A novel adaptive state-of-charge balancing control scheme for cascaded H-bridge multilevel converter based battery storage systems.

Variations in state-of-charges (SOCs) of batteries in a cascaded H-bridge multilevel converter (CHB-MLC) based battery storage system (BSS) could lead to undesired efficiency and performance drops, even failure of the whole system. Hence, SOC balancing is crucial for BSSs. Avoiding over-modulation region, ensuring zero common-mode voltage and reaching balanced SOC condition as quickly as possible are the key points to consider while performing SOC balancing. In this paper, a gain-scheduling based adaptive SOC balancing method is proposed for single-phase CHB-MLC based BSSs. In the proposed method, gains of the proportional controllers are updated at each sampling time based on the mathematical relationship between instantaneous SOCs and voltage reference of the CHB-MLC. Performance of the proposed method is validated through a Monte Carlo simulation based numerical analysis and experimental studies on a single-phase three-module CHB-MLC based BSS. Results reveal that the proposed method achieves SOC balancing at least two times faster than the traditional constant gain methods while avoiding over-modulation region and having zero common-mode voltage.

Is emergency gastrointestinal system tumor surgery safe under treatment of antitrombotics?

BACKGROUND: The use of antitrombotic (antiaggregant and anticoagulant) drugs is increasing all over the world and in our coun-try. About 12.6% of patients who underwent gastrointestinal tumor surgery receive antitrombotic therapy for various reasons, and in this study, we aimed to demonstrate the safe feasibility of elective or emergency gastrointestinal tumor surgery with the correct perioperative antitrombotic therapy management. METHODS: The patients who were planned for gastrointestinal tumor surgery under antitrombotic treatment were analyzed in three groups as those whose pre-operative treatment management treatment was discontinued, those who underwent bridging treat-ment, and those whose treatment continued. Anti-embolic stockings or intermittent pneumatic compression devices were applied to all patients preoperatively and postoperatively as mechanical prophylaxis. Post-operative complications, especially post-operative bleeding and thrombosis, were evaluated using the Clavien-Dindo post-operative complication classification. RESULTS: When patients who were under antithrombotic therapy, whose therapy was discontinued, and who underwent surgery under bridging therapy, no significant difference was found between the three groups in terms of bleeding complications. CONCLUSION: In tertiary centers with high clinical experience, elective and emergency gastrointestinal system tumour surgery can be safely performed under antitrombotic therapy without increasing the thromboembolic risk.

Femoral artery aneurysm developed on intimal sarcoma: Case report.

Intimal angiosarcoma is a rare vascular malignancy, and diagnosis is very difficult due to nonspecific symptoms. There are controversial points regarding the diagnosis, treatment and follow-up of intimal angiosarcomas. The purpose of this case report was to evaluate the diagnosis and treatment process of a patient diagnosed with femoral artery intimal angiosarcoma. Furthermore, in line with previous studies, it was aimed to illuminate controversial points. A 33-year-old male patient, who had been operated on due to ruptured femoral artery aneurysm, was diagnosed with intimal angiosarcoma with the pathology result. Recurrence was observed during clinical follow-up, and the patient was treated with chemotherapy and radiotherapy. Since there was no response to treatment, the patient underwent aggressive surgery including the surrounding tissues. No recurrence or metastasis was observed in the patient's 10th month follow-up. Although intimal angiosarcoma is rare, it should be considered in differential diagnosis when femoral artery aneurysm is detected. The most important step in treatment is aggressive surgery, but adding chemo-radiotherapy to the treatment should be considered.

Recommendations for Trauma and Emergency General Surgery Practice During COVID-19 Pandemic.

COVID-19 is a new disease, based on currently available limited information, older adults and people of any age who have severe underlying medical conditions may be at higher risk for severe illness from COVID-19. People of all age groups are also at risk. Healthcare providers have always been the professionals most exposed to the risk of contracting to any kind of infection due to the nature of their profession. Elective interventions have been postponed to give care of patients with COVID-19. However, some interventions cannot be delayed, such as trauma surgery, acute abdomen, and emergency endoscopies. To maintain the sustainability of the healthcare system, the protection of healthcare providers should be the top priority. On the other hand, patients, who need emergency healthcare, should also be provided with appropriate treatment. Healthcare professionals should choose a treatment method appropriately in the circumstances to protect themselves and their patients as much as possible. This paper aims to summarize how a surgeon may act appropriately when an intervention is inevitable during the COVID-19 pandemic.

