Surgery, surgeon, and measurement of value and quality of surgeons' work.

Surgery has undergone a significant change and development entering the 21st century. The changes and development have been technology driven, both in therapy and diagnosis. There have been significant changes in the health-care systems as well universally. The changes have created a significant challenge both for the profession and the surgeon. The surgeon should be prepared for further developments and innovations and adapt himself or herself to survive practicing surgery and conserving the humanistic approach of medicine and professionalism including respect to professional values. The profession needs to prepare itself for the future to train good surgeons accordingly for better community health.

Prognostic factors of the mortality of postoperative intraabdominal infections.

PURPOSE: We investigated the relationship between the prognostic factors of postoperative peritonitis and mortality. METHODS: Data from 56 patients re-operated for postoperative secondary peritonitis in our hospital between 1991 and 2001 were collected retrospectively. Demographic features, comorbidity, malignancy, organ failure, type and timing of the primary operation, intraoperative findings, etiology of postoperative peritonitis, number of relaparotomies, source control failure, Mannheim peritonitis index (MPI), and mortality were noted. The time intervals between the first operation and relaparotomy, and between symptom onset and the second operation were also noted. RESULTS: The overall mortality rate was 32% (n = 18). Organ failure (p = 0.001), time elapse between symptoms and the second operation (p = 0.046), severity of peritonitis (p = 0.035), source control failure (0.047), and MPI scores (p = 0.032) were significantly related with the mortality of postoperative peritonitis in a univariate analysis. MPI score >30 had a higher mortality rate. CONCLUSION: Delaying relaparotomy for more than 24 h and presence of organ failure result in higher mortality.

External validation of Cleveland Clinic Foundation colorectal cancer model in a University Clinic in terms of predicting operative mortality.

BACKGROUND: The aim of this study was to perform an external validation of Cleveland Clinic Foundation colorectal cancer model in a single center. METHODS: Relevant data of 771 patients who underwent surgery for colorectal cancer between January 1997 and November 2008 were retrospectively collected. The performance of the scoring system was evaluated by discrimination and calibration. Discrimination was evaluated by using the area under the receiver operator characteristics curve and calibration by using the Hosmer-Lemeshow goodness-of-fit test. RESULTS: Mean age was 60.8 (18-91). Forty-four percent of patients were female, and 56% were male. Overall mortality was 3.9%. Cleveland Clinic Foundation colorectal cancer model showed good discrimination but poor calibration. CONCLUSION: These data suggest that the Cleveland Clinic Foundation colorectal cancer model is a suitable model to be used in our center for patients with colorectal cancer but requires recalibration.

Insulinoma: an evaluation by a single institution.

INTRODUCTION: Insulinoma is a rare pancreatic islet cell tumour that is associated with hypoglycaemia. Diagnosis of the disease, localisation of the tumour and surgical therapy may be challenging and the aim of this study is to evaluate the problems concerning insulinoma. MATERIALS AND METHODS: The surgical records of patients who were operated on for insulinoma at Hacettepe University Department of General Surgery between January 1980 and December 2006 were evaluated retrospectively. The evaluated parameters were the gender and ages of the patients with symptoms, signs, diagnostic tools and surgical methods. RESULTS: Twenty-six patients were included in the study. There were 17 male and nine female patients. The median age was 34. The median diagnostic period was 285 days. Abdominal computer tomography was the most frequently used diagnostic method. A total of 15 enucleations, nine distal pancreatectomies and three pancreaticoduodenectomies were performed. Histopathologically most of the tumours were benign islet cell tumours. CONCLUSIONS: There are still difficulties in the diagnosis, localisation and histopathologic evaluation of insulinoma. Appropriate pre-operative evaluation, through exploration and palpation of the pancreas during the surgery, as well as experienced centres are important to increase the success of the surgery of insulinoma.

The postoperative analgesic efficacy of intraperitoneal tramadol compared to normal saline or intravenous tramadol in laparoscopic cholecystectomy.

