Umit Ozcelik

Liver Transplantation for Biliary Atresia

Biliary atresia is the most common indication for liver transplantation (OLT) in children. We present our experience with OLT as a treatment for end-stage liver disease in children with biliary atresia. We performed a retrospective review of 20 biliary atresia patients (11 male, 9 female patients; mean age, 21.4 months; range, 6 to 84 months) who had undergone OLT. Mean preoperative weight and height were 10.1 +/- 5.8 kg and 72.5 cm, respectively. Thirteen recipients were younger than 1 year of age, and 15 weighed less than 10 kg at the time of OLT. Fourteen recipients had undergone a Kasai operation prior to the OLT. The mean serum total bilirubin level was 22.56 mg/dL before OLT. Eighteen left lateral segment grafts and two whole grafts were transplanted. The mean recipient operative time was 9.25 hours. The mean recipient intraoperative blood loss was 1.81 U. Two hepatic arterial thromboses and one biliary leak occurred soon after surgery. Portal vein stenoses developed in two recipients at 10 and 12 months after OLT; both were treated with balloon dilatation. Two biliary stenoses, which occurred at 10 months and 3.5 years after surgery, were treated with balloon dilatation. Two recipients died at 2 and 12 days after OLT because of respiratory distress syndrome and sepsis, respectively. The remaining 18 (90%) recipients are alive with good graft function. The overall rejection rate was 31.25%. OLT is an effective treatment for children with biliary atresia and a failed Kasai procedure. Living related liver grafts represented an excellent organ supply for these patients.

Laparoscopic Treatment of Gallstone Ileus

Gallstone ileus is a rare complication of cholelithiasis that has high morbidity and mortality. An intestinal obstruction can be caused by migration of a large gallstone through a biliary enteric fistula or by impaction within the intestinal tract. In this study, we present the case of an 81-year-old woman with a mechanical bowel obstruction by a gallstone that was treated by laparoscopy.

Effect of Topical Platelet-Rich Plasma on Burn Healing After Partial-Thickness Burn Injury.

Background To investigate the effects of platelet-rich plasma on tissue maturation and burn healing in an experimental partial-thickness burn injury model. Material/Methods Thirty Wistar albino rats were divided into 3 groups of 10 rats each. Group 1 (platelet-rich plasma group) was exposed to burn injury and topical platelet-rich plasma was applied. Group 2 (control group) was exposed to burn injury only. Group 3 (blood donor group) was used as blood donors for platelet-rich plasma. The rats were killed on the seventh day after burn injury. Tissue hydroxyproline levels were measured and histopathologic changes were examined. Results Hydroxyproline levels were significantly higher in the platelet-rich plasma group than in the control group (P=.03). Histopathologically, there was significantly less inflammatory cell infiltration (P=.005) and there were no statistically significant differences between groups in fibroblast development, collagen production, vessel proliferations, or epithelization. Conclusions Platelet-rich plasma seems to partially improve burn healing in this experimental burn injury model. As an initial conclusion, it appears that platelet-rich plasma can be used in humans, although further studies should be performed with this type of treatment.

Massive alimentary tract bleeding due to cytomegalovirus infection in an elderly patient

In recent years, cytomegalovirus (CMV) has been recognized as an important common pathogen in immunocompromized patients. This is due to the increasing number of immunosuppressive medications, intensive cancer chemotherapy use, recurrent transplantations, progressively aging population, and the higher number of human immunodeficiency virus infections. Cytomegalovirus infection especially interests the gastrointestinal tract, anywhere, from the mouth to the anus. Namely, the most commonly affected area is the colon, followed by duodenum, stomach, esophagus and small intestine. The most frequent manifestations of CMV colitis are: diarrhea, fever, gastrointestinal bleeding and abdominal pain. We report here the case of an 82-year-old woman, who was treated for non-Hodgkin lymphoma; she was admitted to the emergency department for abdominal pain and diffuse arthralgia, following massive upper- and lower- gastrointestinal bleeding, due to duodenal and colonic ulcers related to CMV infection.

Jejunal torsion around the right ureter presenting as postoperative bowel obstruction: a case report

IntroductionSince abdominal radical hysterectomy was first described by Clark and Reis in 1895, it has been commonly used in the primary surgical treatment of carcinoma of the cervix. We report the case of a 45-year-old woman who was diagnosed with a small bowel obstruction due to jejunal torsion to her right ureter mimicking postoperative adhesion ileus.Case presentationA 45-year-old Turkish woman was admitted to our emergency department with complaints of abdominal pain, constipation, nausea and vomiting. She had undergone an abdominal radical hysterectomy for cervical carcinoma three years earlier. Computed tomography scans revealed intestinal dilatation, a large amount of free fluid in the abdominal cavity and an area suspicious for jejunal perforation. Because of these radiological findings suggestive of obstruction and bowel ischemia, our patient underwent emergency surgery. Operative findings that showed a jejunal segment was turned around her right ureter so that it was mimicking a fibrous band.ConclusionsIn this current case, we present the first determined complication of radical hysterectomy. According to our case report, surgical oncologists should be aware of this complication and review the surgical technique. It is considered that readaptation of the dorsolateral peritoneal layer after extended pelvic lymph node dissection resulted in fewer complications.

