René Leriche and "Philosophy of Surgery" in the light of contemporary medical ethics.

Prof. Dr. René Leriche was a famous French surgeon who lived between 1879 and 1955. After working as a vascular surgeon in Lyon, he was appointed professor at the University of Strasbourg in 1924 and later the Paris Collége de France in 1937. Leriche had proposed vascular patches as the ideal treatment for obliterated vascular segments and advocated the necessity of sympathectomy in arterial diseases in the 1920s. He defined "Leriche Syndrome" in 1923 which is known by his name and which develops as a result of incomplete obstruction of the aortic bifurcation. René Leriche wrote a monograph entitled "La Chirurgie de la Douleur-Pain Surgery" in 1940 and he also became a pioneer in the sympathectomy procedure for pain treatment. René Leriche focused on topics that must be remembered again today, including surgery advanced into science, the physiological basis of surgery, research methods, as well as issues such as business technology, humanity in surgery, surgical essence and surgeon's qualifications in the book entitled "La Philosophie de la Chirurgie-Philosophy of Surgery" that he wrote in 1951. In this review, the issues that Prof. Dr. René Leriche addressed in middle of the 20(th) century were revised in the light of contemporary medical ethics.

A randomized clinical study evaluating the need for drainage after Limberg flap for pilonidal sinus.

BACKGROUND: This prospective randomized clinical study was conducted to evaluate the need for drainage after rhomboid excision and a Limberg flap (RELIF) for the treatment of pilonidal sinus. METHODS: One hundred one patients undergoing the RELIF procedure were randomly treated with drainage or not. Operating time, postoperative pain assessed on a visual analogue scale (VAS), total amount of intramuscular analgesic administered, hospital stay, complications, recurrence rate, and patient satisfaction were assessed. RESULTS: The mean operating time (P = 0.036), VAS scores on postoperative day 0 (P = 0.039) and day 1 (P = 0.006), intramuscular analgesic requirement (P = 0.009), mean amount of intramuscular analgesic administered (P = 0.025), complication rate (P = 0.027), and mean hospital stay (P = 0.0001) were significantly reduced in the non-drained group. The recurrence rate was similar in the two groups (P = 0.32). CONCLUSIONS: This study indicates that drain placement after the RELIF procedure might negatively affect the postoperative outcomes of patients with pilonidal sinus. On the basis of these finding, we suggest that the use of drains may not be necessary after the RELIF procedure for the treatment of pilonidal sinus.

[Fournier's gangrene: analysis of risk factors affecting the prognosis and cost of therapy in 18 cases]. / Fournier gangreni: 18 olgudaki prognoza etki eden risk faktörlerinin ve tedavi maliyetinin degerlendirilmesi.

BACKGROUND: Fournier's gangrene (FG) is a rapidly progressive, polymicrobial, synergistic necrotizing fasciitis, and the mortality rate is still high. We aimed to determine the risk factors affecting prognosis and treatment cost. METHODS: Eighteen patients operated for FG during 2003-2007 were investigated retrospectively. Surviving and exitus groups were compared regarding demographic data, etiological factors, laboratory findings, treatment modality, length of hospital stay, and treatment cost. RESULTS: Mean age was 54.5 years, and the female/male ratio was 6/12. Mortality was observed in 6 (33.3%) patients and was significantly high among females (66.6%) (p=0.035). Mean duration of complaint in the exitus group (9+/-3 days) was higher than in survivors (5+/-3 days) (p=0.018). The most frequent comorbid disease was diabetes (39.2%), the most frequent etiology was perianal abscess (55.6%) and the primary location of infection was anorectal region (61.1%). Hyponatremia was significantly high in surviving patients (p=0.039). Mean of FG severity point in the exitus group (6.83) was higher than in survivors (3.17) (p=0.011). The most frequently cultivated microorganism, Escherichia coli (66.6%), was significantly high in the exitus group (p=0.012). The mean number of debridements was 4.67. Fecal diversion was performed in 7 (38.8%) patients. Hospital stay in the surviving group (34.17 days) was higher than in the exitus group (10.50 days) (p=0.002). Treatment cost between groups was indifferent (p>0.05). CONCLUSION: Female gender, duration of complaint, FG severity point, and cultivated microorganism (E. Coli) were thought to affect mortality. FG is a disease that might cause extended hospital stay and high treatment cost.

