Yusuf Bilen

Complications of metallic stent placement in malignant esophageal stricture and their management.

Objective At the present time, covered self-expandable metallic stent placement is the palliative treatment method for inoperable esophageal cancer. However, life-threatening early and late complications are seen related to esophageal stent placement. In this study, we discuss complications of esophageal stent placement with their management and present our own experience. Methods Between January 2000 and February 2009, 215 covered esophageal stent placements were performed in 174 inoperable esophageal cancer and/or esophagorespiratory fistula patients in the Department of Thoracic Surgery at the Ataturk University Hospital. Results Major complications related to stent placement developed in 24 patients (11 bleeding, 6 aspiration pneumonia, 3 tracheal compressions, 2 perforations, and 2 esophagorespiratory fistulas). Two hundred and thirty minor complications were observed among 174 patients (165 chest pain, 29 tumoral overgrowth, 17 stent migration, 6 gastroesophageal reflux, 3 failure in stent placement, 3 hiccup, 2 foreign body sensation, 2 failure in stent expansion, 1 tumor ingrowth, 1 granulation tissue formation, and 1 food bolus obstruction). Reintervention was required in 56 (32.2%) patients who experienced complications. Stent-related mortality was seen in 4 (2.3%) patients (2 aspiration pneumonia, 1 tracheal compression, and 1 esophagorespiratory fistula). One hundred sixty-two of 174 patients died during follow up. The mean survival time was 177.3±59.3 days (range: 2 to 993 d). Conclusions The complication rate of self-expandable metallic stent placement is high in inoperable esophageal cancer patients. Although some of these complications are life threatening, many of them can be managed successfully with endoscopic reintervention.

Palliative management of esophagorespiratory fistula in esophageal malignancy.

Introduction Esophagorespiratory fistula (ERF) is a complication of an esophageal malignancy that has serious effects on the mortality of a patient, whose survival is limited to weeks. Sealing of fistula and recovery of swallowing has greater importance than treating underlying primary malignancy. In this study, we aimed to present our clinic experience in patients with ERF and to discuss the findings together with the literature. Materials and Methods Between January 2003 and December 2008, 326 patients with malignant esophageal disorder were admitted to our clinic, and ERF detected in 18 (5.5%) patients. There were 10 men and 8 women with a mean age of 54.7±11.9 years (range: 34 to 75 y). Metastases in the lung and liver were detected in 4 and 2 patients, respectively. Empyema was found in 3 of the ERF patients. Pneumonic infiltration was detected via radiologic evaluation in 7 (38.9%) of the 18 patients. Two patients did not accept any intervention. A feeding gastrostomy tube was placed in 2 other patients. Fluoroscopy-guided Ultraflex esophageal stent placement was applied to the remaining 14 patients. Eleven (78.6%) patients underwent stent placements during generalized anesthesia via rigid esophagoscopy, and the remaining 3 (21.4%)patients via flexible esophagoscopy with sedation. Results One of the patients who did not accept intervention died after 2 weeks, and the other died 6 weeks after admission. One of the patients who received a feeding gastrostomy tube died 17 weeks after admission, and the other was still alive after a month, when this article was written. Closure of the ERF was seen in all 14 patients who underwent palliative covered self-expandable metallic stent placement in the esophagus. No complications occurred in the stent-placed patients either during or after the procedure. Dyspeptic complaints and pain were treated successfully with medical therapy in 6 and 5 patients, respectively. Symptoms of aspiration disappeared after stent placement. No reopened fistulae were observed during follow-up. Thirteen of the 14 stent-replaced patients died during follow-up. The mean survival rate for these 13 patients was 11.2 weeks (range: 1to 49 wk). The mean length of hospital stay after stent placement in the 14 patients was 3.7 days (1 to 15 d). Discussion Covered self-expandable metallic stent placement in malign ERF patients is a technically simple and safer method for fistula closure and seems to be the most effective method that is easily available.

Prognostic Value of Baseline Neutrophil-Lymphocyte and Platelet-Lymphocyte Ratios in Local and Advanced Gastric Cancer Patients

BACKGROUND We aimed to investigate the prognostic value of baseline neutrophil, lymphocyte, and platelet counts along with the neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) in local and advanced gastric cancer patients. MATERIALS AND METHODS In this retrospective cross-sectional study, a total of 103 patients with gastric cancer were included. For all, patient characteristics and overall survival (OS) times were evaluated. Data from a complete blood count test including neutrophil, lymphocyte, monocyte, white blood cell (WBC) and platelet (Plt) count, hemoglobin level (Hb) were recorded, and the NLR and PLR were obtained for every patient prior to pathological diagnosis before any treatment was applied. RESULTS Of the patients, 53 had local disease, underwent surgery and were administered adjuvant chemoradiotherapy where indicated. The remaining 50 had advanced disease and only received chemotherapy. OS time was 71.6±6 months in local gastric cancer patients group and 15±2 months in the advanced gastric cancer group. Univariate analysis demonstrated that only high platelet count (p=0.013) was associated with better OS in the local gastric cancer patients. In contrast, both low NLR (p=0.029) and low PLR (p=0.012) were associated with better OS in advanced gastric cancer patients. CONCLUSIONS This study demonstrated that NLR and PLR had no effect on prognosis in patients with local gastric cancer who underwent surgery and received adjuvant chemoradiotherapy. In advanced gastric cancer patients, both NLR and PLR had significant effects on prognosis, so they may find application as easily measured prognostic factors for such patients.