Evaluation of Transplanted Kidneys and Comparison with Healthy Volunteers and Kidney Donors with Diffusion-Weighted Magnetic Resonance Imaging: Initial Experience.

OBJECTIVES The aim of this study was to evaluate the feasibility of diffusion-weighted magnetic resonance, by comparing imaging in renal allograft recipients for functional assessment of kidney transplants versus imaging of these features in healthy volunteers and kidney donors with native kidneys. MATERIALS AND METHODS Seventy renal transplant recipients (group A) with stable graft function at postoperative month 1, 40 healthy volunteers (group B), and 40 kidney donors (group C) underwent diffusion-weighted magnetic resonance imaging. An echo-planar diffusion-weighted imaging sequence was performed in coronal orientation by using 6 b values (0, 200, 400, 600, 800, 1000 s/mm²). The apparent diffusion coefficients were determined for the upper and lower poles of the kidney cortex and medulla. Relations between apparent diffusion coefficients and allograft function, determined by the estimated glomerular filtration rate (comparing rates > 60 mL/min/1.73 m² [group A1] versus < 60 mL/min/1.73 m² [group A2]), were investigated in renal transplant recipients, and apparent diffusion coefficients in groups A, B, and C were compared. RESULTS Apparent diffusion coefficients were statistically higher in group A1 than in group A2 (P < .05) and statistically higher in group A than in groups B and C (P < .001). There were no significant differences between groups B and C (P > .05). CONCLUSIONS We observed that apparent diffusion coefficients of transplanted kidneys at postoperative month 1 were higher than values in native kidneys of healthy volunteers and kidney donors. In addition, apparent diffusion coefficients of transplanted kidneys with estimated glomerular filtration rates > 60 mL/min/1.73 m² were higher than transplanted kidneys with rates < 60 mL/min/1.73 m².

Cutaneous Necrosis As a Result of Isosulphane Blue Injection in Mammarian Sentinel Lymph Node Mapping: Report of Two Cases

Skin-sparing mastectomy with sentinel lymph node biopsy (SLNB) and synchronous breast reconstruction are widely used in breast cancer surgery nowadays. Difficulties in feeling confident in this technique and postoperative surgical complications are the major obstacles against the widespread usage of this technique. Compared with the other surgical techniques, the complications are hard to treat. Cutaneous necrosis because of methylene blue used for sentinel lymph node mapping in patients who underwent skin-sparing mastectomy and SLNB is already reported in the literature. We present here two cases with cutaneous necrosis because of isosulphane blue injection after skin-sparing mastectomy and SLNB as a rare complication of dye injection.

Surgical Treatment for Ureteral Obstruction After Kidney Transplantation

Introduction Ureteral obstruction occurs in 2% to 10% of renal transplant patients postoperatively, usually presenting within the first few weeks or the first year. Ureteric ischemia is the most common cause, accounting for around 90% of occurrences. The first option for treatment is interventional radiological methods. Percutaneous therapy of ureteral strictures consists of balloon dilatation with or without temporary stenting. If all of these methods are unsuccessful, surgical treatment should be applied. We evaluate the outcomes of 5 patients who treated with surgical teqniques for ureteral obstruction. Materials and Methods Since November 1975, we performed 2646 RT procedures at two different centers by the same transplantation team. At our institution, we perform ureteral anastomoses by means of a corner saving technique. We performed 7 surgical procedures for ureteral obstructions. All patients with ureteral occlusion had recurrent urinary tract infection before surgical treatment and interventional radiological procedures were performed prior to surgery. Results Four of the patients were living donor kidney transplantation and 3 of them were deceased donor transplantation. Four of them were female. For 4 patients, the old ureteroneocystostomy was terminated and new ureteroneocystostomy was performed. In 1 patient, we performed native nephrectomy and end-to-side anastomosis between the native ureter and graft’s renal pelvis. In 2 patients, we performed ureteroureterostomy and side-to-side anastomosis between the native and graft ureters. During the surgical procedure, double J stent was placed in to the anastomosis and removed in the first month. After reconstruction procedure urinary tract infection did not occur. During the follow up period graft functions are normal. Conclusions Ureteral strictures are rare complications that can lead to graft loss. Prompt diagnosis and remedial treatment are vital to prevent graft loss. The interventional radiological methods are the first choice for treatment, surgical procedures should be performed in patients who do not benefit from these treatments.