Effects of sulfasalazine on lipid peroxidation and histologic liver damage in a rat model of obstructive jaundice and obstructive jaundice with lipopolysaccharide-induced sepsis.

BACKGROUND: Sulfasalazine, an inhibitor of cyclooxygenase, 5-lipoxygenase, and nuclear factor κB (NF-κB), has been found to alleviate oxidative damage, proinflammatory cytokine production, bile-duct proliferation, neutrophil infiltration, and fibrosis. Therefore, it may have a potential effect in attenuating lipid peroxidation and histologic liver damage in patients with biliary obstruction and biliary obstruction with sepsis. OBJECTIVE: The aim of this study was to investigate the effect of sulfasalazine on lipid peroxidation and histologic liver damage due to obstructive jaundice (OJ) and to OJ with lipopolysaccharide (LPS)-induced sepsis in an experimental model. METHODS: Male Wistar rats, weighing 150 to 220 g, were randomized into 6 groups: OJ; OJ + LPS; OJ + sulfasalazine; OJ + sulfasalazine + LPS (sulfasalazine administered before sepsis); OJ + LPS + sulfasalazine (sulfasalazine administered after sepsis); and sham. Liver malondialdehyde (MDA) and myeloperoxidase (MPO) activities were assessed to monitor lipid peroxidation and neutrophil infiltration in liver tissue. Histologic liver damage was evaluated with hematoxylin-eosin stained slides. Liver tissue NF-κB and caspase-3 expression were studied immunohistopathologically to evaluate lipid peroxidation, liver damage, and hepatocyte apoptosis. RESULTS: Forty-eight rats were evenly randomized into 6 groups of 8. MDA (P = 0.001), MPO (P = 0.001), NF-κB (P = 0.003), caspase-3 expression (P = 0.002), and liver injury scores (P = 0.002) increased significantly in the OJ group compared with the sham group. Compared with the OJ group, MDA (P = 0.030) and MPO levels (P = 0.001), and liver injury scores (P = 0.033) were decreased significantly in the OJ + sulfasalazine group. In the OJ + sulfasalazine + LPS and OJ + LPS + sulfasalazine groups, MDA (P = 0.008 and P = 0.023, respectively) and MPO (both, P = 0.001) were significantly decreased; however, liver NF-κB, caspase-3 expression, and liver injury scores were not significantly different compared with the OJ + LPS group. There was no significant difference between the OJ + LPS + sulfasalazine and OJ + sulfasalazine + LPS groups in regard to all end points when comparing the effects of sulfasalazine administered before or after sepsis. CONCLUSIONS: Sulfasalazine was associated with decreased neutrophil accumulation and lipid peroxidation in these rats with OJ. Administration of sulfasalazine before or after LPS-induced sepsis was associated with a reduction in lipid peroxidation and neutrophil accumulation; however, it did not attenuate histologic liver damage. There was no difference between the findings when sulfasalazine was administered before or after sepsis in OJ.

Liver tissue inducible nitric oxide synthase (iNOS) expression and lipid peroxidation in experimental hepatic ischemia reperfusion injury stimulated with lipopolysaccharide: the role of aminoguanidine.

