Probiotic agent Saccharomyces boulardii reduces the incidence of lung injury in acute necrotizing pancreatitis induced rats.

BACKGROUND: Acute necrotizing pancreatitis is a severe acute inflammatory disease of the pancreas that can lead to extrapancreatic organ involvement. Supervening lung injury is an important clinical entity determining the prognosis of the patient. Probiotics are dietary supplements known to reduce or alter inflammation and inflammatory cytokines. In the present study, we hypothesize that probiotics may reduce lung injury by reducing bacterial translocation, which results in reduced infection, inflammation, and generation of proinflammatory cytokines in an experimental model of acute necrotizing pancreatitis. METHODS: Pancreatitis was induced by concomitant intravenous infusion of cerulein and glycodeoxycholic acid infusion into the biliopancreatic duct. Saccharomyces boulardii was used as the probiotic agent. Rats were divided into three groups: sham, pancreatitis-saline, which received saline via gavage at 6 and 24 h following the pancreatitis, pancreatitis-probiotics, which received probiotics via gavage method at 6 and 24 h following the pancreatitis. The rats were sacrificed at 48 h, venous blood, mesenteric lymph node, pancreatic and lung tissue samples were obtained for analysis. RESULTS: Serum pancreatic amylase, lactate dehydrogenase, secretory phospholipase A(2), and IL-6 were found to be increased in pancreatitis-saline group compared with the other groups (P < 0.05). Histological analyses revealed that edema, inflammation, and vacuolization as well as polymorphonuclear leukocyte infiltration in the lung tissue was significantly reduced in the probiotic treated group. Bacterial translocation was significantly reduced in the probiotic treated group compared with the other groups (P < 0.05). CONCLUSION: These results suggest that Saccharomyces boulardii reduce the bacterial translocation. As a result of this, reduced proinflammatory cytokines and systemic inflammatory response was observed, which may be the reason underlying reduced lung injury in acute necrotizing pancreatitis.

Fine-tuning of the extent of lateral internal sphincterotomy: spasm-controlled vs. up to the fissure apex.

PURPOSE: This study was designed to compare the results of controlled lateral internal sphincterotomy by using anal calibrators with those of sphincterotomy up to the fissure apex in a randomized, prospective fashion. METHODS: In the fissure apex group, sphincterotomy was extended to the level of the fissure apex, and in the spasm-controlled group, serial small sphincterotomies and anal caliber measurements followed until an anal caliber of 30 mm was obtained. RESULTS: The preoperative anal caliber was 24 +/- 1.9 (range, 20-28) mm and 24.9 +/- 2.44 (range, 19-28) mm in the spasm-controlled and fissure apex groups, respectively (P = 0.127). Postoperatively, the spasm-controlled group had a mean anal caliber of 31.5 +/- 1.28 (range, 30-32) mm, and the fissure apex group had 32.5 +/- 2.33 (range, 25-37) mm (P = 0.035). In the fissure apex group, a significant negative correlation was determined between the postoperative anal caliber and time of relief of pain (r = -0.568, P = 0.001). The early (7 and 28 days) postoperative anal incontinence scores were significantly higher in the fissure apex group (P = 0.002, P < 0.0001, respectively). A significant positive correlation between the anal caliber measurements and anal incontinence scores at 28 days and 2 months also was noted in the fissure apex group (r = 0.406, P = 0.023; and r = 0.364, P = 0.044). CONCLUSIONS: Controlled sphincterotomy provided a faster relief of pain, and it was associated with a lower rate of early postoperative disturbance of continence and an insignificantly lower rate of treatment failure compared with sphincterotomy up to the fissure apex.

Efficacy of radical surgery in preventing early local recurrence and cavity-related complications in hydatic liver disease.

BACKGROUND: Hydatic disease of the liver remains to be a complex worldwide problem especially in rural areas. Early local recurrence and cavity-related complications are still a matter of conflict in the management of hydatic liver disease. The aim of this study is to investigate efficacy of the type of surgical treatment in preventing early local recurrence and cavity-related complications of this disease. Here, we present the preliminary results of our study. METHODS: This study was performed prospectively including 32 patients who were operated for hydatic liver disease between January 2001 and January 2005. Patients were randomized into radical and conservative surgery groups. Recurrences at the primary surgical site in the first 2 years were considered as early local recurrence and biliary leakage, biliary fistula, cavity abscess, etc. were considered as cavity-related complications. RESULTS: Early local recurrences were observed only after conservative surgical procedures (p=0.045). Recurrent cysts were found to be due to satellite cysts or pericystic disease. Cavity-related complications were seen in six patients in the conservative surgery group (p=0.011). CONCLUSIONS: In suitable patients, radical surgical resection provides an effective surgical management option in preventing early local recurrence and cavity-related complications when compared to conservative surgical approaches.

