Yüksel Arikan

The Comparison of the Oxidative Stress Effects of Different Gases and Intra-abdominal Pressures in an Experimental Rat Model

BACKGROUND Laparoscopy is used for almost all types of abdominal surgery because of its advantages, which include shorter postoperative hospital stay. However, pneumoperitoneum used to facilitate the visual field has severe metabolic, hemodynamic, and inflammatory consequences depending on the pressure level and the gas used. Helium (He), an inert gas, has been recommended for establishment of pneumoperitoneum since it does not alter the blood pH and PCO(2). Yet the oxidative response after He insufflation remains unknown. This study was undertaken to compare the levels of free radical production and antioxidant status following He and CO(2) pneumoperitoneum at different intra-abdominal pressure values. MATERIALS AND METHODS The subjects were 40 Sprague-Dawley male rats randomized to the following groups: He 10 (n = 8) was subjected to He pneumoperitoneum at 10 mm Hg for 60 minutes; He 15 (n = 8) was subjected to He pneumoperitoneum at 15 mm Hg for 60 minutes; CO(2) 10 (n = 8) was subjected to CO(2) pneumoperitoneum at 10 mm Hg for 60 minutes; CO(2) 15 (n = 8) was subjected to CO(2) pneumoperitoneum at 15 mm Hg for 60 minutes; and Control (n = 8) was subjected to sham operation without pneumoperitoneum. At the end of the experiment blood samples were obtained and plasma malondialdehyde, carbonyl, and sulphydryl levels were measured. RESULTS CO(2) pneumoperitoneum produced higher malondialdehyde and carbonyl responses and sulphydryl consumption compared to He, especially at 15 mm Hg (P = 0.01, P = 0.01, and P = 0.059, respectively). CONCLUSION Helium seems to limit the postoperative oxidative response following laparoscopy.

A Comparison of the Oxidative Stress Response and Antioxidant Capacity of Open and Laparoscopic Hernia Repairs

BACKGROUND Free radical-induced lipid peroxidation that is associated with a decrease in the antioxidant status of plasma occurs in many kinds of surgical procedures. In this study, we aimed to investigate markers of oxidative stress--malondialdehyde (as thiobarbituric acid reactive substances), protein carbonyls, and protein sulfhydryls--in patients undergoing Lichtenstein tension-free hernioplasty (LH) or laparoscopic preperitoneal hernia (LPPH) repair. METHODS Seventeen patients with unilateral inguinal hernia and no complications or recurrence were included in this study. Ten were randomized to undergo LH and seven to LPPH repair. Heparinized blood samples were taken to measure the levels of oxidative stress markers in the patients undergoing hernia repair. Levels of malondialdehyde, protein carbonyls, and protein sulfhydryls were measured preoperatively and at 6 and 24 hours postoperatively in all patients. RESULTS Both types of hernia repair caused a significant increase in the oxidative stress response and a decrease in antioxidant activity. Plasma levels of malondialdehyde and carbonyls (indicators of oxidant activity) were significantly higher in the LH than in the LPPH repair group (P<.05), and plasma sulfhydryl levels (indicators of antioxidant activity) were significantly lower in the LH than in the LPPH group (P<.05). In both groups, significant differences were also found between the preoperative levels and the postoperative levels 6 and 24 hours (P<.05). CONCLUSIONS These data demonstrate that both LH and LPPH repair cause a significant increase in markers of oxidative stress; however, the oxidative stress response associated with LH is greater than that associated with LPPH repair.

The effects of increased intraabdominal pressure on colonic anastomoses.

BackgroundThis experimental, randomized, controlled study was designed to investigate the effects of increased intraabdominal pressure (IAP) on colocolic anastomoses. To our knowledge, this is the first study to address this important issue.MethodsFor this study, 50 Wistar albino rats were randomized into five groups. The animals in all the groups underwent laparotomy and colocolic anastomosis. The rats in the control group were not subjected to increased IAP. Accordingly, IAP’s of 14, 20, 25, and 30 mmHg were established by carbon dioxide insufflation and maintained for 60 min in study groups 1, 2, 3 and 4, respectively. Colocolic anastomosis was realized after these periods of IAP in the study group. Half of the surviving rats in all the groups were sacrificed on postoperative days 7 and 14 to allow comparison between the control and study groups with respect to their mean body weights, mean anastomosis bursting pressures, and histopathologic characteristics of their anastomosis sites.ResultsThe mean body weights of all the groups were comparable at all times during the study. The anastomosis bursting pressures of the animals subjected to increased IAP were lower than that of the control group, with the differences reaching statistical relevance for the animals subjected to an IAP of 20 mmHg or higher on postoperative day 7 (p<0.0005 for study groups 2, 3, and 4 vs the control group). The anastomosis bursting pressure showed an inverse correlation with IAP. The adequacy of mucosal layer formation at the anastomosis line was lower and the degree of inflammation was higher in the groups exposed to an IAP of 20 mmHg or higher in the control group (p<0.05 for both comparison among study groups 2, 3, and 4 vs the control group).ConclusionsAn IAP increased to 20 mmHg and higher was found to result in impaired strength and wound healing in colocolic anastomoses, as reflected by the decreased bursting pressure and mucosal layer formation, and by the increased inflammation at the anastomosis sites of animals subjected to high IAP values.