BACKGROUND: Hepatic ischemia-reperfusion (HIR) is a severe condition that is seen after hepatic arterial injury and in hepatic grafts in living donor transplantation. HIR not only causes liver injury by lipid peroxidation, but also stimulates systemic and portal endotoxemia. Also, lipopolysaccharide (LPS) induces hepatic injury mediated by inducible nitric oxide synthase (iNOS). There is little knowledge on the role of specific iNOS inhibitors in prevention of HIR injury followed by LPS administration. The aim of this study on a LPS induced HIR model was to investigate the effect of aminoguanidine (AG) administration on hepatic tissue iNOS expression and lipid peroxidation when given before or after LPS. METHODS: Six groups were designed; A: Sham, B: HIR, C: HIR + AG, D: HIR + LPS, E: HIR + LPS + AG, F: HIR + AG + LPS. No substance was given to the rats in Group A and B. HIR injury was induced with vascular occlusion for 45 min and reperfusion for 45 min. Drugs were given intraperitoneally 10 min before reperfusion. Serum and tissue analysis for myeloperoxidase (MPO), and malondialdehyde (MDA), and tissue NA+/K+ adenosine 5'triphosphatases (ATPase) and tissue iNOS staining were performed. Permission for this study was obtained from the local Ethics Committee. RESULTS: The level of MPO, MDA, and iNOS staining scores in Group B were significantly higher than Group A and ATPase was lower in Group B (P < 0.05). Contrary to results in Group C, results of MPO, MDA, and iNOS staining scores of Group D was higher than Group B (P < 0.05); however, although iNOS in Group C was lower than Group B, the difference was not significant (P > 0.05). MPO and MDA levels of Groups E and F were significantly lower than Group D. Level of ATPase in Group F was significantly different from Groups D and E. iNOS scoring was low in Group F compared with Group D (P < 0.05). MDA, MPO, and iNOS levels of Group F was lower than Group E, and ATPase of Group F was higher than Group E (P < 0.05). CONCLUSIONS: The results of this study in a LPS induced HIR model showed that LPS after HIR aggravated HIR injury by increasing neutrophil activation and lipid peroxidation both in serum and liver tissue and iNOS in liver, and depleting energy in liver. AG, a selective iNOS inhibitor, ameliorated the negative effects of endotoxemia induced by LPS after HIR; however, energy depletion and iNOS expression in liver tissue were attenuated only when AG was administered prior to LPS. The findings of this study supported the hypothesis that LPS after HIR would aggravate HIR injury and AG would ameliorate this aggravated injury.

Total thyroidectomy is safer with identification of recurrent laryngeal nerve.

OBJECTIVE: To investigate the effect of recurrent laryngeal nerve (RLN) identification on the complications after total thyroidectomy and lobectomy. METHODS: Total 134 consecutive patients undergoing total thyroidectomy or thyroid lobectomy from January 2003 to November 2004 were investigated retrospectively. Patients were divided into two groups: RLN identified (Group A) or not (Group B). The two groups were compared for RLN injury and hypocalcaemia. RESULTS: The numbers of patients and nerves at risk were 71 and 129 in Group A, and 63 and 121 in Group B, respectively. RLN injury in Group A (0) was significantly lower than that in Group B (5 [7.9%]) patients, 7 [5.8%] nerves) for the numbers of patients (P=0.016) and nerves at risk (P=0.006). Temporary hypocalcaemia was significantly higher in Group A than in Group B (14 [24.1%] vs 6 [10.3%], P=0.049). Permanent complications in Group B were significantly higher than those in Group A (13 [20.6%] vs 4 [5.6%], P=0.009). CONCLUSION: RLN injury was prevented and permanent complications were decreased by identifying the whole course and branches of the recurrent laryngeal nerve during total thyroidectomy.

Drainage after total thyroidectomy or lobectomy for benign thyroidal disorders.

OBJECTIVE: This prospective randomized clinical trial was conducted to evaluate the necessity of drainage after total thyroidectomy or lobectomy for benign thyroidal disorders. METHODS: A total of 116 patients who underwent total thyroidectomy or lobectomy for benign thyroidal disorders were randomly allocated to be drained or not. Operative and postoperative outcomes including operating time, postoperative pain assessed by visual analogue scale (VAS), total amount of intramuscular analgesic administration, hospital stay, complications, necessity for re-operation and satisfaction of patients were all assessed. RESULTS: The mean operating time was similar between two groups (the drained and non-drained groups). The mean VAS score was found to be significantly low in the non-drained group patients in postoperative day (POD) 0 and POD 1. The mean amount of intramuscular analgesic requirement was significantly less in the non-drained group. One case of hematoma, two cases of seroma and three cases of transient hypoparathyroidism occurred in the non-drained group, whereas one case of hematoma, two cases of seroma, two cases of wound infections and two cases of transient hypoparathyroidism occurred in the drained group. No patient needed re-operation for any complication. The mean hospital stay was significantly shorter and the satisfaction of patients was superior in the non-drained group. CONCLUSION: These findings suggest that postoperative complications cannot be prevented by using drains after total thyroidectomy or lobectomy for benign thyroid disorders. Furthermore, the use of drains may increase postoperative pain and the analgesic requirement, and prolong the hospital stay. In the light of these findings, the routine use of drains might not be necessary after thyroid surgery for benign disorders.