Combined proper hepatic artery and common hepatic duct injury in open cholecystectomy: case report and review of the literature.

A 24-y-old male patient underwent elective open cholecystectomy at another center. On the third postoperative day, he developed fever and jaundice, for which he underwent reoperation at the same center on the seventh postoperative day. During the second surgery, massive bleeding was encountered, suture ligations were applied, and T-tube drainage was performed. After the surgery was completed, the patient developed hepatic microabscess, and sepsis ensued. The patient presented at this hospital for further evaluation. To rule out vascular injury, which was suspected in this patient, celiac angiography was performed; it showed that the hepatic artery was occluded near the eminence of the gastroduodenal artery, and the liver was supplied by many collaterals. After the patient's condition had stabilized and the sepsis had resolved, Roux-N-Y hepaticojejunostomy was performed on the 59th d after admission.

Timing of laparoscopic cholecystectomy for subacute calculous cholecystitis: early or interval--a prospective study.

BACKGROUND/PURPOSE: The aim of this prospective study was to evaluate the safety and feasibility of early laparoscopic cholecystectomy for subacute cholecystitis and to compare it with interval laparoscopic cholecystectomy. METHODS: The study was performed in 74 patients who had been diagnosed with subacute cholecystitis between January 2000 and June 2005. The patients were divided into two groups. The early laparoscopic cholecystectomy group was composed of 31 patients who underwent laparoscopic cholecystectomy 24 h after admission to the hospital. The interval laparoscopic cholecystectomy group was composed of 43 patients who underwent laparoscopic cholecystectomy 8-12 weeks after medical treatment. RESULTS: There was no significant difference between the conversion rate, intraoperative bleeding, need for intraoperative cholangiography, minor bile duct injury, and postoperative complications in the two groups. Eleven patients in the interval group underwent urgent laparoscopic cholecystectomy or additional procedures because of recurrent cholecystitis, choledocholithiasis, or biliary pancreatitis. The early group had a significantly shorter total hospital stay (P = 0.031), lower cost of treatment (P = 0.042), and less difficulty with Calot's triangle dissection (P = 0.008). CONCLUSIONS: Early laparoscopic cholecystectomy can be done without hesitation in patients with subacute cholecystitis, in the light of obstacles observed in the interval group, such as dissection difficulty, lack of success in "cooling down", and additional problems such as choledocholithiasis and biliary pancreatitis.

[Hepatic portal venous gas: a case report]. / Hepatik portal vende gaz: olgu sunumu.

Gas in hepatic portal vein is a rare entity. This may be apparent after mesenteric ischemia, blunt abdominal trauma, intestinal obstruction, and intra-abdominal infection. Intrahepatic gas was detected by direct abdominal graphy in a 58 year-old man who was admitted to our emergency service with acute abdomen. On computed tomography; portal vein gas, pneumatosis intestinalis, and occlusion of superior mesenteric vein and artery were detected. The patient who had had significant concomittant operative risks, died prior to surgery. Gas in portal vein is a good predictive factor for diagnosis, management, and prognosis. This sign may avoid unnecessary surgery and also it may help to make an early decision for surgery.

Management of acute calculous cholecystitis in high-risk patients: percutaneous cholecystotomy followed by early laparoscopic cholecystectomy.