Clinical course of abdominal aortic aneurysms in Behçet disease: a retrospective analysis.

Arterial aneurysms are rare manifestations of Behçet Disease (BD) with high morbidity and mortality. This study aimed to investigate the clinical course of BD patients with abdominal aortic aneurysms (AAA). We retrospectively searched charts of BD patients, followed up between 1988 and 2011, to identify those with AAA with at least 6-month clinical and radiological follow-up data. Chart review revealed 12 patients (11 males) with AAA amongst 1224 patients; follow-up data from 11 patients were available. The most common symptoms were lower back and abdominal pain. The only pre-treatment complication was a spontaneous rupture. All but one patient received corticosteroid and cyclophosphamide pulses for the induction, and corticosteroid and azathioprine for the maintenance treatment; one patient received only the maintenance treatment. Two patients had surgical graft interposition, without postoperative complications. Seven patients had endovascular stenting; five of them (71.4%) showed radiological regression after 32.5 (13.4-53.8) months, while four (57%) had clinical improvement after 11.8 (0.2-29.4) months. However, one non-responsive patient developed stent infection and exsanguinated during percutaneous drainage, and one patient developed femoral artery pseudo-aneurysm at the catheter insertion site. Another patient developed a new aneurysm under the maintenance treatment. Medical treatment alone yielded radiological regression in one of two patients. Current immunosuppressive, surgical or endovascular approaches can provide clinical and radiological improvements lately in BD patients with AAA. Furthermore, complication rates seem to be high with interventional approaches. These findings suggest an unmet need for safer alternative treatments.

The effects of compression garments and electrostimulation on athletes' muscle soreness and recovery.

In this study, we explained the effects of compression garment and electrostimulation on athletes' recovery period by evaluating blood lactate and isokinetic peak torque parameters. Twenty volunteers (15.55± 0.51 yr) were included to study. At recovery period, blood samples was taken for lactate values at 0th, 3rd, 5th, 15th, 30th min. The isokinetic strength test was performed on right ankle at 15th min and on the left ankle at 30th min. The same protocol was performed for compression garment on 2 weeks and for electrostimulation on third weeks and results were compared. There wasn't any significant difference on blood lactate levels within groups. At women; there was not any significant difference on isokinetic peak torques within two groups. but at electro-stimulation usage we found significant increases on right plantar flexion (P<0.1), right dorsal flexion (RDF) (P<0.1) and left plantar flexion (LPF) (P<0.1) values compared to control measurements. At men; with compression garment usage, there was significant increase on LPF values compared to control measurements. At electrostimulation usage, we found significant increases on RDF (P<0.1) and left dorsal flexion (P<0.1) values compared to control measurements. During recovery, there is not any beneficial effect seen on blood lactate level within two groups. When compared to passive rest, compression garments and electrostimulation interventions effects on force generation capacity at recovery are statically significant. Also in terms of force generation capacity; usage of electrostimulation during 15 min and compression garments during 30 min were statically more significant.

Gene expression levels of elastin and fibulin-5 according to differences between carotid plaque regions.