The effects of exogenous l-carnitine on lipid peroxidation and tissue damage in an experimental warm hepatic ischemia-reperfusion injury model.

BACKGROUND: l-Carnitine is the essential endogenous factor for the transport of long-chain fatty acids from the cytoplasm to within the mitochondrion where the ß-oxidation process takes place. l-Carnitine is a superoxide scavenger and an antioxidant that possesses an anti-ischemic action and a stabilizing effect on cell membranes. It may be of help in liver ischemia reperfusion injury. RESULTS regarding the effects of l-carnitine on liver ischemia and reperfusion injury are few and conflicting. OBJECTIVE: The aim of this study was to investigate the efficacy of exogenous l-carnitine on lipid peroxidation and protecting liver at different stages of experimental total warm hepatic ischemia-reperfusion (TWHIR) procedure in rats. METHODS: This experimental study in healthy, weanling, male Wistar rats (weighing 180-200 g) was conducted at the Experimental Animal Research Laboratory of the Faculty of Medicine of Mersin University, Mersin, Turkey. Rats were randomly divided into 5 groups: (A) Control group; (B) TWHIR procedure only; (C) l-carnitine administered 2 hours before the TWHIR procedure; (D) l-carnitine administered just before the TWHIR procedure; and (E) l-carnitine administered after total warm hepatic ischemia but just before the reperfusion procedure. Total warm hepatic ischemia (via the Pringle maneuver) and reperfusion were performed for 45 and 30 minutes, respectively. l-Carnitine (200 mg/kg) was administered intravenously. At the end of each procedure a blood sample was drawn and total hepatectomy was performed following reperfusion. Malondialdehyde (MDA) and myeloperoxidase (MPO) levels of both plasma and liver tissue, total antioxidant capacity (TAOC), alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels in plasma, and histopathologic examination were analyzed to assess lipid peroxidation and damage in liver tissue. RESULTS: Thirty-four rats (mean [SD]age, 59.26 [1.2]days; mean [SD] weight, 194.1 [5.1] g) were used in the study. There was a significant difference observed between groups A (n = 5) and B (n = 5) for all evaluation parameters. The TWHIR procedure performed in group B was associated with significant increases versus baseline in ALT, AST, MDA, and MPO in plasma, and MDA and MPO in liver tissue, but a significant decrease of TAOC in plasma. ALT, AST, serum and liver MDA, and MPO levels of group B were significantly higher than all groups administered l-carnitine. l-Carnitine administration between total warm hepatic ischemia and reperfusion was associated with a significant attenuation in all parameters. The liver MDA levels of groups C (n = 8) and D (n = 8) were significantly lower than that of group E (n = 8) (mean [SD]: C, 16.53 [3.32] and D, 18.28 [1.67] vs E, 23.05 [3.52]; P = 0.001 and P = 0.016, respectively). The mean (SD) liver MPO level of group C (1.09 [0.16]) was significantly lower than that of groups D (2.12 [0.25]) and E (2.11 [0.28]) (both, P = 0.001). The TAOC of group B (0.77 [0.12]) was significantly lower than that of groups C (1.34 [0.19]) and D (1.08 [0.20]) (P = 0.001 and P = 0.015, respectively). The TAOC of group C was significantly higher than that of the other l-carnitine groups (E, 0.94 [0.13]) (P = 0.023 vs group D; and P = 0.001 vs group E). Histopathologic scores of groups A, C, and E were significantly lower than that of group B, but the difference between groups B and D was not statistically significant. CONCLUSIONS: In this experimental study, administration of exogenous l-carnitine was associated with significantly decreased lipid peroxidation in plasma and liver tissue when administered prior to a TWHIR procedure. In addition, l-carnitine seemed to be more effective with regard to decreasing lipid peroxidation in liver tissue when administered before warm hepatic ischemia. l-Carnitine was associated with significantly decreased leukocyte sequestration in plasma and liver tissue. A significant increase in TAOC was associated with l-carnitine administered prior to ischemia. These observations suggest that l-carnitine might have a protective effect against ischemia-reperfusion injury in rat liver tissue.

Contribution of Rho-kinase in human gallbladder contractions.