BACKGROUND AND OBJECTIVE: The aim of this study was to compare the postoperative analgesic efficacy of intraperitoneal tramadol with intravenous tramadol or normal saline in patients undergoing laparoscopic cholecystectomy. METHODS: Sixty-one patients undergoing laparoscopic cholecystectomy were randomized to one of three groups in a double-blind manner via coded syringes. All patients received an intravenous and an intraperitoneal injection after installation of the pneumoperitoneum and again before removal of the trocars. In the control group, all injections were with normal saline. In the intravenous tramadol group, patients received intravenous tramadol 100 mg and intraperitoneal saline. In the intraperitoneal tramadol group, patients received intravenous saline and intraperitoneal tramadol 100 mg. All patients had a standard anaesthetic. Postoperative analgesia was with morphine. Postoperatively, numeric pain scores for parietal and visceral pain, 1 h and 24 h morphine consumption, and adverse effects were recorded. RESULTS: Parietal and visceral pain scores were lowest in the intravenous tramadol group during the first postoperative hour (P < 0.016 compared with control). The delay until the first analgesic administration was longest in the intravenous tramadol group (median 23 min, range 1-45), when compared with the intraperitoneal tramadol group (10, 1-120 min, P = 0.263) or with the control group (1, 1-30 min, P = 0.015). One-hour morphine consumption was significantly lower in the intravenous tramadol group (mean +/- SD; 3.4 mg +/- 2.5) and in the intraperitoneal tramadol group (4.4 +/- 4.3 mg) compared with the control group (6 +/- 2 mg) (P = 0.044). There was no difference between the three groups regarding pain scores, morphine consumption and incidence of shoulder pain or adverse effects at 24 h. CONCLUSION: Intravenous tramadol provides superior postoperative analgesia in the early postoperative period after laparoscopic cholecystectomy compared with an equivalent dose of tramadol administered intraperitoneally and with normal saline in patients undergoing laparoscopic cholecystectomy.

Parenchymal transection with ultrasonic scalpel in liver resection.

BACKGROUND: There is no ideal tool for parenchymal transection in liver resection and bleeding is still a major complication. The purpose of this study was to evaluate the usefulness of an ultrasonic scalpel and to describe our clinical experience in open liver resection. METHODS: An ultrasonic scalpel was used in seven consecutive patients undergoing liver resection. During parenchymal transection coagulation shears were used with the power level set at 2 or 3, and the blunt blades were selected. RESULTS: In each case, bleeding from the liver parenchyma was trivial, but haemostasis of large vessels required suture ligation. Postoperatively none of the patients experienced local technical complications such as haematoma, bile leak or infection. DISCUSSION: Although complete haemostasis of large vessels cannot be achieved, the ultrasonic scalpel may be used for parenchymal transection in liver resection to reduce blood loss. Larger series of patients are needed before a definitive statement regarding the efficacy of this method can be made.

Surgeons' attitudes toward HIV/AIDS in Turkey.

Currently HIV/AIDS is one of the most difficult challenges for health care professionals. As primary medical care providers, attitudes of the physicians towards HIV/AIDS are of utmost significance. The aim of this research is to determine the attitudes of the surgeons towards HIV/AIDS in their working environment. Data were collected from a self-administered questionnaire given to 128 surgeons. Results revealed that gender, age and professional experience are not significant. This study demonstrated that doctors are worried about contracting HIV/AIDS from the patients. In some circumstances doctors' attitudes, are not clear which may lead to some ethical problems. It is concluded that doctors overestimate the risks and they need special education about HIV/AIDS, as well as professional help to handle their attitudes toward HIV/AIDS.

Validation of MPI and PIA II in two different groups of patients with secondary peritonitis.