AIM: The purpose of this study was to investigate the gene expression levels of elastin and fibulin-5 according to differences between carotid plaque regions and to correlate it with clinical features of plaque destabilization. MATERIALS AND METHODS: The study included 44 endarterectomy specimens available from operated symptomatic carotid artery stenoses. The specimens were separated according to anatomic location: internal carotid artery (ICA), external carotid artery (ECA) and common carotid artery (CCA), and then stored in liquid nitrogen. The amounts of cDNA for elastin and fibulin-5 were determined by Quantitative real-time PCR (Q-RT-PCR). Target gene copy numbers were normalized using hypoxanthine-guanine phosphoribosyltransferase (HPRT1) gene. The delta-delta CT method was applied for relative quantification. RESULTS: Q-RT-PCR data showed that relative fibulin-5 gene expression was increased in ICA plaque regions when compared to CCA regions but not reaching significance (p=0.061). At the same time, no differences were observed in elastin mRNA level between different anatomic plaque regions (p>0.05). Moreover, elastin and fibulin-5 mRNA expression and clinical parameters were compared in ICA plaques versus CCA and ECA regions, respectively. Up-regulation of elastin and fibulin-5 mRNA levels in ICA were strongly correlated with family history of cardiovascular disease when compared to CCA (p<0.05). Up-regulation of fibulin-5 in ICA was significantly associated with diabetes, and elevated triglycerides and very low density lipoprotein (VLDL) when compared to ECA (p<0.05). CONCLUSION: The clinical significance is the differences between the proximal and distal regions of the lesion, associated with the ICA, CCA and ECA respectively, with increased fibulin-5 in the ICA region.

Iatrogenic major vascular injury during lumbar discectomy: report of three cases.

Iatrogenic vascular injury rarely occurs during lumbar disc surgery and can be fatal if it is not recognized instantly. In this paper we aim to introduce three iatrogenic vascular injuries that occurred during the lumbar disc surgery. The first case was consulted because of the sudden hypotension attack during lumbar disc surgery. The left common iliac artery and bilateral common iliac vein injuries were detected in emergency laparotomy, and repaired primarily. The second case was consulted to our clinic because of the hypotension attack at the first postoperative day. Left common iliac artery and vein injuries were diagnosed by CT angiography. Left common iliac vein was ligated and left common iliac arterial injury was repaired primarily by laparotomy. The third case was referred to our clinic for left lower extremity ischemia. Left common iliac artery injury was diagnosed by simple physical examination. Reconstruction by PTFE graft interposition was performed. The first patient died due to disseminated intravascular coagulation at the early postoperative period. Pulmonary embolus developed in the iliac vein ligated patient but was well treated by anticoagulant therapy. The last patient was discharged without any problem. Two of the patients are well on long-term follow-up.

The management of mesenteric vein thrombosis: a single institution's experience.

BACKGROUND: Mesenteric vein thrombosis occurs rarely and is responsible for approximately 5-15% of all cases of acute mesenteric ischemia. The aim of this report was to discuss the management of mesenteric vein thrombosis based on our experience with 34 patients. METHODS: In the present study, 34 patients who were admitted to our emergency surgery department between January 2007 and January 2010 with a diagnosis of acute mesenteric vein thrombosis were assessed retrospectively. Patients with peritoneal signs first underwent diagnostic laparoscopy to rule out perforation or bowel gangrene. We performed a second-look laparoscopy within 72 hours of the first operation. All patients were administered 100 mg/kg of the anticoagulant enoxaparin twice daily. In the 6th and 12th months of follow up, CT angiography was performed to evaluate recanalization of the veins. RESULTS: CT angiography revealed superior mesenteric vein thrombosis in 25 (73%) patients, portal vein thrombosis in 24 (70%) patients, and splenic vein thrombosis in 12 (35%) patients. Eleven patients with peritoneal signs underwent diagnostic laparoscopy; eight of the patients underwent small bowel resection, anastomosis, and trocar insertion. During second-look laparoscopy, small bowel ischemia was found in two patients and re-resection was performed. CONCLUSION: Early diagnosis with CT angiography, surgical and non-surgical blood flow restoration, proper anticoagulation, and supportive intensive care are the cornerstones of successful treatment of mesenteric vein thrombosis.

Local thrombolytic therapy in acute mesenteric ischemia.