Emergency cholecystectomy for acute cholecystitis is associated with high morbidity and mortality rates in patients with significant comorbidities and high-risk surgery. The aim of this study was to evaluate the effectiveness, possible advantages, and complications of percutaneous cholecystostomy (PC) followed by an early laparoscopic cholecystectomy (LC) in relation to conservative treatment followed by a delayed LC in high-surgical risk patients. Between 2002 and 2004, patients were randomly classified into 2 groups: the first group consisted of patients who had PC followed by an early LC (PCLC group, n = 31) and the second group consisted of patients who had conservative treatment followed by a delayed LC (DLC group, n = 30). The groups were statistically compared regarding their demographic, comorbidity, hospital stay, conversion, and complication rates. PC was technically successful in 31 patients with no attributable mortality or major complications. No difference had been found in regarding demographic, comorbidity, and complication rates. In PCLC group, all the patients experienced symptom relief within 24 hours, and early LC was attempted in 31 patients once their clinical condition was sufficiently stable, this was successfully accomplished in 29 (93.5%). In the DLC group, delayed LC was attempted in 30 patients, and this was successfully accomplished in 26 (86.6%). The hospital stay was shorter and cost was in the PCLC group was lower than in the DLC group. PC allows resolution of sepsis in patients at high surgical risk. Early LC could be safely performed once sepsis and acute infection resolved in these patients.

The effect of platelet activating factor antagonist BN 52021 on bacterial translocation and ICAM-I expression in experimental obstructive jaundice.

Expression of intracellular adhesion molecule-1 (ICAM-1) in an obstructive jaundice model and the potential protective role of platelet activating factor antagonist over small intestine and liver together with its effects on bacterial translocation are examined in this study. Forty-eight male Wistar albino rats were assigned into four equal groups of 12. In groups I and II, animals were sham operated. In groups III and IV, common bile duct ligation and division were performed. In group I and group III, 0.5 ml/day normal saline was applied intraperitoneally daily from day 2 to 6 of the study; in group II and group IV, 1 mg/kg/day BN 52021 was applied intraperitoneally daily from day 2 to 6 of the study. All animals were sacrificed on postoperative day 7. ICAM-1 expression (CD54 positivity) was analyzed in the liver and ileum tissue by immunohistochemical method. Samples from blood, liver mesenteric lymph nodes, and spleen were cultured under aerobic conditions. It is revealed that ICAM-1 expression was statistically higher in group III, with highest bacterial translocation and liver and spleen injury when compared to other groups. Serum alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP), gamma-glutamyltranspeptidase (GGT), bilirubin, tumor necrosis factor alpha (TNFalpha), and interleukin 1beta(IL-1beta) values were at the highest level in group III, and there was a statistical decrease in group IV compared to group III. The administration of BN52021 in experimental obstructive jaundice is a useful way to reduce liver and intestinal mucosal villi damage by inhibiting bacterial translocation and systemic inflammatory response.

Laparoscopic cholecystectomy in patients with previous abdominal surgery.

BACKGROUND: Laparoscopic cholecystctomy has become the treatment of choice for symptomatic gallstones. The potential risks have dissuaded some surgeons from using the laparoscopic procedure in patients with previous abdominal surgery. Therefore, we aimed to investigate the effect of previous abdominal surgery on the feasibility and safety of laparoscopic cholecystectomy. METHODS: This study included 600 well-documented patients with gallstones who underwent laparoscopic cholecystctomy at our surgical department between May 2000 and January 2004. The patients were classified into 3 groups: group 1, patients without a history of previous abdominal surgery (n = 408); group 2, patients with a history of upper abdominal surgery (n = 92); group 3, patients with a history of lower abdominal surgery (n = 100). The data were collected and analyzed for open conversion rates, operative times, perioperative and postoperative complications, and hospital stay. RESULTS: Of the 600 study patients, 192 had undergone previous abdominal surgery (92 upper, 100 lower). Conversion rate, hospital stay, and complication rates were similar in each group. Mean operating time was the longest (57 +/- 9.8 min) in patients with previous upper abdominal surgery (P < 0.05). On the other hand, the operative time was similar in groups 1 and 3 (P > 0.05). CONCLUSION: Previous abdominal surgery is not a contraindication to safe laparoscopic cholecystectomy. However, previous upper abdominal surgery is associated with a prolonged operation time.

Urgent laparoscopic cholecystectomy is the best management for biliary colic. A prospective randomized study of 75 cases.

