Sinan Çarkman

The effects of hyperbaric oxygen on normal and ischemic colon anastomoses.

BACKGROUND Leakage from colonic anastomoses is a major complication causing increased mortality and morbidity, and ischemia is a well-known cause of this event. Inadequate tissue oxygenation could be reversed by using hyperbaric oxygen. This study was designed to investigate the effects of hyperbaric oxygen on the healing of ischemic and normal colon anastomoses in the rat model. METHODS Standardized left colon resection 3 cm above the peritoneal reflection and colonic anastomosis were performed in 40 Wistar rats divided into four groups. The control group (I) received no further treatment. To mimic ischemia, 2 cm mesocolon was ligated on either site of the anastomosis in group II and IV rats. Hyperbaric oxygen therapy was started immediately after surgery in group III and IV rats (therapeutic groups). All animals were sacrificed on the fourth postoperative day. After careful relaparotomy, in situ bursting pressure was measured. The hydroxyproline contents of the anastomotic segments in equal length were determined. RESULTS The hydroxyproline assay revealed that rats in group II with ischemic colonic anastomosis have significantly lower levels (P <0.05). The highest levels are in the group III rats with normal colonic anastomosis treated by hyperbaric oxygen (P <0.05). There was no significant difference in hydroxyproline levels between group II and group IV animals (P >0.05). Group III animals had significantly higher bursting pressures than any other group (P <0.05). Group II rats had lowest bursting pressures (P <0.05). Group IV animals had significantly higher levels than group II (P <0.05). Mean bursting pressure values both in groups III and IV and hydroxyproline levels in group III were significantly increased by hyperbaric oxygen therapy (P <0.05). CONCLUSIONS Ischemia impairs anastomotic healing. Hyperbaric oxygen increases anastomotic healing of both normal and ischemic colonic anastomosis and reverses ischemic damage. This study demonstrated that hyperbaric oxygen improves anastomotic healing.

Rupture of the Hydatid Disease of the Liver into the Biliary Tracts

Background: To analyze the diagnosis and the surgical treatment of intrabiliary ruptured hydatid disease of the liver. Methods: Between 1990 and 1995, 263 patients with hydatid cysts of the liver underwent surgery in a university hospital. Twenty-five (9.43%) patients with intrabiliary rupture of hepatic hydatid cyst were retrospectively reviewed. Results: Diagnosis was principally made using ultrasonography and computed tomography scanning and was confirmed by the findings of other tests. In 12 patients (48%) partial cystectomy with primary closure; 5 patients (20%) partial cystectomy with drainage; 5 patients (20%) cystotomy with drainage; 3 patients (12%) left hepatic resection (atypic, segmentary or lobar) was performed. Omentoplasty was performed in 6 patients. The common bile duct was explored in all patients and it was drained by a T-tube in 22 patients, and by a choledochoduodenostomy in 3 others. The average postoperative hospitalization time was 8.3 and 22.5 days in patients treated with choledochoduodenostomy and T-tube drainage respectively. Cholecystectomy was performed in 18 patients. Complications were seen in 4 patients (16%) with 1 pleural effusion and 3 wound infections. There was only 1 death (4%) due to duodenal peptic ulcus perforation with intrabiliary ruptured hydatid cyst. Conclusion: This study indicates that T-tube drainage and choledochoduodenostomy in intrabiliary ruptured hydatid cysts are effective procedures with low morbidity and mortality rates.

Lack of evidence that Obesity is a cause of pilonidal sinus disease

OBJECTIVE To find out whether pilonidal sinus is more common among obese people. DESIGN Retrospective study from hospital records. SETTING Two university hospitals, Turkey. SUBJECTS 419 patients who were operated on for pilonidal sinus disease; and 213 age and sex matched patients with benign diseases other than pilonidal sinus disease and who were not morbidly obese acted as controls. MAIN OUTCOME MEASURES Comparison of body mass index (BMI) in the two groups. RESULTS Patients with BMI of 25-30 were classified as overweight (61/419, 15% compared with 28/213, 13%), and those with BMI of 30 or more as obese (7/419 compared with 4/213, 2% in each group). Mean (SD) BMI of patients with pilonidal sinus disease was 26.0 (3.9) compared with 25.6 (3.9) in the control group (p = 0.4). CONCLUSION Obesity alone is not an important factor in the aetiology of pilonidal sinus disease.