BACKGROUND: The aim of the study was to evaluate the local thrombolytic therapy (LTT) in combination with laparoscopy, in management of acute mesenteric ischemia (AMI). METHODS: From January 2000 to January 2010, patients who were admitted to the hospital with AMI due to acute arterial occlusion were analysed retrospectively. Patients presenting with acute abdomen with a suspicion of AMI were evaluated with computerized tomography angiography (CTA). Patients who had findigs of AMI on CTA, were underwent selective mesenteric angiography and LTT eventhough without peritoneal signs. LTT was carried out before or after laparoscopy or laparotomy, and initiated with recombinant plasminogen activator. RESULTS: LTT was performed in 13 (17.1%), out of 76 patients. From the remaining patients, 56 underwent necrotic bowel resection and 7 underwent tromboembolectomy. The median age was 62 years (45-87). The median duration of symptoms was 24 h. Four (30.7%) patients presented within 24 h onset of symptoms, whilst 9 (69.3%) patients presented after 24 h onset of symptoms. There were 5 (39.5%) patients, who presented with abdominal pain without peritoneal signs on physical examination and 8 (61.5%) patients, who had peritoneal signs. The mortality rate was 20% (1/5) in the first group who presented without peritoneal signs, whilst it was 62.5% (5/8) in the remaining. CONCLUSION: Early intervention in AMI is the key to better results. CTA combined with early laparoscopy and LTT may have beneficial effects at this setting.

An observational study for venous thromboembolism risk assessment among hospitalized patients in general surgery clinics across Turkey.

OBJECTIVE: Venous thromboembolism (VTE) still remains a significant public health problem due to gaps between recommendations and clinical practice in VTE prophylaxis. This is the first clinical study designed to evaluate the applicability of a standard 'VTE prophylaxis and risk factor assessment form (VTE-PRAF)' and prescription of VTE prophylaxis among hospitalized patients in the daily practice of general surgeons in Turkey. METHOD: A total of 1472 patients (mean age: 52.4 ± 16.9 years; 50.6% were men) were included in cross-sectional (n = 537), first longitudinal (n = 452) or the second longitudinal (n = 483) phases. Data on demographics, hospitalization, surgical intervention and prophylaxis were collected during the cross-sectional phase, whereas utilization of form was evaluated during longitudinal phases. RESULTS: While 62.1% of patients were identified to be at 'high+ highest' risk, prophylaxis was evident only for 65.9%. Utilization of the form was higher in the second longitudinal phase (P < 0.001) but there was no relation between implementation of the form and prophylaxis use. VTE-PRAF was completed for 70.6% and 84.8% of patient who received prophylaxis while it was completed for 50.8% and 50.4% of patients with no prophylaxis, in the first and second longitudinal phases, respectively. Prophylaxis was administered in 58.6% and 62.6% of patients with completed VTE-PRAF in the first and second longitudinal phases, respectively. 'Suggested' and 'used' prophylaxis regimens were significantly more consistent for the cases evaluated with VTE-PRAF (P < 0.001). CONCLUSION: Based on the use of prophylaxis only for 65.9% of general surgery inpatients at high risk for VTE, low use of prophylaxis is assumed to remain a significant threat to public health across Turkey. Inclusion of a standard VTE-PRAF in the hospital protocol seems to raise clinical awareness of VTE risk assessment and appropriate management in VTE which otherwise well-known to be associated with significant mortality and morbidity. Impact of e-VTE-PRAF is worth investigating.

Long-term efficacy and safety of once-daily enoxaparin plus warfarin for the outpatient ambulatory treatment of lower-limb deep vein thrombosis in the TROMBOTEK trial.