BACKGROUND/AIM: Delay of laparoscopic cholecystectomy after the diagnosis of biliary colic may increase the probability of recurrent emergency admission while awaiting elective cholecystectomy. The aim of this study was to compare the possible advantages and safety of urgent laparoscopic cholecystectomy (ULC) with elective laparoscopic cholecystectomy (ELC) in patients with biliary colic. PATIENTS AND METHODS: Between 2001 and 2003, 75 patients with biliary colic were included in this study. The patients were classified into following two groups: patients who had ULC in 24 h were in group I (n = 28) and patients who had ELC (mean interval 4.22 +/- 1.42 months) were in group II (n = 35). Conversion to open cholecystectomy, operative time, postoperative hospital stay, costs, and complications were evaluated. RESULTS: In group II, 9 patients made a total of 13 return visits to the emergency department with recurrent attacks of biliary colic or complications of gallstone disease. Mean operative time increased from 35.1 +/- 6.74 min for urgent laparascopic cholecystectomy to 49.9 +/- 6.12 min for ELC (p > 0.05) and hospital stay time increased from 1.06 +/- 0.4 to 2.31 +/- 2.36 days (p < 0.05). Conversion to open cholecystectomy increased from 0% in group I to 17.2% in group II (p < 0.05). DISCUSSION: ULC for biliary colic may be the most medically efficacious and cost-effective treatment.

V-Y advancement flap closures for complicated pilonidal sinus disease.

BACKGROUND AND AIMS: Hair entry into the midline is the generally accepted theory in pilonidal sinus formation. This theory is also involved in the pathogenesis of the recurrence after different types of operations for pilonidal sinus disease. The relationship of the suture lines and the midline was evaluated in this study. PATIENT AND METHODS: Thirty-four patients with stage 4 or recurrent pilonidal sinus disease who underwent V--Y advancement flap closure were randomized into two groups: vertical suture line unrelated to midline (VLUM, n=18) and vertical suture line related to midline (VLRM, n=16). RESULTS: None of the patients with or without a suction drain developed flap necrosis, local haematomas or seromas. The median length of the postoperative hospital stay was 3 days for theVLRM group and the VLUM group (p>0.05). The median follow-up period was 32 months. During the follow-up period, two recurrences were determined 22 and 15 months after operation in the VLRM group. Recurrences were situated in the scar tissue over the midline. INTERPRETATION AND CONCLUSION: Routine application of suction drains is not recommended after V--Y advancement flap closure. Avoidance of the relationship of the postoperative suture line and the midline, if possible, offers a safe method of definitive reconstruction.

Ultrasonography in the diagnosis of true gallbladder polyps: the contradiction in the literature.

Polypoid lesions of the gallbladder (PLGs) are often incidentally identified during ultrasonographic examination of abdominal pain. The present study was designed to determine the reliability of ultrasonography (US) in the diagnosis of PLGs. The records of 853 patients who underwent laparoscopic cholecystectomy (LC) for PLGs in Gazi Medical School from January 2000 to January 2004 were reviewed. Data were collected regarding the patients' gender, age, symptoms, serum lipid levels, the size and the number of polyps on US, surgical indications for PLGs and histopathological diagnosis. In all, 56 of 853 patients had PLGs and underwent LC. Right upper quadrant pain (59%) was the most common presenting symptom that led to gallbladder US. Nearly 75% of the lesions were smaller than 10 mm. At histopathologic examination cholesterolosis was found in 17 of 56 (30%) patients, and 12 of 56 (21%) demonstrated only cholelithiasis; 17 (30%) patients had both cholesterolosis and stones. Only 10 (18%) patients had adenomatous polyp and 8 of these polyps were larger than 1 cm. Overall US-based diagnosis of gallbladder polyp was inaccurate in 82%. The sensitivity and specificity of US for polyps <1 cm was 20% and 95.1%, respectively, whereas the sensitivity and specificity of US for polyps >1 cm was 80% and 99.3%, respectively. The accuracy of US in diagnosing PLGs was poor, especially in polyps <1 cm.

Unexpected gallbladder cancer during laparoscopic cholecystectomy.