Comparison of the Electrothermal Vessel-Sealing System Versus Endoclip in Laparoscopic Appendectomy

BACKGROUND Various techniques have been used for the division of mesoappendix, such as endoloops, endoscopic linear cutting staplers, an electrothermal vessel-sealing system (LigaSure), the Harmonic Scalpel, clips, and bipolar coagulation. In the present study, LigaSure and an endoclip were compared in laparoscopic appendectomy (LA). MATERIALS AND METHODS This study included patients who underwent LA for acute appendicitis at Istanbul University, Cerrahpasa Medical Faculty, Emergency Unit (Istanbul, Turkey) between May 2003 and April 2007. The patients were assigned to two groups according to the mesoappendix dissection device: LigaSure and endoclip groups. The main outcome measures (e.g., operating time, conversion rate, hospital stay, postoperative complications, etc.) were then compared. RESULTS LA was performed in 280 patients with acute appendicitis. LigaSure and endoclips were used in 127 and 153 patients, respectively. The mean operative times were 41 and 54 minutes in the LigaSure and endoclip groups, respectively. Conversions to open rates were found to be 9.4% (12 patients) in the LigaSure and 11.1% (17 patients) in endoclip groups. No statistically significant differences regarding hospital stay or complications were found, whereas significant differences were observed in surgical time and conversion rate. CONCLUSION The use of LigaSure facilitates the dissection of mesoappendix and shortens the operation time in LA. We believe that LigaSure is a safe, useful tool for mesoappendix dissection.

Enteroclysis-guided laparoscopic adhesiolysis in recurrent adhesive small bowel obstructions.

The aim of this study was to point out the efficiency of enteroclysis assay in localization of intraabdominal adhesions that impede small bowel transit in patients with recurrent adhesive small bowel obstruction who underwent laparoscopic partial adhesiolysis. Between January 1998 and June 2001, 15 selected patients with recurrent adhesive small bowel obstructions were treated successfully by medical means and evaluated with enteroclysis to define the pathologic adhesive site that impeded bowel transit. If the results of enteroclysis were indicative, they underwent laparoscopic partial adhesiolysis. The mean duration of the laparoscopic procedure was 99 minutes. In one patient conversion to laparotomy occurred because of excessive adhesions, and in another patient a small bowel injury occurred and enterorrhaphy was performed laparoscopically. Mean postoperative hospital stay was 4 days. During a mean follow-up of 17.2 months (range, 6–39), there was no delayed morbidity or recurrence. Identification of the small bowel site of recurrent obstruction with enteroclysis permits limited laparoscopic adhesiolysis. This approach may be a rational alternative to not only open procedures but also complete laparoscopic adhesiolysis without enteroclysis.

The Effect of Halofuginone, a Specific Inhibitor of Collagen Type 1 Synthesis, in the Prevention of Pancreatic Fibrosis in an Experimental Model of Severe Hyperstimulation and Obstruction Pancreatitis

BACKGROUND The aim of this paper is to assess the effects of halofuginone, a specific inhibitor of synthesis of collagen Type 1, on fibrogenetic process in an experimental model of early pancreatic fibrosis. METHODS Thirty rats were divided into three equal groups: group 1, sham laparotomy; group 2, severe hyperstimulation and obstruction pancreatitis (SHOP) with no treatment; group 3, SHOP with halofuginone treatment group. SHOP model was induced by complete pancreatic duct obstruction and daily cerulein hyperstimulation (50 microg/kg, intraperitoneally). Halofuginone was administered daily from the operative day (5 mg/kg, intraperitoneally). All of the animals were sacrificed, and blood and pancreatic tissue samples were obtained for biochemical and histopathological examination on the 5th postoperative day. RESULTS No mortality was observed in any group. Serum amylase, lipase, hyaluronic acid, and nitric oxide levels were significantly higher in groups 2 and 3 compared with group 1 (P < 0.05), but were significantly lower in group 3 compared with group 2 (P < 0.05). No significant differences were observed regarding serum malondialdehyde and glutathione levels between groups 1 and 3. Tissue hydroxyproline levels were found to be significantly higher in groups 2 and 3 compared with group 1 (P < 0.001), but were significantly lower in group 3 compared with group 2 (P < 0.001). Although tissue hydroxyproline levels were significantly higher in the halofuginone treatment group compared with the control group, histopathological evaluation did not reveal a significant difference between these groups regarding collagen deposition. When group 3 was compared with group 2, halofuginone significantly reduced inflammation and acinar atrophy in the pancreas as well (P < 0.05). CONCLUSION Halofuginone was found to be effective in reducing SHOP-related inflammation, acinar atrophy, and fibrosis in the pancreas.