Does decreased mean platelet volume predict inflammation in chronic renal failure, dialysis, and transplanted patients?

Abstract Objectives: Increased platelet activation contributes to cardiovascular mortality in chronic kidney disease patients (CKD). Larger platelets are more active and this increased activity had been suggested as a predictive biomarker for cardiovascular disease. In this study, we aimed to evaluate mean platelet volume (MPV) as an inflammatory marker in a broadened group of CKD patients. Our study is unique in literature as it covers all types of CKD including renal replacement therapies. Materials and methods: 200 patients (50 renal transplanted, 50 hemodialysis, 50 peritoneal dialysis, 50 chronic renal failure stages 3–4) were investigated who were between 18 and 76 years of age. The collected data included demographic properties, platelet count, MPV, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and hemoglobin. All of the patients had at least 12 month of therapy of either renal replacement modality. Results: The mean CRP value was detected statistically significantly higher in hemodialysis (HD) patients compared to the resting three groups of patients (p < 0.01). Mean CRP level was detected significantly higher in the pre-dialysis group compared to transplanted and peritoneal dialysis (PD) patients (p < 0.01). There is no statistically significant difference detected among the mean MPV values of all patient groups (p > 0.05). Conclusions: ESR and CRP were significantly increased in hemodialysis patients compared to the other groups. We did not detect a significant difference among MPV between the groups. ESR was detected lowest in transplanted patients. Transplantation is coming forward as the favorable choice of renal replacement therapy which decreases inflammation.

Fenofibrate monotherapy-induced rhabdomyolysis in a patient with type-2 diabetes.

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Comparison of Serum Vitamin D Levels Among Patients With Chronic Kidney Disease, Patients in Dialysis, and Renal Transplant Patients

OBJECTIVE Vitamin D is a hormone with a variety of functions, and its deficiency and insufficiency are commonly seen both in the general population and in patients with chronic renal disease. The aim of this study was to compare vitamin D levels in patients with chronic renal disease who are on hemodialysis, peritoneal dialysis, or no renal replacement therapy and patients who underwent renal transplantation. METHODS A total of 169 patients who had not used vitamin D for ≥ 1 year and who had no diabetes mellitus or proteinuria were included in the study. These included: 40 patients with renal transplantation, 40 patients on hemodialysis, 49 patients on peritoneal dialysis, and 40 patients with chronic renal failure stage 1, 2, 3, or 4. 25-Hydroxy vitamin D levels were evaluated in the sera of the patients. RESULTS 25-Hydroxy vitamin D levels in patients with renal transplantation and in predialysis patients were 12.74 ± 10.24 ng/mL and 11.16 ± 12.25 ng/mL, respectively. The levels were 7.77 ± 6.71 ng/mL and 5.96 ± 4.87 ng/mL in patients on hemodialysis and peritoneal dialysis, respectively. CONCLUSIONS Vitamin D levels are lower in patients on hemodialysis and peritoneal dialysis compared with the patients with renal transplantation for a variety of reasons. In this study, objective results were obtained supporting the administration of vitamin D supplements without glomerular filtration rate measurement in all patient groups with the diagnosis of chronic renal failure in accordance with the guidelines.

Neutrophil-Lymphocyte Ratio Is Significantly Decreased in Preemptive Renal Transplant Patients