Our Experience with Paired Kidney Exchange Transplantation

Introduction Paired kidney exchange (PKE) transplantation has gained popularity worldwide as the best alternative for renal recipient candidates who are sensitized to their donors or have ABO incompatible donors. In this study we present our early results of paired kidney exchange transplants. Materials and Methods We started our PKE transplantation programme in July 2015. Various incompatible pairs were matched depending upon the availability of suitable donors and compatible recipients. Matching and donor allocation was done manually. As far as possible, donors were matched for age and glomerular filtration rate. In a meeting before transplantation, all details of the surgery as well as the legal and ethical requirements were given, informed consent was received. Induction was offered to all patients. Antithymocyte globulin induction therapy was administered at the time of transplantation as well as the third day posttransplant; tacrolimus (target level 8-10 ng/mL), mycophenolate mofetil (1g twice a day) and prednisolone were started as immunosuppressive therapy and tacrolimus was maintained with a target level of 6-8 ng/mL 3 months after the operation. All patients were followed up twice weekly for the first 2 weeks, once weekly for the second 2 weeks, once a fortnight for the second and third months. Data were collected from medical records, including demographic data, follow-up serum creatinine, acute rejections, graft, and patient loss and infections. Results Seven pairs were matched from July 2015 to September 2017 and we performed 14 PKE (5 women, 9 men) transplants. Mean recipient age was 49.8±11.5 (range: 23-61) and mean donor age was 50.4± 12.4 (range: 38-64) years. Five of the donors were fathers, one of them was a mother, 3 were husbands and 5 were wives. Mean mismatch ratio was 5±1 (range: 3-6). Reason for exchange was ABO incompatibility for 10 patients and positive crossmatch and presence of donor specific antibodies for 4 patients. All were 2-way donations. Median waiting time for getting suitable donor after registration was 3 months. Two of the recipients were retransplanted and desensitization with plasmapheresis was needed for panel reactive antibody positivity. One patient underwent preemptive kidney transplant. Mean serum creatinine level at one month and at third month after transplant were 1.03±0.37 and 0.97±0.25 mg/dL. There were only 2 early biopsy-not-proven acute rejection episodes treated with pulse steroids and 2 urinary tract infections treated with oral antibiotics. In 1 patient external iliac artery was replaced with ePTFE vascular graft due to complete dissection. All patients are alive with no serious complications. Conclusions ABO incompatibility continues to pose a serious problem for transplantation candidates, especially in kidney and liver transplants. Our small series shows that PKE transplantation is an alternative for patients without a viable living-related donor or deceased compatible donor organ.

Comparison of Kidney Extraction Incisions in Laproscopic Living Donor Nephrectomy: A Single-Center Experience

Introduction Laparoscopic donor nephrectomy has become alternative to the open procedure. Many studies comparing techniques and extraction incisions during laparoscopic donor nephrectomy have been reported. Here our aim is to compare our Pfannenstiel and extended iliac port site incisions for kidney extraction in transperitoneal laparoscopic donor nephrectomy. Materials and Methods Between October 1985 and October 2017 we performed 2781 kidney transplantation procedures at our centers. Since January 2015, we performed 54 laparoscopic transperitoneal donor nephrectomies. Kidney retrieval were done through either Pfannenstiel incision or extended iliac port incision. Two groups were compared according to demographic features, graft weight, warm ischemia, hospital stay and cosmetic results. Results In group 1; 21 kidneys were extracted through Pfannenstiel incision. In group 2; 34 kidneys were retrieved via extended iliac port incisions. There were not any statistical difference between group 1 and 2 with respect to BMI (mean 24.73 vs 25.29), graft weight (mean 184.66 gr vs 206.06 gr) and hospital stay (mean 1.5 vs 1.8 days). However, warm ischemia time was significantly shorter in group 2 (mean 248.09 vs 166.21 seconds) (p< .001). The cosmetic results were analyzed with POSAS scale and in Pfannenstiel incision group cosmetic results were much more better. Conclusion In living donor nephrectomy kidney retrieval procedure should be safe and comfortable, without compromising the function of the graft. To date several modifications of the standard transperitoneal laparoscopic approach have been applied and each of them claim to have specific advantages. According to our experience, extraction of kidney through extended iliac port incision has worse cosmetic results but significantly short warm ischemia time than Pfannenstiel incision.