Vedat Kirimlioglu

Spontaneous Small Bowel Perforations Due to Intestinal Tuberculosis Should Not Be Repaired by Simple Closure

Intestinal tuberculosis is a major problem in many regions of the world. The incidence of it is rising in Western countries due to immigration from Third World countries and human immunodeficiency virus infection. The difference between the simple closure and resection and anastomosis was evaluated in this study. Retrospectively, 12 patients with intestinal tuberculosis diagnosed histopathologically among 50 patients with free intestinal perforations operated on between 1995 and 2003 at Turgut Ozal Medical Center were evaluated. Each patient underwent routine laboratory tests and radiologic studies. The most common symptoms of patients were abdominal pain, night sweats, and weight loss. Sites of perforation were ileum in 10 patients (multiple perforation in 4) and jejunum in 2 patients (both had multiple perforations). The perforation was closed by primary closure in 7 patients. Resection-anastomosis was performed in 5 patients. Leaks occurred in overall 3 of 7 patients with primary closure. Three of the 7 patients with leaks due to septicemia died. The mortality rate among all patients was 25%. Intestinal tuberculosis should be kept in mind as a cause in free intestinal perforations. Because of high mortality rate, the resection of the affected area and anastomosis may be the treatment of choice rather than primary closure.

Spontaneous Intestinal Perforation Due to Non-Hodgkin's Lymphoma: Evaluation of Eight Cases

Primary intestinal lymphoma with spontaneous perforation and after systemic chemotherapy is rare. The present study summarizes retrospectively the outcome of eight free intestinal perforated patients diagnosed with intestinal non-Hodgkins lymphoma. Two patients had a history of systemic chemotherapy before perforation. The most common symptoms of the patients were abdominal pain, nausea, vomiting, weight loss, and fever. Sites of perforation were ileum in four, jejunum in two, cecum in one, and sigmoid colon in one patient. Synchronous lymphoma was present in three patients. The perforation was closed by primary closure in three patients. Resection/anastomosis was performed in four patients and sigmoid colostomy was performed in one patient. Three patients were lost due to leakage or septicemia. Intestinal lymphoma might be kept in mind as a cause in free intestinal perforations. Because of the high mortality rate early diagnosis and treatment are important to improve the prognosis of bowel perforation in patients with non-Hodgkins lymphoma.

Expression of Matrix Metalloproteinases 2 and 9 in Donor Liver, Cirrhotic Liver, and Acute Rejection After Human Liver Transplantation

Matrix proteinases are known to play an important role in the cell migration during cancer invasion, in organ development, and in tissue damage during inflammatory process. Among the matrix proteinases, matrix metalloproteinases (MMP) are the most powerful proteinases. Changes at the extracellular matrix components play an essential role in acute rejection after orthotopic liver transplantation (OLT). This prospective clinical study investigated the alterations in the expression of MMP-2 (72-kd gelatinase type IV collagenase [gelatinase A]) and MMP-9 (92-kd gelatinase type IV collagenase [gelatinase B]) in patients with acute cellular rejection (ACR) compared with the biopsies of cirrhotic livers (CL) of patients who underwent OLT, and with healthy livers (HL) of the donors. Although MMP-2 expression was not present in the hepatocytes of the HL, it was in the endothelium; it was moderate in CL and severe in the livers suffering from ACR. MMP-9 expression, on the other hand, is found to be present only in the inflammatory cells, with an increasing intensity in HL, CL, and in livers suffering from ACR. The results suggest that MMP-2 and MMP-9, beside their roles in liver injury with tissue remodeling and fibrosis as mentioned in the previous studies, can be a marker of acute rejection.

Effect of resveratrol and melatonin on oxidative stress enzymes, regeneration, and hepatocyte ultrastructure in rats subjected to 70% partial hepatectomy.