OBJECTIVE: The present study was designed to evaluate the long-term efficacy and safety of once-daily enoxaparin plus warfarin for the outpatient ambulatory treatment of lower-limb deep venous thrombosis (DVT). METHODS: A total of 246 patients, comprising 128 men (mean age, 54.28±16.48 years) and 118 women (mean age, 50.11±16.47 years) with symptomatic lower extremity DVT, were included in this open-label, single-arm, multicenter, phase IV clinical trial conducted at 14 centers in Turkey. All patients were administered subcutaneous enoxaparin (1.5 mg/kg, once-daily) until international normalized ratio (INR) levels reached to 2 to 3, followed by oral warfarin (5 mg/d) for at least 3 months and elastic compression stockings (30-40 mm Hg). Clinical signs (leg circumference), symptoms (edema, pain, tenderness), recanalization rates upon duplex ultrasound examination, laboratory findings (D-dimer and INR levels), and postthrombotic syndrome status with CEAP classification were the efficacy parameters evaluated every 3 months during 18 months of follow-up. Safety end points included minor and major bleeding as well as serious adverse events. RESULTS: Ambulatory treatment with enoxaparin plus warfarin significantly reduced physical symptoms, including tenderness, edema, pain (P<.001), and the circumference of the affected leg (P<.001). The leg circumference difference in almost all patients was <1.5 cm at the end of 18 months (P<.001). Recanalization rates for occluded iliofemoral vein were 76.1% at 3 months and 86.5% at 18 months (P<.001). An early and significant decrease obtained in D-dimer levels on day 10 continued to decline significantly until month 6 and remained unchanged afterwards (P<.001). Of four patients diagnosed with major bleeding during oral anticoagulant use, three recovered with conservative treatment (reduction in hemoglobin levels in 2 developed at visit 2 [day 10] and intracranial bleeding in 1 developed at visit 3 [day 30]), and one patient required a hysterectomy after menorrhagia developed at visit 7 (month 18). Two of the 65 (9.9%) adverse events documented were serious adverse events, but none of the serious adverse events leading to death were related to the study medications. CONCLUSION: Ambulatory treatment with enoxaparin plus warfarin seems to be effective in symptomatic healing and in clinical improvement by reducing thrombus formation and organization at all levels of lower extremity venous system with DVT, without a significant major bleeding risk. Therefore, the results of our conventional conservative treatment are in line with 1A level evidence reported in the recent American College of Chest Physicians guideline.

[Venous thromboembolism prophylaxis methods in trauma and emergency surgery intensive care unit patients: low molecular weight heparin versus elastic stockings + intermittent pneumatic compression]. / Travma ve acil cerrahi yogun bakim hastalarinda venöz tromboemboli profilaksisi: Düsük molekül agirlikli heparin ile elastik çorap + aralikli pnömotik kompresyonun karsilastirilmasi.

BACKGROUND: We aimed to evaluate the efficacy and safety of low molecular weight heparin (LMWH) compared to elastic stockings in combination with intermittent pneumatic compression (ES+IPC) in venous thromboembolism (VTE) prophylaxis in the intensive care unit (ICU) of trauma and emergency surgery. METHODS: From June 2005 to June 2007, 259 patients who were on mechanic ventilation in the ICU were assigned to two groups as either LMWH (152 patients) or ES+IPC (94 patients). Color flow Doppler sonography was performed on the 3rd and 7th days. RESULTS: Deep venous thrombosis was determined in 3 (2%) of the LMWH group and in 1 (1%) in the ES+IPC group. Minor bleeding was seen in 15 patients. The frequency of VTE was 1.5%. Two patients suffered from fatal pulmonary embolism (PE) among a total of 4 patients with PE. CONCLUSION: We believe that the protocol applied for VTE prophylaxis in the Emergency Surgery Department of Istanbul Medical Faculty is effective and safe in this group with such high mortality and morbidity.

Femoral artery occlusion secondary to a spontaneously "migrated" hip prosthesis: case report.

A 77-year-old male patient was admitted to the hospital with a worsening acute ischemia of the left lower extremity. The patient, who had a coxarthrosis and was being followed by the orthopedic clinic, had undergone a total hip prosthesis, with a revision performed at the sixth month of its placement. The physical examination revealed the absence of the femoral, popliteal and distal pulses of the left lower extremity. The left hip movements were painful and limited in external rotation posture. Doppler ultrasonography showed an acute occlusion of the left common femoral artery due to the dislocated hip prosthesis, and right-to-left femorofemoral expanded polytetrafluoroethylene graft bypass was carried out. After successful surgery and an uneventful postoperative period with palpable femoral and popliteal pulses, the patient was put on low molecular weight heparin and referred to orthopedics once the ischemia had subsided with the intervention. Case reports regarding occlusions due to migration of total hip prosthesis are rare in the literature. The emphasis of this case report is to describe one such case.

The impact of valvular oxidative stress on the development of venous stasis ulcer valvular oxidative stress and venous ulcers.

