Etiology, treatment options and prognosis of abdominal abscesses: A tertiary hospital experience.

INTRODUCTION: The principle of abdominal abscess treatment is drenage. However, whether this drainage is percutaneous or open surgery is the choice of the specialist or center. Recently, there have been reports indicating that percutaneous drainage is superior. In this study, patients followed up and treated in a ten-year period in our clinic were evaluated for both of the methods that we applied. METHODOLOGY: Cases of intra-abdominal abscess followed-up in a ten-year period were evaluated retrospectively. As well as some of the characteristics of the patients, the methods of drainage applied were recorded. The subjects who received percutaneous drainage and those undergoing open surgery were compared in terms of length of hospitalization, length of treatment and prognosis. RESULTS: The most common abscess site was intraperitoneal, and the origins of the abscesses were often hospital-based. The most commonly isolated organism, at a level of 33.8%, was Escherichia coli. Percutaneous drainage was applied at source control in 49 (43.8%) patients and open surgery drainage in 60 (53.6%). However, length of hospitalization, length of treatment and duration of drainage catheter use were statistically significantly higher in the percutaneous drainage group. No significant difference was observed between the groups in terms of prognosis. CONCLUSION: We attribute these results in disagreement with the literature to more patients being recommended for percutaneous drainage due to the fact that these patients were thought to be incapable of tolerating open surgery and to the higher probability of additional disease and complications.

Effects of peritoneal lavage and dry cleaning on bacterial translocation in a model of peritonitis developed using cecal ligation and puncture.

BACKGROUND: Currently, all progress in diagnostic techniques, surgical techniques, antibiotherapy, and intensive care units is accompanied by a decrease in the mortality due to severe secondary peritonitis; however, the rate is still unacceptably high. To remove the source of peritonitis, a surgeon has several options, such as closure, exclusion, and resection, depending on the preference of the surgeon and the condition of the patient. The aim of this study is to determine the rates of bacterial translocation by comparing the dry cleaning method (gauze squeezed with saline) and peritoneal lavage method (cleaning with saline), which are among the peritoneal cleaning methods. METHODS: A total of 64 rats were studied as sham, control, dry cleaning, and saline cleaning groups. Only laparotomy was performed in the sham group, and cecal ligation puncture was performed in the control group. After ligation puncture operations in the other two groups, one of them was subjected to dry cleaning and the other to isotonic cleaning. The samples obtained from the liver, spleen, and mesothelium were sacrificed and cultured under aerobic and anaerobic environments. RESULTS: There was no significant difference in the anaerobic bacterial counts, although there was a significant difference in the results of the aerobic bacterial counts in liver, spleen, and mesothelium samples on comparing the dry cleaning and saline cleaning groups. CONCLUSION: According to our study, the cleaning of intraabdominal infections with dry gauze is more effective than the cleaning with physiological saline for the elimination of aerobic bacteria. There is no difference observed with respect to the anaerobic bacterial counts.

Effects of saline lavage temperature on peritoneal fibrinolysis and adhesion formation.

BACKGROUND: Peritoneal lavage with saline at room temperature causes peritoneal hypothermia, vasoconstriction, hypoxia, and acidosis, which are effects that are known to reduce fibrinolysis. Decreased fibrinolysis causes permanent adhesions. Normothermic lavage may prevent this deleterious process and reduce peritoneal adhesions. METHODS: A rat model of cecal abrasion was used. Control animals received no medication while hypothermic or normothermic saline lavage were administered intraperitoneally to the experimental groups (n=24 for each group). Cardinal parameters of peritoneal fibrinolysis (tissue plasminogen activator [tPA] and plasminogen activator inhibitor type 1 [PAI-1]) were determined in peritoneal tissue samples on postoperative day 1, 3, and 10. On postoperative day 10, adhesions were graded. In the sham group (n=8), following laparotomy, peritoneal samples were taken to determine basal values of tPA and PAI-1 in healthy peritoneum. RESULTS: Cecal abrasion increased PAI-1 levels about tenfold on postoperative day 1 and caused adhesions. Normothermic saline lavage prevented this traumatic PAI-1 increase and stabilized it to baseline values throughout the experiment and reduced peritoneal adhesion formation. Hypothermic lavage also caused an inhibition of PAI-1 rise but adhesion, prevention was not significant. CONCLUSION: Our results suggest that normothermic saline lavage reduces adhesions by improving peritoneal fibrinolysis.

