones for patients with idiopathic granulomatous mastitis (IGM), this study is the largest to date. A wide surgical excision is the preferred approach for treating patients with IGM because of the low recurrence rate.

Effects of a tissue sealing-cutting device versus monopolar electrocautery on early pilonidal wound healing: a prospective randomized controlled trial.

BACKGROUND: Monopolar electrocauterization produces thermal effects on neighboring tissues, causing tissue damage. Recently, tissue sealing-cutting devices, which are easy to use and achieve simultaneous selective sealing and cutting with less production of heat, have been used. OBJECTIVE: The aim of this study was to investigate the effects of a tissue sealing-cutting device vs monopolar electrocautery on wound healing in the early postoperative period after pilonidal sinus surgery. DESIGN: This study was a prospective randomized clinical trial. SETTING: This study was conducted at Military Hospital, Eskisehir, Turkey. PATIENTS: In total, 128 patients with chronic pilonidal disease were randomly assigned into 2 clinically comparable groups between December 2009 and June 2010. INTERVENTION: Pilonidal sinus excision was performed with monopolar electrocautery in the control group (n = 64) and with a tissue sealing-cutting device in the study group (n = 64). Data regarding wound healing, demographic variables, history, physical examination findings, defect dimensions, and scores for a visual analog scale were recorded. MAIN OUTCOME MEASURES: The main outcomes measured were surgical site infection, early wound failure (dehiscence), and unhealed wound rate. RESULTS: Wound infection and dehiscence rates were significantly lower (P = .01 and .02), but the duration of surgery was significantly longer (P < .01) in the tissue sealing-cutting group. The unhealed wound rate was 12.5% in the electrocautery group and 4.7% in the tissue sealing-cutting group (P = .01). When the distance from the lowest margin to the anus was 5 cm or less, wound infection and dehiscence rates were lower in the tissue sealing-cutting group (P < .01 and .03). LIMITATIONS: We could not obtain data regarding the cost-effectiveness of the instruments. CONCLUSIONS: A tissue sealing-cutting device in pilonidal sinus surgery yields better wound healing than monopolar electrocautery.

Spontaneous giant splenic hydatid cyst rupture causing fatal anaphylactic shock: A case report and brief literature review

Hydatid disease is a parasitic infection characterized by cyst formation in any organ, although the liver and lungs are most commonly involved. Hydatid disease of the spleen is uncommon, representing <8% of all human hydatid diseases. Splenic hydatid cysts usually coexist with liver hydatid cysts (secondary form), although the spleen is the primary location (primary form) in some cases. The clinical signs and symptoms of splenic hydatid cysts depend on their size, relationship with adjacent organs, and complications. One of the complications of splenic hydatid cysts is cyst rupture either after trauma or spontaneously as a result of increased intracystic pressure. These cysts may rupture into a hollow organ, through the diaphragm into the pleural cavity, or directly into the peritoneal cavity. A splenic hydatid cyst that ruptures into the peritoneal cavity may cause complications, including signs of peritoneal irritation, urticaria, anaphylaxis, and death, as in our case. Therefore, a hydatid cyst rupture requires both emergency surgery and careful postoperative care. In this study, we present a case of a giant splenic hydatid cyst that ruptured into the peritoneal cavity without any trauma. A review of cases reported in the English literature about splenic hydatid cyst perforation is also discussed.

Parasitic Infections of the Appendix as a Cause of Appendectomy in Adult Patients

OBJECTIVE Assessment of frequency and clinical findings of parasitic infections for etiology of acute appendicitis. METHODS Data of 1452 patients who were carried out appendectomy between January 1999 and December 2012 were analyzed retrospectively. Appendectomy was performed in 1159 of the patients with a pre diagnosis of acute appendicitis. Demographics, physical findings, radiologic and laboratory studies, operative findings, pathological results, presence and type of parasitosis were investigated. RESULTS Among the 1159 patients done appendectomy with a pre diagnosis of acute appendicitis, 719 (62%) were males and 440 (38%) were females. Parasitic infection was demonstrated in 17 (1.4%) of them. Mean average age of these patients was 36.6 ± 20.1 years. Enterobius vermicularis was present in 15 (88.2%) and Entamoeba histolytica in 2 (11.8%) of the patients. Of the pathology specimens of appendix consisting Enterobius vermicularis, 12 (80%) were normal appendix tissues, 1 (6.6%) was acute uncomplicated appendicitis and 2 (13.3%) were perforated appendicitis. One (50%) of the two specimens consisting Entamoeba histolytica was normal appendix and the other (50%) was acute appendicitis. CONCLUSION Differential diagnosis of parasitic infections in etiology of acute appendicitis should be made properly. It must be remembered that this attention can save patients from a negative laparotomy and morbidity and mortality of it.