AIM We sought to compare the antioxidant effects of resveratrol (R) and melatonin (M) after 70% partial hepatectomy (PH) as evidenced by ultrastructural alterations and effects on hepatocyte proliferation and apoptosis. METHODS Twenty-six male Wistar albino rats were randomized into four groups: group A (n = 8) resveratrol (R); group B (n = 8) melatonin (M); group C (n = 5) control PH; group D (n = 5) sham operated animals. The rats that received either R or M were sacrificed a week after PH. The malondialdehyde, glutathione, glutathione S-transferase, and nitric oxide levels were estimated in liver homogenates. The morphological changes were investigated using light and electron microscopy (EM). Cell proliferation was detected by immunohistochemical staining with monoclonal antibodies to Ki-67. Apoptosis was detected by the transferase-mediated dUTP nick end-labeling method. RESULTS PH induced hepatic LP, decreased GSH and NO, and inhibited GST activity (P < .05). R and M completely prevented PH-induced lipid peroxidation, decreased hepatic GSH and NO levels (P < .05). The inhibition of GST activity was prevented by R (P < .05), but not with M (P > .05). In the PH group EM showed severe morphological changes: mitochondrial degeneration, vacuoles, lipid droplets, and myelin-like figures. In both the R and M groups, morphological alterations repaired protective effects more prominently in the R group. Ki-67 indices (KI) were increased in the PH group and decreased in both R and M groups (P < .001). In the M group, KI was the lowest, but the difference compared with R was not significant (P > .05). Apoptosis was slightly increased in PH, but in either the R or M groups, apoptosis was intensively increased (P < .001). Increased apoptosis was greatest in the M group and the difference compared with the R group was statistically significant (P < .05). CONCLUSION R and M suppressed PH-induced oxidative damage, attenuated proliferation, and stimulated apoptosis. When we compared R and M, R showed more potent antioxidative effects and was morphologically more protective to hepatocytes. Antiproliferative effects of M were more potent. Because of their potent antioxidative effects, R and M can be effective for oxidative damage like ischemia-reperfusion injury; however, because of the adverse effects on proliferation and apoptosis more studies are needed in states in which regeneration is critical.

A Life-saving but Inadequately Discussed Procedure: Tube Duodenostomy. Known and Unknown Aspects

ObjectiveThe most successful method of managing the difficult duodenum, including the stump leakage, has been the tube duodenostomy technique, but it has not gained wide acceptance and is rarely used. The purpose of this study is to describe the details of the procedure for indication, technical approach, and postoperative care.MethodsDuring the period from 1998 to 2006, a tube duodenostomy was performed in 31 patients for possible insecure duodenal stump closure during gastric resection, postoperative duodenal stump leakage, duodenal leak after primary closure of duodenum for perforation or injury, or anostomotic leak after choledochoduodenostomy. All of the tube duodenostomies were performed through the open end of the duodenum. We also inserted a T-tube into the common bile duct in 19 of 31 patients (61.2 %) with tube duodenostomy.ResultsA tube duodenostomy was performed in the primary operation in 15 of 31 patients. None of those 15 patients required a second operation, and there were no leaks and no deaths. Among the larger group (31 patients), there was one (3.2 %) duodenal stump leak after tube duodenostomy, and it ceased spontaneously; one patient had a subhepatic collection after removal of the duodenostomy tube, and three patients had associated incisional infections. Two patients died; one after a myocardial infarction and the other from irreversible sepsis. The mean length of hospital stay was 26.9 days.ConclusionsWe conclude that tube duodenostomy is a simple, effective, and safe method to prevent rupture of an insecure duodenal stump or to treat the leakage from the duodenal stump or primary repair on the duodenum.