Structural deteriorations of the human peritoneum during laparoscopic cholecystectomy. A transmission electron microscopic study.

BACKGROUND: In previous studies, changes in the surface of the peritoneum during laparoscopic surgery are well defined. Nevertheless, almost all of these studies were performed on rodents via scanning electron microscopy. In the present study, structural alterations of the mesothelial cells of peritoneum were examined during laparoscopic cholecystectomy using transmission electron microscopy. METHODS: Twenty patients with symptomatic cholelithiasis were included in the study. Peritoneal biopsy was performed immediately after CO2 pneumoperitoneum creation and at the end of surgery just before gallbladder removal. Biopsies were taken from the right upper quadrant, i.e., apart from operative manipulation. Peritoneal sample cross-sections were compared using transmission electron microscopy. RESULTS: The carbon dioxide pneumoperitoneum during laparoscopic cholecystectomy caused deteriorations of the peritoneal mesothelium. Apoptosis were developed in mesothelial cells. Bulging of mesothelial cells, irregular cell junctions, focal intercellular clefts, apical cell membrane degeneration, deep nuclear invaginations, and lipid droplets in the cytoplasm of the mesothelial cells were other remarkable findings. Mesothelial edema also was determined. DISCUSSION: As seen in previous studies, basement membrane nudity appeared after carbon dioxide pneumoperitoneum could be attributable to mesothelial cell apoptosis, deterioration of the cell structure, and cell organelles.

Activated protein C and normal saline infusion might prevent deleterious effects of remote acute lung injury caused by intestinal ischemia-reperfusion: an experimental study in the rat model.

BACKGROUND: Intestinal ischemia-reperfusion is a common medical event associated with both clinical and experimental distant organ injury. In particular, the lung tissue appears to be susceptible to injury resulting from systemic inflammatory mediator activation. Drotrecogin α (activated) or recombinant human activated protein C has antithrombotic, anti-inflammatory, and profibrinolytic properties. We hypothesized that APC infusion would decrease lung inflammation and ameliorate lung injury resulting from intestinal ischemia-reperfusion (IIR). A rat model of intestinal ischemia-reperfusion was used to test this hypothesis, and several parameters of lung injury were measured in lung samples. MATERIAL AND METHODS: Forty Wistar albino rats were divided into four groups: a sham-operated group (Sham), an ischemic control group (IIR), an APC-infusion group (IIR'APC), and a normal saline-infusion group (IIR'NS) (n = 10, each). A marker for lipid peroxidation, malondialdehyde (MDA), free radical scavenger glutathione peroxidase (GSH-Px), an index of polymorphonuclear neutrophils, myeloperoxidase (MPO) activity, and lung polymorphonuclear leukocytes (PMNL) were investigated in the lung tissue samples. RESULTS: MDA and MPO levels, and lung PMNL sequestration were decreased, but GSH-Px levels were increased in APC treated group versus IIR group. MDA levels were decreased and GSH-Px levels were increased in NS treated group versus IIR group. MPO levels and lung PMNL counts were similar across the IIR and IIR'NS groups. CONCLUSIONS: This study documents that APC attenuates acute lung injury in intestinal ischemia-reperfusion. NS infusion had also some favorable effects regarding MDA and MPO.

An evaluation of normal saline and taurolidine on intra-abdominal adhesion formation and peritoneal fibrinolysis.