Results of modified Dufourmentel rhomboid flap in patients with extensive Sacrococcygeal pilonidal disease.

Abstract Purpose: The aim of our study was to assess our modified Dufourmentel flap outcomes in a standardized patient group (a symptom duration of equal to or greater than 60 months, presence of equal to or more than 3 sinus ostia or presence of sinus ostia fistulized equal to or greater than 2 cm laterally, and a normal body mass index) with extensive pilonidal sinus. Methods: Patients who were diagnosed with chronic pilonidal sinus disease and gave consent to surgical repair with modified Dufourmentel flap were enrolled. Patients were assessed with respect to age, sex, body mass index, presenting symptom, symptom duration, number of previous operations, number of sinus ostia, length of flap rims, depth of inter-gluteal sulcus, distance of sinus from anus, duration of operation, time of drain removal, length of hospital stay, early postoperative complications, postoperative pain, loss of labor, length of follow-up, and recurrences. Results: A total of 42 patients were enrolled. Average duration of presenting symptoms was 64.4 ± 4.7 months and average length of follow-up was 29.4 ± 3.6 months. Average length of hospital stay was 4.2 ± 0.8 days, and time to return to work was 16.3 ± 2.1 days. Two patients (4.7%) developed postoperative wound infection, one patient (2.4%) developed seroma, and three patients (7.1%) had wound dehiscence. There was no recurrence. Conclusion: Modified Dufourmentel flap application can be safely used in the treatment of extensive pilonidal sinus disease.

Surgical treatment modalities for complicated aneurysms and pseudoaneurysms of arteriovenous fistulas

Purpose This study was designed to determine the clinical presentation, characteristics, and management of aneurysm/pseudoaneurysm formation (APF) in dialysis access fistulas. Methods The treatment methods and outcomes of 31 patients who underwent surgery for APF in dialysis access fistulas were retrospectively reviewed over a 9-year period. Results We performed 1558 operations for arteriovenous fistulas (AVFs) between 2000 and 2009 at our centre. Of the 1558 operations, 35 were carried out for APFs (2.2%) on 31 patients. Thirty of these operations were restorative. Twenty-two (71%) of these patients had their original access done elsewhere, and all corrective surgeries were performed at our hospital. Approximately 52% of the subjects were female, with a mean age of 45.7 ± 17 years. The mean duration of end-stage renal disease was 70.2 ± 51.5 months. The mean number of AVFs per patient was 2.2 ± 1.5. Synthetic grafts were used in five patients (16.1%). Most of the procedures were left-sided (67.7%) and brachial-cephalic fistulas (48.3%). Among 31 complications, 22 were arterial/venous aneurysms (71%) and nine were pseudoaneurysms (29%). Fourteen patients (46.6%) were treated by excision of the aneurysm and primary suture repair. The post-intervention primary patencies for all revised APFs were 68%, 56%, and 52% at 1, 6, and 12 months, respectively. Dysfunction of AVF (16.1%) and bleeding (12.9%) were the most encountered complications after aneurysmectomy. Conclusion Reformative operations should be considered in cases of urgency and irresponsiveness to endovascular surgery rather than closing the fistulas directly, as it prolongs the duration of AVF patency.

Factors affecting morbidity in urgent repair of abdominal wall hernia with intestinal incarceration in adults

BACKGROUND The aim of this study was to investigate factors that affect morbidity in adults with incarcerated intestinal hernia of the abdominal wall. METHODS 124 patients with a mean age of 61 ± 13.87 years (73 males) underwent emergency surgery for incarcerated intestinal hernia between March 1999 and March 2008. The median duration of the hernia was 5 years (0.1-30). Type and duration of hernia, accompanying diseases, surgical procedure, and operation-related complications were retrospectively evaluated. RESULTS Twenty-five patients (20%) had complications. Twelve patients (10%) had surgical site infection and 10 patients (8%) had septic complications. Four patients (3%) died in the postoperative period. Out of 40 patients developing strangulation, 18 underwent bowel resection. The only independent variable concerning bowel resection other than inguinal hernia was found to be ventral hernia (p=0.039). There was no statistical significance between duration of hernia and incarceration and complications. The rate of complications was significantly high in the patients with accompanying diseases (p<0.001). The relation between age and complications was also significant (p=0.034). Multivariate analyses showed high ASA scores as the only independent variable for development of complications (p<0.001). CONCLUSION Patients with comorbid diseases and high ASA scores should be informed about the elevated risk of complications, and scheduled surgery before the development of incarceration should be recommended.