Subcutaneous hydatid cysts occurring in the palm and the thigh: two case reports

IntroductionHydatid cyst disease is common in some regions of the world and is usually located in the liver and lungs. This report presents two cases of primary hydatid cysts located subcutaneously: one in the medial thigh and one in the left palm between the index and middle fingers.Case presentationsA 64-year-old male farmer visited our hospital because a swelling on the right medial thigh had grown during the last year. Superficial ultrasound and computed tomography revealed a lesion resembling a hydatid cyst. A germinative membrane was encountered during surgical excision. Pathological examination was compatible with a hydatid cyst. The second case involved a 67-year-old male farmer who complained of a swelling that had grown in his left palm in the last year. The preliminary diagnosis was a lipoma. However, a hydatid cyst was diagnosed during surgical excision and after the pathological examination. The patient did not have a history of hydatid cyst disease and hydatid cysts were not detected in other organs. There has been no disease recurrence after following both patients for 3 years.ConclusionA hydatid cyst should be considered in the differential diagnosis of subcutaneous cystic lesions in regions where hydatid cysts are endemic, and should be excised totally, with an intact wall, to avoid recurrence.

Abdominal actinomycosis simulating malignancy of the right colon.

Actinomycosis is a chronic, suppurative, and granulomatous disease caused by an anaerobic or microaerophilic gram-positive bacterium, Actinomyces israelii, manifesting itself as fistula, sinus, inflammatory pseudotumor, or abscess formation. The cervicofacial region (50 to 65%) accounts for the majority of the cases followed by abdomen (20%) (1–5). Abdominal infection mostly involves the cecal area and can simulate malignant tumor on clinical and radiological examinations (1, 4, 6, 7). The diagnosis is almost always ascertained after surgery and histopathological examination of the specimen. The purpose of this report is to emphasize the possibility of encountering an abdominal mass related to actinomycosis in emergency cases and the benefit of limited surgical procedure.

Role of Matrix Metalloproteinase-7 in Colorectal Adenomas

Matrix metalloproteinases (MMPs) degregade and remodel the extracellular matrix. They are known to be overexpressed as normal mucosa progresses to adenomas and carcinomas. In our prospective study we measured the overexpression of MMP-7 immunohistochemically in various types of colonic adenomas. Although MMP-7 has already been shown to be overexpressed in various types of colonic adenomas, tubular versus villous adenomas had not been further seperated to date. Seventy-six patients had either normal mucosa (n=15) or tubular (n=32), tubulovillous (n=16), or villous (n=13) colonic adenoma. MMP-7 expression was classified into three categories, as negative, weakly stained, or strongly stained, depending on the percentage of cells stained. Each adenoma was graded according to the percentage of strongly stained areas in the adenoma as G0, G1, G2, or G3. Sixty-nine percent of villous adenomas showed grade 3 staining of MMP-7, versus none of the tubular adenomas. G0 and G1 staining was not detected in the villous adenomas. The results of the study show that the degrees of overexpression of the three subtypes of colonic adenomas were statistically significantly different. In conclusion, MMP-7 overexpression is thought to be an early event in the adenoma-carcinoma pathway.

Partial hepatectomy is curative for the localized type of Caroli's disease: A case report and review of the literature

The case of a 58-year-old woman who was diagnosed with the localized type of Carolis disease is presented. This disease involves the whole of the left half of the liver. A left hepatectomy was followed by complete resolution of symptoms. The current article suggests that hepatic resection may be aggressively performed in selected patients with the localized form of Carolis disease.

Resveratrol, a Red Wine Constituent Polyphenol, Protects Gastric Tissue Against the Oxidative Stress in Cholestatic Rats

This experimental study was designed to determine the effects of resveratrol on the level of malondialdehyde (MDA), reduced glutathione (GSH), and nitric oxide (NO) in gastric tissue after bile duct ligation (BDL). Swiss albino rats were divided into three groups: Group 1, sham (n = 7); Group 2, BDL (BDL only group; n = 7); and Group 3, BDL plus resveratrol (n = 7). Animals in the resveratrol group were treated with 10 mg/kg resveratrol (i.p.) once a day throughout 28 days. In the resveratrol group, levels of MDA and NO in gastric tissue were significantly lower than in the BDL-only group (P < 0.001). The level of GSH in the resveratrol group was significantly higher than in the BDL-only group (P < 0.001). The present study demonstrates that intraperitoneal administration of resveratrol maintains antioxidant defenses and reduces oxidative gastric damage. This effect of resveratrol may be useful to preserve gastric tissue under oxidative stress due to cholestasis.