BACKGROUND: Intraoperative lavage with normal saline or taurolidine solutions is commonly used in abdominal surgery. For this purpose, normal saline and taurolidine, which may modify the intrinsic fibrinolytic activity of the peritoneum by breaking the peritoneal adhesions, are frequently used. We aimed to evaluate how normal saline and taurolidine affect peritoneal fibrinolysis and adhesion formation. METHODS: A rat model of peritoneal adhesion was used. Control animals received no medication, while normal saline or taurolidine solutions were administered intraperitoneally to the remaining two groups (n = 20 for each group). At postoperative day 10 adhesions were graded, and cardinal parameters of peritoneal fibrinolysis (activities and concentrations of tissue plasminogen activator [tPA], plasminogen activator inhibitor type 1 [PAI-1], and tPA/PAI-1 complex), and hydroxyproline contents were determined in peritoneal tissue samples. RESULTS: Total adhesion scores were decreased in both of the treated groups. Median tissue levels of tPA and tPA activity were higher in the treated groups versus controls. The PAI-1 levels were similar among the three groups. tPA/PAI-1 complex levels were higher in animals that received normal saline and in those treated with taurolidine solution compared with control animals. Peritoneal hydroxyproline levels were similar across the three groups. CONCLUSIONS: Our results suggest that normal saline and taurolidine solution administrations might reduce peritoneal adhesion formation, probably by altering peritoneal fibrinolytic activity.

[Can dexpanthenol prevent peritoneal adhesion formation? An experimental study]. / Peritoneal adezyon olusumu dekspantenol uygulamasiyla azaltilabilir mi? Deneysel çalisma.

BACKGROUND: Peritoneum has an intrinsic fibrinolytic activity that breaks the peritoneal adhesions. Ischemic peritoneal injuries interfere with this fibrinolytic activity. Local application of dexpanthenol, the alcohol form of pantothenic acid (vitamin B5) accelerates wound healing by increasing mitosis. We hypothesized that dexpanthenol would decrease peritoneal adhesions. METHODS: In rats, antimesenteric border of cecum was abraded with gauze. No medication was given to the control group (n=15). Dexpanthenol was administered intraperitoneally (IP) (n=15, 25 mg/kg, before abdominal closure) or intravenously (IV) (n=15, 25 mg/kg, for 9 days after operation) in the experiment groups. On postoperative day 10, adhesions were graded; activities and concentrations of tissue plasminogen activator (tPA), plasminogen activator inhibitor type 1 (PAI-1), tPA/PAI-1 complex and hydroxyproline contents were determined in peritoneum. RESULTS: Adhesion formation was decreased in IP dexpanthenol group compared with control group (p=0.034). tPA concentration and activity and tPA/PAI-1 complex levels were increased in the treated groups compared to controls. PAI-1 levels were similar among the three groups. Peritoneal hydroxyproline levels were lower in animals receiving IV dexpanthenol compared with control animals and in addition, they remained unchanged in IP dexpanthenol treated group (p=0.009, p=0.84, respectively). CONCLUSION: Our results suggest that dexpanthenol administration through IP may reduce peritoneal adhesion formation probably by altering peritoneal fibrinolytic activity.

Higher incidence of cholelithiasis in chronic renal failure patients with secondary hyperparathyroidism undergoing peritoneal dialysis.

BACKGROUND: In this study, we endeavored to determine whether the incidence of cholelithiasis (CL) was increased in chronic renal failure (CRF) patients with secondary hyperparathyroidism on a peritoneal dialysis (PD) program. We also evaluated the factors that might have some influence on the development of CL. METHODS: A total of 59 CRF patients undergoing PD were included in the study. We studied the following groups to determine whether parathyroid hormone (PTH) levels were increased in CRF-PD patients: twenty patients with secondary hyperparathyroidism (group 1) and 39 patients with normal PTH levels (group 2). PTH levels were maintained at three times the upper limit of normal. Biochemical parameters were obtained for each CRF-PD patient. All patients underwent abdominal ultrasonography to screen for the presence of cholelithiasis. For statistical analysis, chi2, t test, and logistic regression analysis were used; p < 0.05 was considered as significant. RESULTS: We found an almost ten times higher incidence (25% vs. 2.6%) of CL in group 1 patients with statistical significance (p = 0.007). When the incidence of CL according to sex, creatinine, and PTH levels were considered, female gender, creatinine, and PTH levels were higher in group 1, which was also significant statistically. No significant relationship was detected between gallbladder stone formation and the other analyzed biochemical parameters. CONCLUSIONS: We found that the incidence of CL in CRF-PD patients with secondary hyperparathyroidism was higher than CRF-PD patients with normal PTH levels. It was also detected that female gender, high creatinine levels, and elevated PTH levels might influence the development of CL in CRF-PD patients.