BACKGROUND: It is widely believed that venous ulcers result from venous insufficiency related to venous valve damages. To further investigate the pathogenesis of venous ulcers, we compared the influence of oxidative stress in venous valvular tissue on stasis ulcer formation in patients with venous ulcers secondary to superficial venous reflux disease. METHODS: Thirty-nine consecutive patients with superficial venous reflux who underwent saphenectomy were included in the study. Patients were divided into 2 groups: with healed venous ulcers (group 1, n = 15) and without ulcers (group 2, n = 24). All patients were preoperatively evaluated with duplex ultrasound scanning and their blood samples were obtained to examine leukocyte count, interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha), and C-reactive protein (CRP) levels. All patients underwent standard above-knee saphenectomy. Extracted saphenous vein segments were from the saphenofemoral junction, the first valve along. The biochemical analysis of the valve tissues included matrix metalloproteinase (MMP)-9, MMP-2, IL-6, TNF-alpha, superoxide dismutase (SOD), malondialdehyde (MDA), and nitric oxide (NO) studies. RESULTS: There was no significant difference between patients in terms of age, gender, hospital stay, and preoperative blood levels of leukocyte, IL-6, TNF-alpha, and CRP (P > .05). Biochemical examination of valve tissue showed that the levels of MMP-9, MMP-2, IL-6, TNF-alpha, SOD, MDA, and NO in patients with healing venous ulcer were higher than those of the second group. CONCLUSION: A higher oxidative stress in the valvular tissue may contribute to venous stasis ulcer formation.

The role of the ankle brachial pressure index in the diagnosis of peripheral arterial injury.

BACKGROUND: Angiography is the "gold standard" diagnostic tool for patients presenting soft signs of arterial injury. To reduce the number of unnecessary angiographies, we aimed to evaluate the role of the ankle brachial pressure index (ABPI) in the diagnosis of peripheral arterial injury in extremity trauma with soft signs. METHODS: The data of 1772 patients with the suspicion of peripheral arterial injury was recorded prospectively. Two hundred eighty-three patients (16%) with any hard sign underwent immediate surgery. ABPI was calculated in 1489 patients with soft signs. Patients with ABPI <1 were evaluated by duplex ultrasonography and/or angiography, and if arterial injury was detected, the patients underwent surgery. Patients with an ABPI > or =1 were followed up conservatively. RESULTS: 1343 (90%) patients had ABPI > or =1; seven (0.5%) of them developed symptoms and signs of arterial injury and healed without morbidity. One hundred forty-six (10%) patients had ABPI <1; with DUS/angiography, arterial injury was detected in 39 of them (26.7%), and they underwent surgery. The sensitivity of ABPI <1 was 84.8%; specificity 92.6%; positive predictive value 26.7%; negative predictive value 99.5%; and overall accuracy 92.3%. CONCLUSION: ABPI excludes arterial injury in 99.5% of patients with soft signs of arterial injury and avoids unnecessary examinations in 90% of patients. In the management of extremities with soft signs, ABPI measurement should be the first-line diagnostic choice.

Serious lower extremity venous injury management with ligation: prospective overview of 63 patients.

Management of lower extremity venous trauma using repair or ligation has been an area of controversy during the past decades. However, in unstable patients or if primary repair is technically impossible as a result of extensive disruption of the vein, ligation is recommended. This study investigated the effects of venous ligation on major veins in the lower extremities when primary repair is impossible as a result of extensive laceration of the vein. Between January 2001 and April 2004, 63 patients with Grade III and IV venous injuries were observed prospectively. Compression ultrasonography was performed postoperatively on the fifth day, once before discharge, and at the 3-month visit to assess deep vein thrombosis (DVT) and the patency of arterial repair. If DVT was present, the patient was given an oral anticoagulant (warfarin Na) for 3 months (international normalized ratio, 2.0-3.0), and Class II compression stockings (Sigvaris-212, Ganzoni, Switzerland) were used for 1 year. Follow-up visits occurred at 1, 3, 6, and 12 months and at 6-month intervals thereafter. Combined arterial and venous injuries were present in 50 (79.4%) patients and pure venous injuries were present in 13 (20.6%) patients. DVT developed in 49 patients (77.7%; postoperative n = 37 [58.7%], late n = 12 [19%]). Three arterial restenoses (4.7%) and one pseudoaneurysm (1.6%) of the superficial femoral artery developed. Five early (prophylactic) and two late (compartment syndrome) fasciotomies were performed. Postoperative edema was seen in 56 (88.8%) patients and wound infection was seen in 19 patients (30.1%; n=18 superficial, n=1 deep). Two amputations (3.2%) were performed. One patient (1.7%) died as a result of irreversible shock. After a median of 18 months, 25 patients were classified with Clinical Etiology, Anatomy, Pathology classification: 10 legs C-0, seven legs C-2, and eight legs C-3. No severe postthrombophlebitic syndrome was observed. Early leg swelling after venous ligation was the most common morbidity. We observed no significant sequelae of chronic venous insufficiency, and venous ligation had no detrimental effect on associated arterial repair. In cases of DVT, anticoagulation with low-molecular-weight heparin and oral anticoagulants should begin immediately and continue for 3 months along with compression stocking support for 1 year.