Efficacy of thoracic epidural analgesia for laparoscopic cholecystectomy

IntroductionPostoperative pain is a commonly observed phenomenon after laparoscopic procedures. The use of new low-solubility inhalation anaesthetics leads to faster induction and recovery, but the effect of analgesics on pain when used with them is not sufficiently known. Optimally, analgesic therapy should be started in sufficient time as to be effective at the point of emergence from anaesthesia. We compared the effectiveness of intravenous and epidural analgesia in patients undergoing general anaesthesia with sevoflurane for laparoscopic cholecystectomy in the early postoperative period.MethodsThirty adult patients with American Society of Anesthesiologists (ASA) physical status I–II, scheduled for laparoscopic cholecystectomy, were enrolled in this study. The patients in the intravenous group (n=15) received general anaesthesia with sevoflurane and intravenous infusion of 1.5 μg/ml/kg/h fentanyl analgesia followed by postoperative intravenous infusion of 1.0 μg/ml/kg/h fentanyl, supplied by a programmed continuous analgesia pump. The patients in the epidural group (n=15) had combined epidural analgesia with 0.125% bupivacaine plus 50 μg fentanyl and general anaesthesia with sevoflurane, followed by continuous epidural infusion of 4 ml/h bupivacaine 0.125% plus 50 μg fentanyl. Visual analogue scores and the patients’ needs for analgesics and were recorded.

A rare condition: Ectopic liver tissue with its unique blood supply encountered during laparoscopic cholecystectomy.

Highlights • Developmental abnormalities of liver including ectopic liver are rare conditions.• Although it does not usually produce any symptom clinically, it can rarely result in serious complications such as bleeding, pyloric and portal vein obstruction.• Ectopic liver has the capacity of malignant transformation to hepatocellular carcinoma that makes it essential to be removed.• The vascular anatomy of ectopic liver should be identified before the dissection of gallbladder in order to prevent hemorrhage from the liver parenchyma.

Octenidine hydrochloride in hydatid disease.

Hydatid disease is still endemic in many devoloping countries and continues to be an important cause of morbidity. The objective of this study was to determine the in vitro scolicidal effects of octenidine hydrochloride in different concentrations using different exposure times. After hydatid cyst liquid was left to precipitate for 1 h to obtain cystic sand, various concentrations of octenidine (undiluted, 1% and 0.1% diluted) were added to concentrated hydatid cyst sediments for 5, 10, 15, 20, 25, 30, 45, and 60 min, and scolicidal effects of octenidine were compared with 20% saline and control group for the same times. It was found that undiluted octenidine had a strong scolicidal effect at 15 min compared to saline at 20%. One percent octenidine had a scolicidal effect at 30 min. However, 0.1% octenidine did not have enough scolicidal effect in 1 h. It was concluded that undiluted and 1% diluted octenidine might be used for scolicidal purpose in the treatment of hydatid disease.

The effects of CO2 pneumoperitoneum on the apoptotic index in the peritoneum.

During laparoscopic surgery, gases such as carbon dioxide (CO2), helium, or normal air are insufflated into the intra-abdominal cavity so the surgeon can obtain a clear surgical field; however, this insufflation technique may cause injury to the intra-abdominal organs. This study was undertaken to evaluate the effects of different pressures of CO2 on the apoptotic index in the peritoneum during laparoscopic surgery. A total of 30 Sprague-Dawley male rats were used in the study. CO2 was insufflated into the intra-abdominal cavity via an angiocatheter cannula by an insufflator at pressures of 10 and 20 mm Hg over 60 min. In the control group, the cannula was inserted into the intra-abdominal cavity, but no gas was insufflated. After 60 min, the rats were killed; peritoneum was harvested from the abdominal wall and was cultured in the cell culture laboratory. Apoptotic and living cells were detected immunohistochemically, and the apoptotic index was calculated and statistically analyzed. The data collected revealed that the apoptotic index increases in proportion to the level of CO2 pressure. CO2 pneumoperitoneum is a very useful technique. Gas pressure must be carefully set during the operation, however, or injured mesothelial cells may cause serious malfunction.