BACKGROUND/AIMS: There are several scoring systems designed to predict mortality in patients with peritonitis, which need validation in different patient populations. Our aim was to evaluate Mannheim Peritonitis Index (MPI) and Peritonitis Index of Altona (PIA II) in patients with postoperative peritonitis and other causes of secondary peritonitis. METHODOLOGY: The records of patients operated for intraabdominal infection between 1987-1996 in Hacettepe University Department of General Surgery, were reviewed retrospectively. A total of 473 patients were included in the study; 75 of them had postoperative peritonitis (POSTOP group) and the remaining 398 had secondary peritonitis due to other causes (OTHER group). Using multiple logistic regression, MPI and PIA II were combined in an equation and this new variable was called combined peritonitis score (CPS); CPS = -9 + (0.3 x MPI) + (-1.2 x PIA II). All patients were scored according to MPI, PIA II and CPS. Receiver-operator characteristic (ROC) curves and sharpness of scores were compared. Also mean scores in both groups, proportions of correct predictions of outcome according to scores and correlation of scores with mortality were compared. RESULTS: Overall mortality was 17.8% in OTHER group and 33.3% in POSTOP group (P = 0.0018). Higher MPI scores, lower PIA II scores and higher CPS scores were associated with higher mortality in both groups (P < 0.0001). Mean MPI values were higher, mean PIA II values were lower and mean CPS values were higher in POSTOP group (P < 0.001). The areas under ROC curves of CPS were bigger than MPI and PIA II in both groups. Sharpness of CPS was higher in both groups compared to MPI and PIA II (P < 0.05). Proportion of correct predictions of outcome was highest in CPS among the three scores (P = 0.0074). CPS had the best correlation with observed mortality. CONCLUSIONS: POSTOP group patients had higher MPI, lower PIA II and higher CPS values ending up with higher mortality. This may be because of the delay in diagnosis and treatment, resulting with higher organ failure rates. Generally the results of evaluations for MPI and PIA II are similar. When these two peritonitis scores are combined and used together in the form of CPS, all the parameters improve.

Diagnosis and treatment of uncomplicated hydatid cyst of the liver.

Hydatid disease of the liver is still endemic in certain parts of the world. The diagnosis of noncomplicated hydatid cyst of the liver depends on clinical suspicion. Ultrasonography and computed tomography, the most important diagnostic tools, are helpful for determining the complications and planning treatment. The modern treatment of hydatid cyst of the liver varies from surgical intervention to percutaneous drainage or medical therapy. Surgery is still the treatment of choice and can be performed by the conventional or laparoscopic approach. Percutaneous drainage and treatment of the cyst with hypertonic saline or alcohol seems to be a good alternative to surgery in selected cases. Currently, we treat types I and II by ultrasound-guided percutaneous drainage and types IV and V (excluding totally calcified cysts) surgically. Type III cysts can be managed either way depending on the presence of drainable content. We believe that the laparoscopic approach should be limited to noncomplicated cysts.

Hydatid cyst of the spleen: treatment options.

Hydatidosis is a highly endemic parasitic disease caused by Echinococcus. The spleen is infrequently involved in hydatid disease. Splenectomy is the conventional treatment, but there are other treatment options as well. In this article, we reviewed the data of 14 patients with splenic hydatidosis operated on during the last 20 years. The spleen was involved in 2.5% of all abdominal hydatidosis cases during this period and was the only location of disease in 7 of the 14 patients. Partial cystectomy and omentopexy was performed on 2 patients, and splenectomy was performed on 12 patients. In 2 patients, percutaneous drainage was the initial choice of treatment but was not successful, and splenectomy was performed eventually. There was no mortality, and the morbidity rate was 28.6%. Although currently splenectomy is the conventional treatment, experience suggests that partial cystectomy and omentopexy should be the procedure of choice for the treatment of splenic hydatidosis.

The role of beta-lactam/beta-lactamase inhibitor combinations in surgical infections.

Many surgical infections are characterized by synergistic polymicrobial mixed infection, for which broad-spectrum antimicrobial therapy is usually administered on an empiric basis. Until relatively recently, standard empiric therapeutic regimens have involved the use of two or more antibiotics, such as aminoglycosides and anti-anaerobic agents, to achieve adequate aerobic and anaerobic coverage. There are often substantial drawbacks, however, such as drug-induced toxicity and high costs of treatment. Evidence from a number of clinical studies suggests that single-agent therapy with beta-lactam/beta-lactamase inhibitor combinations is a suitable and cost-effective alternative to multidrug regimens, as well as to monotherapy with cephalosporins or carbapenems in the treatment of intra-abdominal, gynecologic, and diabetic foot infections, and brain abscesses. These agents are also suitable for use in perioperative prophylaxis and may offer benefits over other agents in terms of reduced incidence of surgical wound infections and lower costs.

Detrimental effects of nitric oxide on mesenteric circulation during endotoxaemia and its reversal by aminoguanidine.