Rho/Rho-kinase-mediated pathway has been involved in a variety of physiological processes, including Ca2+ sensitization, which enhances smooth muscle contraction. In this study, first of all we investigated the expression of Rho-kinase (ROCK-2) and then the role of this protein in the control of smooth muscle contraction in the isolated human gallbladder. For this purpose, we examined the effects of a selective Rho-kinase inhibitor, (+)- (R)-trans-4-(1-aminoethyl)-N-(4-pyridyl) cyclohexanecarboxamide dihydrochloride monohydrate (Y-27632, 10(-8)-3x10(-5) M) on carbachol (10(-8)-10(-4) M), cholecystokinin-8 (10(-8) M), endothelin-1 (10(-8) M), histamine (10(-5) M), neurokinin A (10(-7)-10(-6) M), 5-hydroxytryptamine (10(-6)-10(-5) M) and potassium chloride (KCl, 25-50 mM)-induced contractions as well as spontaneous contractile activity. Y-27632 (10(-5) M) significantly reduced 5-hydroxytryptamine, neurokinin A and KCl-induced contractions. Moreover, this Rho-kinase inhibitor (10(-8)-3x10(-5) M, cumulatively) relaxed the contractions produced by cholecystokinin-8, endothelin-1 and histamine in a concentration-dependent manner, being the pEC50 values for Y-27632 5.74+/-0.12, 5.33+/-0.09 and 5.95+/-0.18, respectively. Carbachol (10(-8)-10(-4) M) produced concentration-dependent contractions, which were also inhibited significantly by Y-27632. In addition, the spontaneous contractile activity was suppressed in the presence of Y-27632 (10(-6)-10(-5) M). Moreover, Western blot analysis has revealed that Rho-kinase is expressed in homogenates of the human gallbladder. Taken together, these results show that Rho-kinase is expressed in the human gallbladder, and it has an essential role in agonists and depolarization-induced contractions as well as spontaneous contractile activity.

The effect of aminoguanidine on blood and tissue lipid peroxidation in jaundiced rats with endotoxemia induced with LPS.

Obstructive jaundice (OJ) is a severe condition that leads to several complications. One of the important problems in OJ is the increased incidence of endotoxemia, which is the result of bacterial translocation (BT) and defective host immune response. Lipid peroxidation (LP) is an important problem in OJ and sepsis in which nitric oxide (NO) production and inducible nitric oxide synthase (iNOS) activity are increased and antioxidative activity is decreased. Formation of peroxynitrite (ONOO(-)) anion leads to cellular damage and apoptosis. In this experimental study, we explore the effect of specific iNOS inhibitor aminoguanidine (AG) on blood and tissue (liver and renal) LP and iNOS levels in jaundiced rats with endotoxemia induced with lipopolysaccharide (LPS). Rats were randomized into six groups; group A, sham; group B, obstructive jaundice (OJ); group C, OJ + LPS; group D, OJ + AG; group E, OJ + LPS + AG; group F, OJ + AG + LPS. Serum malondialdehyde (MDA) and serum myeloperoxidase (MPO) activity and liver and renal tissue MDA, MPO, and Na(+)/K(+)-ATPase activity levels were detected in biochemical methods. Liver and renal tissue iNOS levels were examined immunohistopathologically. Serum and tissue MDA and MPO levels and tissue iNOS expression were increased significantly in groups B, C, and E, while tissue ATPase levels were decreased significantly in the same groups. In the group treated with AG (group D), serum and tissue MDA and MPO levels and tissue iNOS expression were decreased while tissue ATPase levels were increased significantly. In group F, if AG was administrated before LPS, we observed that serum and tissue MDA and MPO levels and tissue iNOS expression were decreased while tissue ATPase levels were increased significantly. Thus, our study showed that AG had a protective effect when it was administrated before LPS, but it failed to prevent tissue iNOS expression and LP if there was established endotoxemia in OJ.

Efficacy of topical nonsteroidal antiinflammatory drugs in mastalgia treatment.

