Late results of patients undergoing remedial operations for alkaline reflux gastritis syndrome.

PURPOSE: Many different remedial operations for alkaline reflux gastritis have been described. Analysis of their efficacy is difficult, because while many of the procedures have good early results, there are long-term failures due to their own complications. The aim of this study is to evaluate our experience with patients undergoing remedial operations for alkaline reflux gastritis syndrome. MATERIAL AND METHODS: The clinical features and results of remedial operations of 65 patients with alkaline reflux gastritis syndrome were reviewed retrospectively. Data on the hospital course were collected by interviewing patients directly or by telephone contact. An assessment of each patient's response to remedial operation was then made and a Visick score assigned. RESULTS: All patients had been tried on a medical treatment and dietary restriction or both prior to remedial operation. Long-term follow up was possible in 46 patients. Seventy-six percent of patients who at the final state had a truncal vagotomy, distal gestrectomy and Roux-en-Y gastrojejunostomy have been found to show satisfactory results (Visick-I/Visick II). Three patients who had previously undergone a Roux-en-Y conversion later required re-operation for Roux-stasis syndrome and a near-total gastrectomy was performed on these patients. Other operations performed for alkaline reflux gastritis were converted to "uncut" Roux-en-Y in five patients and dismantling of gastrojejunostomy in two patients. CONCLUSIONS: For patients unresponsive to medical treatment, we reccommend the following strategy: a) for patients with truncal vagotomy plus gastrojejunostomy, dismantling of gastrojejunostomy should be the first choice b) for patients with prior Billroth-II gastrectomy, Roux-en-Y conversion is the most effective corrective operation, although it has its proper including Roux statis syndrome.

Laparoscopic incisional lumbar hernia repair.

PURPOSE: Incisional lumbar hernia is an uncommon hernia type. Open surgical procedures have significant postoperative morbidity and patient dissatisfaction, therefore, for the repair of seven incisional lumbar hernias, we attempted using an intraperitoneal laparoscopic technique that was described to have good short-term results and decreased morbidity. METHODS: We applied a laparoscopic technique using polypropylene meshes in five patients and composite meshes in two patients to cover the defect, then placed prolene sutures and hernia staples to secure the mesh intraperitoneally. RESULT: The technique was successful in all patients, and they tolerated the procedure well. All did well after surgery, ambulating and eating a regular diet on postoperative day 1. No postoperative complications developed. At a mean follow-up of 34.1 months (range 17-43 months) none of them had pain, mass, or evidence of recurrence, and furthermore, cosmesis was excellent. CONCLUSIONS: We believe that the laparoscopic approach is feasible, safe, and the least invasive choice for repairing difficult hernias such as incisional lumbar hernias.

Laparoscopic enucleation of giant liver hemangioma.

The cavernous hemangioma is the most common benign tumor of the liver. It usually becomes symptomatic as it reaches a certain size. A 49-year-old man was admitted with a 1-year history of epigastric pain, which was not relieved by regular analgesic intake, and nausea. The results of physical examination, routine laboratory tests, and upper gastrointestinal tract endoscopy were normal. Ultrasonography showed a 10-cm mass in the left hepatic lobe. Magnetic resonance imaging (MRI) showed a 90-mm hemangioma at left hepatic lobe. Selective celiac arteriogram was performed, and polyvinyl alcohol particles were used as an embolizing agent. After the embolization, the patient underwent laparoscopic enucleation of the liver hemangioma. No blood transfusion was needed during the operation. The operative time was 75 min. The patient was allowed to take a clear liquid diet on the postoperative day 1. The postoperative course of the patient was uneventful, and he was discharged on the postoperative day 2. Enucleation is the best surgical technique for the management of symptomatic giant hemangiomas. It can be performed with no mortality or morbidity, with preservation of all normal liver parenchyma. Enucleation also has been associated with significantly fewer intraabdominal complications than anatomic resection. The laparoscopic approach for enucleation requires patience and careful dissection to prevent bleeding. In conclusion, laparoscopic enucleation of hemangiomas is safe and easy to perform in selected cases.

Rupture of the hydatid disease of the liver into the biliary tracts.