OBJECTIVE: To investigate the effect of endotoxaemia on rat mesenteric vascular bed and plasma nitrite concentrations, the possible beneficial effect of aminoguanidine (the selective inducible nitric oxide synthase inhibitor) compared with N(G)-nitro-L-arginine methyl ester (L-NAME) (non-selective nitric oxide synthase inhibitor). DESIGN: Randomised experiment. SETTING: University surgical research laboratory, Turkey. SUBJECTS: 75 Wistar rats. INTERVENTIONS: Rats were divided into control (n = 30) and endotoxaemia (n = 42) groups. Endotoxaemia was produced by intraperitoneal injection of lipopolysaccharide 20 mg/kg. Subgroups were given either aminoguanidine or L-NAME. MAIN OUTCOME MEASURES: After 4 hours, isolated perfused mesenteric preparations were obtained and pressor responses to phenylephrine and vasodilatation responses to acetylcholine were evaluated, and plasma nitrite concentrations measured. RESULTS: Pressor response to phenylephrine did not alter but vasodilatation in response to acetylcholine was significantly reduced during endotoxaemia. Pretreatment with aminoguanidine prevented the impairment of the response to acetylcholine. However, L-NAME was ineffective. In the control group, aminoguanidine and L-NAME did not alter the vascular reactivity. The baseline plasma nitrite concentrations in the control group were increased 5-fold during endotoxaemia. This increase was significantly reduced with aminoguanidine but not with L-NAME. CONCLUSION: The protection achieved by aminoguanidine but not L-NAME suggested that nitric oxide produced by inducible nitric oxide synthase had a role in the impairment of endothelial response during endotoxaemia, and confirmed the importance of selective inducible nitric oxide synthase inhibition to achieve beneficial effects in endotoxaemia.

Effects of CO2 insufflation and laparotomy on wound healing in mice.

BACKGROUND: The aim of the present study was to evaluate the effects of laparotomy and CO2 insufflation on wound healing in a murine incisional wound healing model. METHODS: Seventy-two male Swiss Albino mice were randomly allocated into three groups of control, laparotomy and CO2 insufflation. A transverse skin incision of 15 mm was made in the dorsum of each mouse, and four interrupted mattress sutures with 4.0 polypropylene thread were laid for wound closure. A median laparotomy was performed in the laparotomy group. CO2 insufflation was performed with an intra-abdominal pressure of 9 mmHg. The retained gas was evacuated from the abdominal cavity at the end of a 60-min period. Mice were killed on the 3rd, 7th and 15th postoperative days. The wound tensile strength and 5-hydroxyproline concentration in the wound tissue were measured. RESULTS: Tensile strength of the incised skin increased as the post-incision period progressed. There was no significant difference between the tensile strengths of the incised skin of control, laparotomy and CO2 insufflation groups throughout the observation period. The skin 5-hydroxyproline concentrations of all groups were not significantly different at the 3rd postoperative day. But laparotomy and CO2 insufflation groups had lower 5-hydroxyproline concentrations at the 7th and 15th postoperative days, when compared to controls (P < 0.02 for 7th and 15th days). CONCLUSION: CO2 insufflation and laparotomy reduce the 5-hydroxyproline concentration of the wound, suggesting a diminished wound healing capacity.

Experimental study of the effect of nitric oxide inhibition on mesenteric blood flow and interleukin-10 levels with a lipopolysaccharide challenge.

The septic shock-induced decrease in mesenteric blood flow and release of proinflammatory cytokines are among the major pathophysiologic changes presumed to lead to multiple organ dysfunction syndrome (MODS). Increased nitric oxide (NO) levels are associated with both decreased mesenteric blood flow and positive modulation of proinflammatory cytokine release. In this study we aimed to determine the effect of the timing of the inhibition of nitric oxide synthase (NOS) on mesenteric blood flow and serum interleukin-10 (IL-10) concentrations during endotoxin shock. A nonspecific NOS inhibitor NG-nitro-L-arginine methyl ester (L-NAME), a specific NOS inhibitor aminoguanidine (AG), or placebo were injected 20 minutes before or 20 minutes after a lipopolysaccharide (LPS) or placebo challenge to Swiss-albino mice, as pretreatment or posttreatment, respectively. At 120 minutes after LPS or placebo injection the mesenteric blood flow was measured, and blood samples from the heart were obtained for IL-10 levels in both groups. Pretreatment and posttreatment with both NOS inhibitors prevented the LPS-induced decrease in mesenteric blood flow. Pretreatment was more effective for this purpose. Pretreatment accentuated the LPS-induced increase in serum IL-10 concentrations, whereas posttreatment had no significant effect. We conclude that the timing of NOS inhibition is important for attenuating some deleterious effects of endotoxin.