The effects of pneumothorax on the respiratory mechanics during laparoscopic surgery.

Pneumothorax is rare but can be a severe complication of laparoscopic surgery. Diagnosis of pneumothorax in laparoscopy includes the sudden increase in end-tidal carbon dioxide (EtCO(2)) with a decrease in compliance and an abnormal increase in airway pressure. By these case reports, we recommend the simultaneous monitoring of airway pressures, dynamic compliance, and particularly, EtCO(2) for an immediate diagnosis and prompt treatment of pneumothorax.

Laparoscopy offers diagnosis and treatment in abdominal stab injuries.

Purpose To assess the role of laparoscopy in the diagnosis and treatment of abdominal stab injuries (ASI). Methods Patients who underwent laparoscopic procedures due to ASI were included in the study. Hemodynamic instability, injuries to the posterior trunk, concomitant severe cranial injuries, and prior abdominal operations were considered as contraindication for laparoscopy. Results From January 1997 to March 2006, 88 patients underwent laparoscopic management of ASI. In 45 patients (51.1%), there was no intra-abdominal pathology requiring surgical intervention (nontherapeutic laparoscopy) and 5 patients in this group had no peritoneal penetration (negative laparoscopy). In another 25 patients (28.4%), laparoscopic treatment was performed (therapeutic laparoscopy), including bleeding control in liver, colonic, gastric, and diaphragmatic repairs and intra-abdominal bleeding control. Laparotomy was avoided in a total of 70 (79.5%) patients. In 18 patients (20.5%), laparoscopy was converted to laparotomy. There was no mortality, and except one missed small bowel injury nor perioperative morbidity in patients undergoing laparoscopy. In the laparotomy group, major complications were seen in 7 patients. Conclusions Laparoscopy is safe and efficient in the management of ASI and should be more frequently considered as a therapeutic tool.

Cecum perforation due to tuberculosis in a renal transplant recipient: a case report

IntroductionTuberculosis can present in many varied clinical situations in immunosuppressed patients. It has been reported that the sigmoid colon is the most common site for colonic perforation in renal transplant recipients and diverticulitis is its most common cause. Cecal perforation because of tuberculosis is extremely rare in a renal transplant recipient. We present the case of a renal transplant patient with cecal perforation due to tuberculosis, 10 years after renal transplantation.Case presentationA 39-year-old Caucasian man, who was a renal transplant recipient, was admitted to our emergency surgery unit with an acute abdomen. A cecal perforation was found at exploratory laparotomy, and a right hemicolectomy with an end ileostomy and transverse colonic mucous fistula were performed. Necrotizing granulomatous colitis due to tuberculosis was reported in the histopathologic examination.ConclusionColonic perforations in immunosuppressed patients may have unusual presentations and unusual causes. Tuberculosis infection should be considered in the differential diagnosis during the histopathologic evaluation in immunocompromised patients such as renal transplant recipients.

Late Results of Patients Undergoing Remedial Operations for Alkaline Reflux Gastritis Syndrome

Abstract Purpose: Many different remedial operations for alkaline reflux gastritis have been described. Analysis of their efficacy is difficult, because while many of the procedures have good early results, there are long-term failures due to their own complications. The aim of this study is to evaluate our experience with patients undergoing remedial operations for alkaline reflux gastritis syndrome. Material and methods: The clinical features and results of remedial operations of 65 patients with alkaline reflux gastritis syndrome were reviewed retrospectively. Data on the hospital course were collected by interviewing patients directly or by telephone contact. An assessment of each patient’s response to remedial operation was then made and a Visick score assigned. Results: All patients had been tried on a medical treatment and dietary restriction or both prior to remedial operation. Long-term follow up was possible in 46 patients. Seventy-six percent of patients who at the final state had a truncal vagotomy, distal gestrectomy and Roux-en-Y gastrojejunostomy have been found to show satisfactory results (Visick-I/Visick II). Three patients who had previously undergone a Roux-en-Y conversion later required re-operation for Roux-stasis syndrome and a near-total gastrectomy was performed on these patients. Other operations performed for alkaline reflux gastritis were converted to “uncut” Roux-en-Y in five patients and dismantling of gastrojejunostomy in two patients. Conclusions: For patients unresponsive to medical treatment, we reccommend the following strategy : a) for patients with truncal vagotomy plus gastrojejunostomy, dismantling of gastrojejunostomy should be the first choice b) for patients with prior Billroth-II gastrectomy, Roux-en-Y conversion is the most effective corrective operation, although it has its proper including Roux statis syndrome.