BACKGROUND: To analyze the diagnosis and the surgical treatment of intrabiliary ruptured hydatid disease of the liver. METHODS: Between 1990 and 1995, 263 patients with hydatid cysts of the liver underwent surgery in a university hospital. Twenty-five (9.43%) patients with intrabiliary rupture of hepatic hydatid cyst were retrospectively reviewed. RESULTS: Diagnosis was principally made using ultrasonography and computed tomography scanning and was confirmed by the findings of other tests. In 12 patients (48%) partial cystectomy with primary closure; 5 patients (20%) partial cystectomy with drainage; 5 patients (20%) cystotomy with drainage; 3 patients (12%) left hepatic resection (atypic, segmentary or lobar) was performed. Omentoplasty was performed in 6 patients. The common bile duct was explored in all patients and it was drained by a T-tube in 22 patients, and by a choledochoduodenostomy in 3 others. The average postoperative hospitalization time was 8.3 and 22.5 days in patients treated with choledochoduodenostomy and T-tube drainage respectively. Cholecystectomy was performed in 18 patients. Complications were seen in 4 patients (16%) with 1 pleural effusion and 3 wound infections. There was only 1 death (4%) due to duodenal peptic ulcus perforation with intrabiliary ruptured hydatid cyst. CONCLUSION: This study indicates that T-tube drainage and choledochoduodenostomy in intrabiliary ruptured hydatid cysts are effective procedures with low morbidity and mortality rates.

Laparoscopic approach to hepatic hydatid disease.

BACKGROUND: The aim of this paper is to present our brief experience on laparoscopic hydatid cyst surgery; we estimated the reproducibility of used techniques in conventional surgery with this relatively recent and attractive method. METHODS: Fifteen cysts in 12 selected hydatid disease patients were treated laparoscopically. Cystotomy, partial cystectomy and drainage were performed in 9 patients. Omentoplasty was added to the procedure in the remaining 3 cases. RESULTS: The mean postoperative hospital stay was 4.9 days. There was no mortality, and 1 patient developed bile leakage. Mean follow-up is 18 months. No recurrence was observed during this period. CONCLUSION: We suggest that laparoscopic treatment of hydatid disease is feasible in selected patients respecting the principles of open surgery and seems beneficial concerning postoperative comfort, hospital stay and return to daily activities.

Changes in knot-holding capacity of sliding knots in vivo and tissue reaction.

OBJECTIVES: To evaluate and compare the in vivo strength, knot efficiency, and knot security of 4 types of sliding knots, and to assess tissue reaction to study the effect of knot configuration, knot volume, and suture size. DESIGN: Randomized trial. SETTING: Experimental Medical Research Institute, Istanbul, Turkey. SUBJECTS: Wistar rats. INTERVENTION: To assess the tissue reaction, a midline laparotomy incision was made in 112 rats and sutured with various interrupted knots in silk and nylon sutures of 2/0 and 4/0 (United States Pharmacopeia) sizes. Suture loops were implanted in subcutaneous pouches in the rat abdomen. Sutures were all extracted at days 4, 7, 11, and 20 to determine their knot-holding capacity. MAIN OUTCOME MEASURES: Knot efficiency and percentage decrease in knot-holding capacity were examined. Knot, tissue reaction, and inflammatory sheath volumes were measured. RESULTS: The 4/0 knots lost more strength than the 2/0 knots. The alternating knots with different patterns were more efficient and secure than the simple alternating ones. The alternating parallel knot was found to be unreliable. The tissue response to all the knots, except 2/0 nylon, was similar. The inflammatory sheath volume varied depending on the knot volume, suture size, and knot configuration. CONCLUSION: The use of alternating sliding knots with different patterns is recommended to replace simple alternating sliding knots.

[Measurement of the sigmoid colon and its relationship with volvulus]. / La détermination des mesures du colon sigmoïde et leur rapport avec le volvulus.

Sigmoid volulus occurs more frequently in Turkish people than the European. The anatomy of the sigmoid colon plays an important role in the etiology. In our study various measurements of the sigmoid colon of 25 preserved cadavers were taken and the results were interpreted according to the frequency of sigmoid volvulus in this country.

[Complicated hydatid cysts of the liver]. / Les kystes hydatiques compliqués du foie.

In 328 cases of hydatid disease of the liver operated between 1979 and 1989, 51 (15.8%) had complicated cysts. The most frequent complication was intrabiliary rupture (2/3 of all complications). The others were intraperitoneal rupture in 7 cases (13.8%), suppuration in 7 cases (13.8%) and intrathoracic rupture in 3 cases (5.8%). Among the intrabiliary ruptured cysts, T-drainage was performed in 15 cases, choledochoduodenostomy was performed in 12 cases, and sphincteroplasty was performed in 7 cases. The cases of intraabdominal rupture were operated immediately. The suppurated cysts were marsupialized in 3 cases and drained in 4 cases. The 3 cases of bronchobiliary fistula were treated by T-tube drainage of the common bile duct, drainage of the pleural space, repair of the diaphragm and closure of the communicating bronchus. In this series, the mortality rate was 7.8% and the recurrence rate was 9.8%.