Tarkan Unek

Risk Factors for Early Bacterial Infections in Liver Transplantation

OBJECTIVE Our aim was to determine perioperative risk factors for early bacterial infection after liver transplantation. METHODS Retrospectively examining medical records using Centers for Disease Control and Prevention (CDC) definitions to identify nosocomial infections, we analyzed data on 367 adult patients. RESULTS The incidence of infection was 37.3% (n = 137): namely, surgical site (n = 74; 20.2%) [corrected], blood stream (n = 64; 17.4%), pulmonary (n = 49; 13.4%), urinary system (n = 26; 7.1%). Significant risk factors within the first 30 days were as follows: deceased donor, Model for End-Stage Liver Disease (MELD) >20, albumin level <2.8 g/dL, intraoperative erythrocyte transfusion >6 U, intraoperative fresh frozen plasma >12 U, bilioenteric anastomosis, postoperative intensive care unit stay >6 days, and postoperative length of stay >21 days. Significant risk factors detected within the first 90 days were as follows: MELD >20, preoperative length of stay >7 days, reoperation, postoperative length of intensive care unit stay >6 days, and postoperative length of stay >21 days. Variability was observed in risk factors according to localization of infection. As a result, except for MELD, type of donor, and biliary anastomosis, the others are preventable factors for early bacterial infection. In addition, the same risk factors showed variability according to the site of infection.

Multivisceral resections for primary advanced rectal cancer.

Abstract Fixation of the locally advanced rectal tumor at the time of operation is an important prognostic variable. It may be difficult to determine whether fixation is caused by inflammatory adhesions or by direct tumor extension tethering the tumor to the surrounding pelvic structures. Extended en bloc removal of the locally advanced rectal cancer with involved adjacent organ(s) increases the resectability rate. We examined the perioperative mortality and morbidity and the prognosis of patients undergoing multivisceral resections for advanced primary rectal cancers. Of 83 patients with rectal cancers 20 (24%) had locally advanced tumors. Cases were divided into Gunderson-Sosin stages B3 and C3 and were further stratified into those with histologically confirmed carcinomatous invasion of the adjacent organ and those with inflammatory adhesions. Perioperative mortality was 5%. Only five patients (24%) showed histopathological confirmation of carcinomatous adhesion into adjacent organ(s)/structure(s). Histological confirmation of contiguous tumor spread was higher in C3 patients. There was no significant difference between patients with positive and negative histopathological confirmation of malignant spread in terms of survival rates. Multivisceral resections can be performed safely for locally advanced rectal cancers with acceptable mortality and morbidity rates. The presence of local tumor extension does not mean incurability, and sound surgical judgement should dictate that in the face of a tethered lesion one must extend the surgical intervention radically to resect any tumor en bloc.

BENEFICIAL EFFECTS OF PENTOXIFYLLINE PRETREATMENT IN NON-HEART-BEATING DONORS IN RATS

BACKGROUND Pentoxifylline (PTX) pretreatment of recipients was shown to protect against liver graft failure from ischemia-reperfusion injury after orthotopic rat liver transplantation. It has also been shown that PTX protects against normothermic ischemia-reperfusion injury to the liver in lobar ischemia model in the rat. Whether PTX can benefit the liver procured from non-heart-beating donors (NHBDs) with up to 9 hr of cold ischemia is unknown. METHODS Donor and recipient rats were pretreated with intraperitoneal PTX (50 mg/kg) 1 hr before cardiac arrest and transplantation, respectively. Grafts were transplanted 0, 30, and 60 min after cardiac arrest with additional 1 and 9 hr of cold ischemia in both PTX-pretreated or untreated (control) groups (10 rats per group). PTX (25 mg/kg/day) was continuously given to the surviving rats for 5 days postoperatively. Recipient survival rates, serum enzyme levels, and histopathological examination of postreperfusion liver biopsies were all analyzed. RESULTS The survival rates, serum enzyme levels, and postreperfusion histology were significantly improved in groups pretreated with PTX compared to the controls. CONCLUSION Donor and recipient PTX pretreatment significantly improves the viability of the liver grafts procured from NHBDs.