Three-port versus four-port laparoscopic cholecystectomy.

BACKGROUND/AIMS: Since the first successful laparoscopic cholecystectomy with the establishment of pneumoperitoneum in France by Mouret in 1987, it has become the golden standard for cholecystectomy. Generally techniques with four trocars have been used with surgeons but some of them prefer 3-trocar techniques. Our aim is to compare the clinical outcomes of three- and four-port techniques prospectively. METHODOLOGY: Between 1998 and 2003, one hundred and forty-six consecutive patients who underwent elective laparoscopic cholecystectomy for cholelithiasis in the Medical Faculty of Suleyman Demirel University were randomized to receive either the three-port or the four-port technique. Operative time, (time from the beginning of the insufflation up to the closure of the skin), success rate, visual analogue pain score, analgesia requirements, postoperative hospital stay were compared. RESULTS: No differences between the two groups could be found. CONCLUSIONS: Three-port technique is safe, effective, and economic but does not reduce the overall pain score and analgesia requirement.

Gallbladder volvulus: review of the literature and report of a case.

Gallbladder volvulus is defined as the rotation of the gallbladder on its mesentery along the axis of the cystic duct and cystic artery. The presence of a redundant mesentery (floating gallbladder) is a prerequisite for volvulus. The disease, described for the first time by Wendel in 1898, is an extremely rare surgical disease. The disease mimics acute cholecystitis symptoms. Because of these two conditions, preoperative diagnosis of the disease is difficult. In any case, the definitive diagnosis is made during surgery. Volvulus of the gallbladder is an acute surgical emergency that must be treated with immediate detorsion and cholecystectomy. We report a case of gallbladder volvulus suspected pre-operatively using pre-operative imaging with ultrasound. The cases reported in the literature are reviewed and the treatment of gallbladder volvulus is also discussed.

Pentoxifylline, a methyl xanthine derivative, reduces peritoneal adhesions and increases peritoneal fibrinolysis in rats.

Peritoneum has an intrinsic fibrinolytic activity that breaks the peritoneal adhesions. Peritoneal injuries with ischemia interfere this fibrinolytic activity and cause adhesions. Pentoxifylline, a methyl xanthine derivative, improves blood flow by decreasing its viscosity and also increases fibrinolytic activity in plasma. We hypothesized that pentoxifylline would increase peritoneal fibrinolysis and ameliorate adhesions. A rat model of peritoneal adhesion (cecal abrasion with gauze, n = 15 for each group) was used to test this hypothesis and cardinal parameters of peritoneal fibrinolysis were measured in peritoneal samples. No medication was given in control animals, while pentoxifylline was administered intraperitonealy (IP) (25 mg/kg, before abdominal closure to whole abdomen) or intravenously (IV) (25 mg/kg, for 9 days after operation) in the experimental groups. At postoperative day 10, peritoneal biopsies were obtained and adhesions were graded qualitatively. Activities and concentrations of tissue plasminogen activator (tPA), plasminogen activator inhibitor type 1 (PAI-1), tPA/PAI-1 complex and hydroxyproline contents were determined. Total adhesion scores were decreased in both treated groups. Mean levels of tPA concentration and tPA activity were increased in the treated groups compared to controls (p < 0.001 and p = 0.001, respectively). The tPA/PAI-1 complex levels were similar among the three groups. PAI-1 levels were lower in animals receiving IP pentoxifylline compared to control animals and those treated with IV pentoxifylline (p = 0.048, p = 0.015, respectively). Peritoneal hydroxyproline levels were similar among the three groups. Our results suggest that pentoxifylline administration either through IV or IP may reduce peritoneal adhesion formation probably by altering peritoneal fibrinolytic activity.

An interesting coexistence: small bowel volvulus and small bowel diverticulosis.