BACKGROUND/PURPOSE: In the present study, we investigated the effectiveness of surgeons in determining incidental gallbladder pathologies at laparoscopic cholecystectomy (LC). METHODS: This study included 548 patients with gallstones who underwent LC between May 1, 2001 and October 15, 2003. The surgeon made an incision on the gallbladder wall for inspection, and palpated the mucosa after removing the gallbladder from the abdominal cavity to look for unsuspected pathologies. If an abnormal mucosa was observed or palpated, it was marked with a silk suture and then histopathologic examination was performed. RESULTS: Fifty of 548 LC specimens were found to be suspi-cious by the surgeon. Histopathological examination of frozen sections revealed incidental pathologies in 15 of these specimens. Strikingly, 5 of these specimens were considered to have gallbladder cancer (GBC). The other incidental pathologies were consistent with adenomyomatosis, xanthogranulomatous cholecystitis, and fibroepithelial and hyperplastic polyps. Four of the other 498 specimens revealed incidental pathologies at definitive histopathological examination, and all of them were consistent with gastric metaplasia. The sensitivity and specificity of the procedure was 78.9% and 93%, respectively. CONCLUSIONS: A simple prosedure; that is, incision and inspection, and palpation of the gallbladder, seems to be useful for the diagnosis of incidental gallbladder pathologies.

Short and long-term effects of bacterial translocation due to obstructive jaundice on liver damage.

BACKGROUND/AIMS: The present study was conducted to determine if obstructive jaundice promotes bacterial translocation and to evaluate the changes in hepatic histopathology in patients with benign biliary obstruction. METHODOLOGY: Between January 1996 and January 1998, 19 patients treated for benign biliary obstruction were studied. Fourteen patients with symptomatic cholelithiasis were taken as the control group. Patient characteristics, preoperative and post-operative laboratory tests with an interval of 7 days were recorded. In all patients, bile and mesenteric lymph nodes samples were taken for bacterial growth and histopathologic changes were studied on the liver excised during surgery. RESULTS: In the control group, bacterial growth was observed in the bile and mesenteric lymph nodes cultures in one (7.1%) and two patients (14.3%), respectively. In the study group, 8 patients (42%) had positive bile cultures and 12 patients (63.2%) had positive mesenteric lymph nodes cultures, respectively. Histopathologic examination of the liver revealed significant increase in the rate of periductal and portal fibrosis in the jaundiced patients, compared with control group (p < 0.001). Postoperative complications in the study group were wound infection (3 cases), renal failure (2 cases), ARDS (1 cases) and intraabdominal abscess (1 cases). In the control group, one patient had wound infection and one had atelectasis. Two patients with jaundice died of multiple organ failure and respiratory failure. In long-term follow-up (mean 17 months), when sclerosing cholangitis and secondary biliary cirrhosis developed in one patient each in the study group, no long-term complication occurred in the control group. CONCLUSIONS: Our clinical results demonstrate that extrahepatic biliary obstruction promotes bacterial translocation and this process is an important cause of morbidity and mortality in patients with jaundice. Also, obstructive jaundice subsequently leads to significant functional and morphological damage in the liver.

Effects of recombinant platelet activating factor acetylhydrolase in obstructive jaundice.

BACKGROUND/AIMS: The aim of this study was to investigate effects of recombinant PAH (platelet activating factor acetylhydrolase), on tissue damage and on antioxidant response. METHODOLOGY: A total of 30 Wistar-Albino type rats were used in this PAH treatment, and the subjects were divided into 3 groups namely sham, ligation and PAH treatment groups, each containing 10 rats. In PAH treatment and ligation groups, laparotomy was made; common bile duct was ligated and incised. Following ligation, blood and liver tissue were taken. In the sham group, the common bile duct was turned but no other procedure was applied. The subjects in the ligation group were given intraperitoneal placebo on the 2nd to 6th days; and those in the PAH treatment group were applied PAH at a 5-mg/kg dose. Blood and liver tissue were taken on postoperative day 7. The parameters examined in the blood sample included, liver function tests, superoxide dismutase, glutathione peroxidase, tumor necrosis factor-alpha and interleukin-6. In liver tissue, histopathologic examination was made. RESULTS: Levels of AST, ALT, GGT, ALP, tumor necrosis factor-alpha and interleukin-6 were significantly higher than the levels in the sham group. These parameters, measured on the 7th day in the PAH treatment group were found to be significantly lower than the ligation group. Portal inflammation in the PAH given group was significantly lower than the ligation group. CONCLUSIONS: Administration of PAH in experimental jaundice has produced improvement in liver functions, significant reductions in serum GGT and ALP, tumor necrosis factor-alpha and interleukin-6, and in liver damage whereas it has brought about an increase in the levels of antioxidant enzymes.