What is the role of the abdominal perfusion pressure for subclinical hepatic dysfunction in laparoscopic cholecystectomy

BACKGROUND Subclinical hepatic dysfunction after laparoscopic cholecystectomy (LC) has been described in the literature. However, this alteration is not encountered in all patients. In order to address this situation, a prospective study was conducted to investigate the effect of abdominal perfusion pressure (APP) on liver function tests after LC performed under constant intra-abdominal pressure (IAP). PATIENTS AND METHODS Of 78 patients who underwent LC between May 2007 and October 2007, 40 patients were eligible for the study. In all the patients, six parameters of liver function (aspartate aminotransferase, alanine aminotransferase, direct bilirubin, indirect bilirubin, alkaline phosphatase, and gamma-glutamyltransferase) were assessed before and 24 hours after surgery. Patients who showed more than a 100% increase in at least one parameter (group 1) were compared to those who did not (group 2) regarding age, sex, body weight, body height, operation time, pneumoperitoneum time, IAP, preoperative, and intraoperative APP. RESULTS Of the patients, 37.5% showed more than a 100% increase in at least one parameter of liver function. No significant difference was found between the two groups with regard to age, sex, body weight, body height, operation time, pneumoperitoneum time, and IAP. There were significant increase in AST and ALT at 24 hours postoperatively in group 1, as compared with group 2 (P = 0.000, P = 0.001). In comparison of preoperative APP with intraoperative APP values, group 1 showed a statistically significant decrease (P = 0.000), while no difference was found in group 2. CONCLUSION Subclinical hepatic dysfunction after LC could mostly be attributed to the negative effects of the pneumoperitoneum on hepatic blood flow. For the evaluation of hepatic hypoperfusion, APP may be a new criterion as a determinant of interaction with mean arterial pressure (MAP) and IAP.

Potentially Curative Resection for Locoregional Recurrence of Colorectal Cancer

PurposeLocal recurrence after curative surgery for colorectal cancer may be treated by potentially curative surgery, defined as resection of all macroscopic disease. We conducted this retrospective study to show the effectiveness of potentially curative resection for patients with locoregional recurrence (LRR).MethodsWe reviewed the records of 242 patients who underwent curative resection of colorectal cancer in our unit between 1988 and 2000. Locoregional recurrence developed in 50 (20.6%) patients, and was treated by R0 resection in 10 (20%) patients (group R0), by R1 resection in 8 (16%) patients (group R1), by R2 resection in 13 (26%) patients (group R2), and by surgery without resection in 12 (24%) patients (group NR). Seven (15%) patients did not undergo surgery (group NS).ResultsThe mean survival periods were 48, 36, 10, 5.6, and 5 months in groups R0, R1, R2, NR, and NS, respectively. There was no significant difference in survival between groups R0 and R1 (P = 0.5), but survival was significantly longer in groups R0 and R1 than in groups R2, NR, and NS (P = 0.001).ConclusionThese findings show that surgeons should aim to achieve at least macroscopic clearance of the recurrent tumor. Potentially curative surgery improves survival in selected patients with LRR after curative resection of colorectal cancer.

The prognostic value of detecting symptomatic or asymptomatic recurrence in patients with gastric cancer after a curative gastrectomy

BACKGROUND Although studies have investigated whether a routine follow-up should be performed after a gastrectomy, no consensus has been reached on the significance of the follow-up or the optimal surveillance protocol. In the present study, we evaluated the significance of the presence or absence of symptoms in the detection of recurrences after curative gastrectomy for gastric cancer. METHODS We retrospectively analyzed 173 patients with recurrent gastric cancer who underwent radical gastrectomy. We evaluated the prognostic significance of the presence of cancer-related symptoms at the diagnosis of recurrence, and the relationship between the presence of symptoms and other clinicopathological factors. RESULTS We detected a symptomatic recurrence in 42.2% of patients. The presence of symptoms were significantly correlated with tumor size, pT stage, pN stage, pathologic stage, and short disease-free interval (<12 mo). The median disease-free survival (DFS), post-recurrence survival (PRS), and overall survival (OS) times for patients with asymptomatic recurrence were significantly longer than those of patients with symptomatic recurrence (disease-free survival was corrected as DFS, 11.1 versus 9.3 mo, P < 0.001; PRS, 4.9 versus 3.1 mo, P = 0.02; OS, 18.3 versus 12.3 mo, P = 0.001, respectively). Multivariate analysis showed that the presence of cancer-related symptoms (P = 0.033; hazard ratio [HR], 0.81) was an independent prognostic factor for PRS, as were short disease-free intervals (P < 0.001; HR, 2.42), age (P = 0.02; HR, 1.53), and the presence of chemotherapy in recurrence (P = 0.001; HR, 0.49). In addition, multivariate analysis indicated that the presence of symptoms, short disease-free interval, and age were also independent prognostic indicators for OS. CONCLUSIONS Our results demonstrate that symptomatic recurrence is an important prognostic factor for PRS of patients with gastric cancer after a curative gastrectomy. The presence of symptomatic recurrence may be a new and beneficial prognostic marker to evaluate biologic aggressiveness, which is an important determinant of survival at the time of recurrence diagnosis during a follow-up for gastric cancer.