Melatonin modulates mesenteric blood flow and TNFalpha concentrations after lipopolysaccharide challenge.

OBJECTIVE: To investigate the effect of various doses of melatonin on reduction in mesenteric blood flow (MBF) and increase in tumour necrosis factor alpha (TNFalpha) concentration caused by injection of lipopolysaccharide (LPS). DESIGN: University Hospital, Turkey. SETTING: Open experimental study. ANIMALS: 59 Swiss albino mice. INTERVENTIONS: Animals were injected with melatonin solvent or 1, 10, 100, or 500 mg/kg melatonin. Ten minutes later control animals were injected with saline, and the experimental group with LPS. MAIN OUTCOME MEASURES: Mesenteric blood flow and serum TNFalpha concentration. RESULTS: In control animals, 100 and 500 mg/kg melatonin reduced MBF. LPS reduced MBF in solvent, 1, and 10 mg/kg melatonin groups. The concentration of TNFalpha was considerably increased in the mice given LPS. Melatonin reduced this response significantly. CONCLUSION: In high doses melatonin directly reduces MBF. It has no protective effect on the LPS-induced decrease in MBF. In lower doses it blocks, but at higher doses reduces, LPS-induced TNFalpha production.

Germ line BRCA1 and BRCA2 gene mutations in Turkish breast cancer patients.

Germ line BRCA1 and/or BRCA2 mutations were screened in 50 Turkish breast and/or ovarian cancer patients composed of hereditary, familial, early onset and male cancer groups. Genomic DNA samples were tested by heteroduplex analysis and DNA sequencing. Two truncating BRCA2 mutations, one novel (6880 insG) and one previously reported (3034 delAAAC), were found in two out of six (33%) hereditary breast and/or ovarian cancer patients. A novel truncating (1200 insA) and a missense (2080A-->G) BRCA1 mutation was found in two of 27 (7%) individuals in the early onset group. A total of four (8%) disease-causing mutations in 50 breast cancer patients were identified in BRCA1 and BRCA2 genes. In addition, five BRCA1 sequence variants have been identified in 23 patients. These results indicate that BRCA1 and BRCA2 genes are involved in some, but not all, forms of hereditary predisposition to breast cancer in the Turkish population.

Coenzyme Q10 concentrations and antioxidant status in tissues of breast cancer patients.

OBJECTIVES: An increasing amount of experimental and epidemiological evidence implicates the involvement of oxygen derived radicals in the pathogenesis of cancer development. Oxygen derived radicals are able to cause damage to membranes, mitochondria, and macromolecules including proteins, lipids and DNA. Accumulation of DNA damages has been suggested to contribute to carcinogenesis. It would, therefore, be advantageous to pinpoint the effects of oxygen derived radicals in cancer development. DESIGN AND METHODS: In the present study, we investigated the relationship between oxidative stress and breast cancer development in tissue level. Breast cancer is the most common malignant disease in Western women. Twenty-one breast cancer patients, who underwent radical mastectomy and diagnosed with infiltrative ductal carcinoma, were used in the study. We determined coenzyme Q10 (Q) concentrations, antioxidant enzyme activities (mitochondrial and total superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), catalase), and malondialdehyde (MDA) levels in tumor and surrounding tumor-free tissues. RESULTS: Q concentrations in tumor tissues significantly decreased as compared to the surrounding normal tissues (p < 0.001). Higher MDA levels were observed in tumor tissues than noncancerous tissues (p < 0.001). The activities of MnSOD, total SOD, GSH-Px and catalase in tumor tissues significantly increased (p < 0.001) compared to the controls. CONCLUSIONS: These findings may support that reactive oxygen species increased in malignant cells, and may cause overexpression of antioxidant enzymes and the consumption of coenzyme Q10. Increased antioxidant enzyme activities may be related with the susceptibility of cells to carcinogenic agents and the response of tumor cells to the chemotherapeutic agents. Administration of coenzyme Q10 by nutrition may induce the protective effect of coenzyme Q10 on breast tissue.