Results of the open surgery after endoscopic basket impaction during ERCP procedure

AIM To report the results of open surgery for patients with basket impaction during endoscopic retrograde cholangiopancreatography (ERCP) procedure. METHODS Basket impaction of either classical Dormia basket or mechanical lithotripter basket with an entrapped stone occurred in six patients. These patients were immediately operated for removal of stone(s) and impacted basket. The postoperative course, length of hospital stay, diameter of the stone, complication and the surgical procedure of the patients were reported retrospectively. RESULTS Six patients (M/F, 0/6) were operated due to impacted basket during ERCP procedure. The mean age of the patients was 64.33 ± 14.41 years. In all cases the surgery was performed immediately after the failed ERCP procedure by making a right subcostal incision. The baskets containing the stone were removed through longitudinal choledochotomy with the stone. The choledochotomy incisions were closed by primary closure in four patients and T tube placement in two patients. All patients were also performed cholecystectomy additionally since they had cholelithiasis. In patients with T-tube placement it was removed on the 13(th) day after a normal T-tube cholangiogram. The patients remained stable at postoperative period and discharged without any complication at median 7 d. CONCLUSION Open surgical procedures can be applied in patients with basket impaction during ERCP procedure in selected cases.

The Comparative Effects of Pneumoperitoneum on Apoptosis and p53 Expression in Gastrointestinal Organs

BACKGROUND Laparoscopic surgical techniques have been increasingly preferred to classic laparotomy by surgeons since 1987. The pneumoperitoneum is often used to facilitate the intra-abdominal field, but it carries the risk of its ischemic potential and has differences [l2]of metabolic, inflammatory, and infectious consequences, depending on the pressure set and kind of gas used. However, the mechanisms related with the cell injury observed after laparoscopy are still unknown. The aim of this study was to evaluate the effects of different pressures of CO(2) on apoptosis and p53 expression in small and large intestines and the stomach. MATERIALS AND METHODS In total, 30 Sprague-Dawley male rats were used in the study. CO(2) is insufflated into the intra-abdominal cavity through a angiocatheter cannule by an insufflator set at two different pressures of 10 and 20 mm Hg during 60 minutes. In the control group, the cannule was inserted into the intra-abdominal cavity without any other surgical procedure and no gas was insufflated. After 60 minutes, the rats were sacrificed and a laparotomy was performed. The small and large intestines and stomach were excised. The samples were histologically processed and an immunohistochemical analysis was performed. RESULTS The results of the study revealed that the number of apoptotic cells in intra-abdominal organs we studied increased in proportion to the CO(2) pressure level. However, the p53 expression was detected only in the stomach. CONCLUSIONS Our study showed that the number of apoptotic cells rises in parallel to the increase in intra-abdominal pressure following the CO(2) pneumoperitoneum in rat large and small intestine and stomach. Although the apoptosis was activated by the p53 pathway in the stomach, it was not so in the large and small intestine.

Laparoscopy Can Aggravate the Severity of Pancreatitis in an Experimental Rat Model

PURPOSE Over the past decade, laparoscopic techniques have markedly evolved, and it has been shown that minimally invasive surgery can provide a safe, effective, and less traumatic management of various surgical diseases. Additionally, it is well known that pancreatitis itself also produced severe oxidative tissue injury by increasing levels of reactive oxygen species. This study therefore aimed to investigate the effects of pneumoperitoneum on the severity of pancreatitis in a rat model of acute pancreatitis induced by cerulein. MATERIALS AND METHODS Thirty-five Wistar albino rats were divided into five groups with seven rats in each. Experimental pancreatitis was induced using intraperitoneal injection of cerulein. The first group received open laparotomy. Groups 2-5 were treated with 5, 10, 15, and 20 mm Hg, respectively, achieved by applying pressure and waiting for 60 minutes. After this waiting interval, all of the rats were sacrificed; blood samples were taken by intracardiac puncture for biochemical assays, and pancreatic tissue samples were taken for light microscope analysis. Histopathology was scored according to edema, granulation, polymorphonuclear leukocytes, and mononuclear cells in all groups. RESULTS Great increases in malondialdehyde and reduced glutathione levels were seen in all of the groups in which pancreatitis was induced. In Group 2-5, more significant increases were detected than in the open laparotomy group (P<.005). In the histopathological examination, Groups 2-5 showed more inflammatory cell infiltration, edema, and granulation tissue than the open laparotomy group (P<.005). CONCLUSIONS It is useful to remember the parameters of the medical treatment of pancreatitis. While surgical treatment is being decided, we think that the process of all kinds of surgery, including laparoscopic surgery, can increase the severity of pancreatitis.