Comparison of Milan and UCSF criteria for liver transplantation to treat hepatocellular carcinoma

AIM To assess the validity of the Milan and University of California San Francisco (UCSF) criteria and examine the long-term outcome of orthotopic liver transplantation (OLT) in patients with hepatocellular carcinoma (HCC) in a single-center study. METHODS This study is a retrospective review of prospectively collected data. Between 1998 and 2009, 56 of 356 OLTs were performed in patients with HCC. Based on pathological examination of liver explants, patients were retrospectively categorized into 3 grou-ps: Milan + (n = 34), Milan -/UCSF + (n = 7) and UCSF - (n = 14). RESULTS Median follow-up period was 39.5 (1-124) mo. The 5-year overall survival rates in the Milan +, Milan -/UCSF + and UCSF-groups were 87.7%, 53.6% and 33.3%, respectively (P < 0.000). Within these groups, tumor recurrence was determined in 5.8%, 14.3% and 40% of patients, respectively (P < 0.011). Additionally, the presence of microvascular invasion within the explanted liver had a negative effect on the 5-year disease free survival (74.7% vs. 46.7%, P < 0.044). CONCLUSION The Milan criteria are reliable in the selection of suitable candidates for OLT for the treatment of HCC. For cases of OLT involving living donors, the UCSF criteria may be applied.

Acute Renal Injury Evaluation after Liver Transplantation: With RIFLE Criteria

BACKGROUND The aim of this study was to identify acute renal injury (ARI) through the use of RIFLE (risk, injury, failure, loss, end-stage kidney disease) criteria and to investigate perioperative risk factors for ARI in liver transplantation (LT). METHODS We reviewed medical records of adult LT patients retrospectively. Postoperative ARI was staged with RIFLE criteria by the 1st and 7th days of the surgery. RESULTS We analyzed 440 adult LT patients, categorized as risk (R), injury (I), or failure (F) according to the RIFLE criteria. In this study, in the first postoperative day, incidence of ARI was 7.95%; all of them were R-class, and, on the 7th day, the incidence of ARI was 7.27%, as R-class 6.59% and I-class 0.68%. Significant risk factors were detected within the first postoperative day including pre-operative hemoglobin levels <9 g/dL (P = .019), intra-operative transfusion of red blood cells (RBCs) (P = .049) and fresh-frozen plasma (FFP) (P = .049), blood loss (P = .011), and post-reperfusion syndrome (P = .023). Multivariate analysis revealed risk factors for ARI as RBCs (odds ratio [OR], 1.049; P = .247) and FFP (OR, 1.017; P = .627) transfusion and blood loss (OR, 1.000; P = .021) (blood loss OR: 0.9996952300184; 95% confidence interval: 0.9994356774026 to 0.999548500399). The only significant risk factor for the 7th postoperative day was the Model for End-Stage Liver Disease (MELD) score (>20) (P = .002). CONCLUSIONS This study showed that RBC and FFP transfusion, perioperative blood loss, and MELD score >20 are risk factors for LT-related ARI. Also normalization of hemoglobin levels with non-blood products in patients with preoperative low hemoglobin levels can diminish the need for RBC and that can prevent ARI.

Papillary carcinoma arising in subhyoid ectopic thyroid gland with no orthotopic thyroid tissue

Ectopic thyroid gland with no orthotopic thyroid tissue is extremely rare. The authors present a case of a follicular variant of papillary carcinoma developed from an ectopic thyroid gland with no orthotopic thyroid tissue.

Chemical necrotizing fasciitis due to household insecticide injection: is immediate radical surgical debridement necessary?

We describe two cases of chemical necrotizing fasciitis in the upper extremities, anterior chest wall and epigastric region of the abdominal wall caused by household insecticide injection. We suggest that surgical debridement can be successfully performed in the subacute period under close observation in hemodynamically stable patients.