AIM Cardiovascular diseases and infections are the leading two causes of morbidity and mortality in end-stage renal disease (ESRD) patients. Kidney transplantation is the preferred method for renal replacement owing to better survival. There are reports of irreversibly damaged immune system in dialysis patients, which did not return to normal even after kidney transplantation. The neutrophil-lymphocyte ratio (NLR) is an easily applicable method for evaluation of inflammation. We hypothesized that preemptive kidney transplantation can improve inflammatory state compared with nonpreemptive recipients. To test our hypothesis, we retrospectively investigated pretransplant and posttransplant NLR and C-reactive protein (CRP) levels of ESRD patients and compared them with values in healthy controls. MATERIALS AND METHODS We retrospectively analyzed NLR, CRP, and other hematologic parameters of ESRD patients who were transplanted between January 2005 and January 2014 on the day of transplantation and at the end of first year. We grouped the patients as preemptive and nonpreemptive ones. We excluded patients with coronary artery disease, obesity, hypotension, hyperthyroidism, uncontrolled diabetes mellitus, hematologic or solid organ cancers, and active documented infection at any evaluation period. RESULTS We included 137 ESRD patient and 34 healthy control individual in our study. Of the 137 ESRD patients, 52 (38%) were transplanted preemptively. Of the patients, 85 were already on either hemodialysis or peritoneal dialysis therapy at the time of transplantation. The white blood cell count value of the patient and control group (7246.72 ± 1460.26 and 76661.76 ± 1286.29, respectively; P = .43), NLR of the control group was significantly lower than patient group (1.98 ± 0.94 and 3.47 ± 2.33, respectively; P = .007). The NLR of the preemptive group was decreased substantially at the end of first year posttransplantation, the NLR of the preemptive group was significantly lower than the nonpreemptive group (3.08 ± 1.32 and 3.71 ± 2.33; P = .01). CONCLUSIONS We showed that all ESRD patients had an increased inflammation rate according to CRP and NLR when compared with healthy controls. We also found that improvement of inflammatory state in preemptive patients is significantly better than nonpreemptive patients at the end of first year evaluation.

DCE-MRI findings of invasive aspergillosis in patient with acute myeloid leukemia

Thoracic radiography and high resolution computerized tomography is used to diagnose pulmonary infections in immunosuppressed patients, although in some cases these do not provide enough information about the lesion. Dynamic contrast‐enhanced magnetic resonance imaging may be useful in these cases, especially for the characterization of cavitary lesions and assessment of their contrast diffusion.

Mercury Toxicity: A Family Case Report

Background: Environmental pollution exposes humans to toxic substances. Herein we present 5 family members aged20-54 years that were poisoned by liquid mercury. Case Reports: Case 1 presented to our clinic with cough, fever, and night sweats. The patient had neutropenia, anemia,and pneumonia, rapidly developed acute respiratory distress syndrome (ARDS), and died on day 4 of hospitalization.Her WBC count was 0.4 × 10³ mm-3 (normal range: 4.3-10.3 × 103 mm-3) and Hb was 10.8 g dL–1 (normal range: 11.5-16.0 g dL–1). Case 2 presented with bicytopenia; the leukocyte count was 1.3 × 103 mm-3 (normal range: 4.3-10.3 × 103mm-3) and the PLT count was 88 × 103 mm-3 (normal range: 150-400 × 103 mm-3). Cases 2 and 3 had toxic peripheralneuropathy. The PLT count in case 3 was 123 × 103 mm-3 (normal range: 150-400 × 103 mm-3). Cases 4 and 5 presentedwith fatigue and headache; these 2 patients did not have positive findings, apart from high levels of mercury in theblood. We have written informed consent. Conclusion: We think that heavy metal exposure—although rare—should be considered in patients that present withnumerous symptoms involving multiple systems, including the cardiovascular, respiratory, and neurological systems.The present report is unique in that in describes mercury poisoning in 5 members of the same family.

High-Grade Inflammation in Renal Failure Patients, According to Mean Platelet Volume, Improves at the End of Two Years After Transplantation

BACKGROUND Chronic kidney disease (CKD) is a worldwide disorder which is characterized by the presence of systemic low-grade inflammation. There is also acquired immune deficiency in this patient group which is clinically present with increased incidence of severe infections, poor response to vaccination, and increased risk of virus-associated cancers. Renal transplantation is one of the renal replacement modalities that restore renal functions. Mean platelet volume (MPV) is emerging as a marker of inflammation in many clinical conditions. In this study we aimed to disclose the improvement of paired immune response of ESRF patients after renal transplantation even though they are under immunosuppressive therapy. METHODS We retrospectively investigated C-reactive protein, MPV, platelets (PLT), and other hematologic parameters on the day of transplantation and at the end of the 1st and 2nd years after transplantation of 58 preemptive and 112 nonpreemptive renal transplant patients. We compared them with a healthy control group. RESULTS The MPV of the control group was 8.00 ± 0.73. The mean MPV of transplant patients before transplantation and at the end of the 1st and 2nd years after transplantation were 7.66 ± 1.01, 8.06 ± 0.97, and 8.20 ± 0.84, respectively. The initial MPV of the patient group was statistically significantly lower than the control group (P = .04). There was a statistically significant increase of MPV after transplantation. At the end of the 2nd year the difference of MPV between the patient and control groups was gone. CONCLUSIONS We detected that CKD patients had a decreased MPV compared with normal individuals and that it normalized at the end of the 2nd year after renal transplantation. We speculated that the decreased MPV in CKD patients is related to increased inflammation and uremic toxins owing to uremia which was improved after renal transplantation.