Planned second-look laparoscopy in the management of acute mesenteric ischemia.

AIM: To investigate the role of second-look laparoscopy in patients with acute mesenteric ischemia (AMI). METHODS: Between January 2000 and November 2005, 71 patients were operated for the treatment of AMI. The indications for a second-look were low flow state, bowel resection and anastomosis or mesenteric thromboembolectomy performed during the first operation. Regardless of the clinical course of patients, the second-look laparoscopic examination was performed 72 h post-operatively at the bed side in the ICU or operating room. RESULTS: The average time of admission to the hospital after the initiation of symptoms was 3 d (range, 5 h-9 d). In 14 patients, laparotomy was performed. In 11 patients, small and/or large bowel necrosis was detected and initial resection and anastomosis were conducted. A low flow state was observed in two patients and superior mesenteric artery thromboembolectomy with small bowel resection was performed in one patient. In 13 patients, a second-look laparoscopic examination revealed normal bowel viability, but in one patient, intestinal necrosis was detected. In two of the patients, a third operation was necessary to correct anastomotic leakage. The overall complication rate was 42.8%, and in-hospital mortality rate was 57.1% (n = 6). CONCLUSION: Second-look laparoscopy is a minimally invasive, technically simple procedure that is performed for diagnostic as well as therapeutic purposes. The simplicity and ease of this method may encourage wider application to benefit more patients. However, the timing of a second-look procedure is unclear particularly in a patient with anastomosis.

Rupture of abdominal aortic aneurysm into sigmoid colon: a case report.

Primary aorto-colic fistula is rarely reported in the literature. Although infrequently encountered, it is an important complication since it is usually fatal unless detected. Primary aorto-colic fistula is a spontaneous rupture of abdominal aortic aneurysm into the lumen of the adjacent colon loop. Here we report a case of primary aorto-colic fistula in a 54-year old male. The fistulated sigmoid colon was repaired by end-to-end anastomosis. Despite inotropic support, the patient died of sepsis and multiorgan failure on the first postoperative day.

Hyperhomocysteinemia in patients with arterial occlusive disease.

PURPOSE: Hyperhomocysteinemia (HHCA) is defined as an independent risk factor for atherothrombotic vascular disease; therefore, screening for HHCA is recommended. However, the incidence and characteristics of HHCA in patients with vascular disease remain unclear. We conducted this study in an attempt to resolve these issues. METHODS: This nonrandomized prospective study included 56 patients who were admitted with occlusive arterial disease (group I), and 39 control patients without occlusive arterial disease (group II). We recorded all the demographic data of both groups and collected blood samples for fasting homocysteine, vitamin B(12), and folic acid. All of the patients were followed up and the results were compared. RESULTS: The mean concentration of homocysteine was 12.69 +/- 3.82 micromol/l in group I and 10.46 +/- 5.08 micromol/l in group II (P = 0.00048). In group I, the mean homocysteine levels for patients aged > or =70 years and those aged <70 years were 13.74 +/- 3.02 and 11.55 +/- 4.15 micromol/l, respectively (P = 0.021). There was no significant difference in mortality between the patients with HHCA and those with normal homocysteine levels during follow-up. CONCLUSION: The incidence of hyperhomocysteinemia was higher in the patients with occlusive vascular disease than in the control patients. More evidence of the association with vitamins B(12) and folate and the benefits of homocysteine-lowering therapy is needed since we found no relationship between these vitamins and homocysteine in this study.