Acquired (non-Meckel's) jejuno-ileal diverticular disease is uncommon, and most surgeons have limited, if any, experience with this condition. We present an interesting case with coexistence of small bowel diverticulum and small bowel volvulus with massive abdominal distension, in which the patient had a history of abdominal distension without abdominal pain over a five-year period. A brief discussion of the common clinical features is given and the principles of treatment of jejuno-ileal diverticular disease and small bowel volvulus are presented. A 29-year- old man with no history of laparotomy was admitted with abdominal distension and abdominal compartment syndrome symptoms. An emergency laparotomy revealed 180 degree clockwise volvulus of the multiple diverticula-bearing terminal ileum. There was no diverticulum in other sites of the small intestine and colon. Additionally, there was neither adhesion nor any congenital anomalies at the other sites of the gastrointestinal system. The viability of the intestine was normal but the diameter of the ileum was extremely enlarged (approximately 20 cm). In addition, the bowel wall was also hypertrophied. The rotated and enormously enlarged diverticula-bearing small intestine was removed with cecum, and ileocolostomy was performed. The patient was discharged uneventfully from hospital on the eighth postoperative day. After the operation, all symptoms of the patient disappeared. Small bowel obstruction is a common cause of emergency surgical admission. Awareness of the fact that volvulus of the diverticula-bearing segment of the jejuno- ileum is a rare cause of small bowel obstruction may lead to earlier and prompt diagnosis and treatment.

Effects of seprafilm on peritoneal fibrinolytic system.

BACKGROUND: There is a high incidence of adhesions after ventral hernia repair with polypropylene mesh. The purpose of the present study was to evaluate the efficacy of Seprafilm in the prevention of adhesion formation and effect on peritoneal fibrinolytic activity. METHODS: An incisional hernia model was created in rats. In the experimental group Seprafilm was placed between polypropylene mesh and abdominal organs. On the 14th day adhesions were evaluated and tissue plasminogen activator (tPA), urokinase plasminogen activator (uPA), plasminogen activator inhibitor (PAI) type 1 and 2 were measured in peritoneal biopsy specimens. RESULTS: Adhesions were significantly reduced in the Seprafilm group (P = 0.002). Nevertheless, there were no difference between the two groups in levels of tPA, PAI-1 and PAI-2. However, the levels of uPA were significantly decreased in the Seprafilm group. CONCLUSIONS: The adhesion preventive effect of Seprafilm is not directly related in peritoneal fibrinolytic activity. Instead, the physical properties (barrier, hydroflotation and sliconizing effect) of the membrane are primarily responsible for adhesion prevention.

Intestinal obstruction caused by a strangulated Morgagni hernia in an adult patient.

A Morgagni hernia is a congenital herniation of abdominal contents into the thoracic cavity through a retrosternal diaphragmatic defect. The reported incidence of congenital diaphragmatic hernias is estimated to be 1 in between 2000 to 5000 births. Morgagni hernias comprise 2% of diaphragmatic hernias. Most Morgagni hernias are found and repaired in children, but 5% are found in adults. They are usually asymptomatic and often found incidentally on chest radiography. Symptoms of these hernias are attributable to the herniated viscera. Morgagni hernias containing bowel may require repair on presentation because of the risk of incarceration. We present a case of an incarcerated and strangulated Morgagni hernia in a 71-year-old woman admitted to our clinic for abdominal pain and symptoms of intestinal obstruction. The diagnosis was made preoperatively by chest radiography, sonography, and computed tomography. Emergent laparotomy was performed, with the herniated transverse colon and omentum reduced into the abdomen. The diaphragmatic defect was repaired, followed by resection of the strangulated omentum. In conclusion, a Morgagni hernia may cause intestinal obstruction. Routine radiographic studies are usually sufficient to arrive at the diagnosis, but a CT scan and sonography may be necessary. Laparotomy is appropriate for the management of symptomatic adult patients with Morgagni hernias, particularly those with findings of intestinal strangulation, with laparoscopic treatment an alternative approach in selected cases.

Intestinal obstruction due to a mesenteric cyst.

Mesenteric cysts are rarely thought of, may be difficult to diagnose, and are usually asymptomatic except when complicated. Intestinal obstruction is a rarely reported complication of these cysts. A case of mesenteric cyst that was causing obstruction of the large bowel is presented, along with a review of the literature.