BACKGROUND: The aim of the study was to investigate the effects of topical nonsteroidal antiinflammatory drugs (NSAIDs) on mastalgia. STUDY DESIGN: A prospective, randomized, blinded, placebo-controlled study was performed to evaluate the effects of topical NSAIDs on cyclic and noncyclic mastalgia. A total of 108 patients, 60 with cyclic (group I) and 48 with noncyclic (group II) breast pain were enrolled. Patients within each group were randomly assigned to receive either topical NSAIDs or placebo three times daily for at least 6 months. Severity of pain was measured before and after 6 months of treatment. RESULTS: The pain score decreased significantly when the mean initial breast pain score was compared with the sixth-month breast pain score of the treatment or the placebo group of cyclic (p = 0.0001 and p = 0.0001, respectively) or noncyclic mastalgia (p = 0.0001 and p = 0.0001, respectively). Significant differences were found when the mean within-person change in pain values in each treatment group were compared with the change in the respective placebo group for either cyclic or noncyclic mastalgia (p = 0.0001 and p = 0.0001, respectively). Changes in pain within treatment groups or placebo groups for cyclic versus noncyclic mastalgia were not found to be statistically different (p = 0.53 and p = 0.96, respectively). No side effect was seen in any group. CONCLUSIONS: Topical application of NSAIDs was effective in both cyclic and noncyclic mastalgia with minimal side effects.

Effect of trapidil in ischemia/reperfusion injury on rat small intestine.

To investigate the effect of trapidil on the intestinal ischemia-reperfusion injury, we determined malondialdehyde levels as a indicator of lipid peroxidation, nitrite and nitrate levels as reflections of nitric oxide metabolism, and histopathological findings in rats subjected to 40 min of ischemia and 2 h of reperfusion. Histopathological evaluation demonstrated that trapidil treatment has a protective effect on intestinal mucosa and reduces inflammatory cell infiltration in lamina propria, which is consistently noted in the untreated ischemic and reperfused intestines. Possible mechanism of this effect may be explained by the reduced lipid peroxidation (mean malondialdehyde level 3.72 +/- 0.27 vs. 6.13 +/- 0.44, p <.0001) and improved nitric oxide metabolism (mean nitrite plus nitrate 38.21 +/- 2.33 vs. 30.14 +/- 1.47, p =.022).

The effect of preoperative intravenous use of tenoxicam: a prospective, double-blind, placebo-controlled study.

In this study, we aimed to investigate the postoperative pain relief effect of preoperative tenoxicam usage in patients who undergo elective laparoscopic cholecystectomy or groin hernia repair. Eighty patients undergoing laparoscopic cholecystectomy or groin hernia repair procedures were randomized to receive either physiologic serum at 100 mL (group I, n = 40) or 20 mg iv tenoxicam (group II, n = 40) immediately before induction. Postoperative analgesic requirement, peroperative side effects and complications of drugs, operating time, post-operative mobilization time and pain score, hospitalization time, and patient pleasure were recorded. Postoperative pain was assessed by the visual analogue scale (VAS) on the recovery unit (RU), at 4, 8, and 24 h and every day at the same times in the morning. The RU median VAS score was also not different when Group 1 was compared with Group 2 (p = .97). However, the postoperative 4-h and 8-h median VAS score was significantly less (p = .01 and p = .03, respectively); first postoperative mobilization time was earlier in group 2 (p = .32). The median pain score and intramuscular analgesic requirement of patients were also reduced in Group 2 in postoperative day 1 (p = .015). The median duration of intramuscular analgesic requirement and total amount of intramuscular analgesic used in patients were also significantly less in Group 2 (p = .0001 and p = .0001, respectively). Thus, this study showed that preoperative use of iv tenoxicam is safe, simple, and effective for postoperative pain relief after laparoscopic cholecystectomy or inguinal hernia repair.

The effect of N-acetylcysteine on oxidative stress in intestine and bacterial translocation after thermal injury.

Ischemia due to transient splanchnic vasoconstriction following major burns causes oxidative and/or nitrosative damage in intestinal tissue followed by reperfusion injury. Thus, burn injury leads to breakdown in the intestinal mucosal barrier which can induce bacterial translocation (BT). As an antioxidant and anti-inflammatory agent the protective effects of N-acetylcysteine (NAC) are documented in several studies. This study was designed to determine the effect of NAC treatment on the oxidative stress in the intestine and BT after burn injury. To evaluate this, 32 Wistar rats were randomly divided into four groups as sham (n = 8), burn (n = 8), pre-burn, NAC injection (150 mgkg(-1), intraperitoneally) 15 min before thermal injury (n = 8), post-burn, NAC injection (150 mgkg(-1), intraperitoneally) 2h after thermal injury. Under anesthesia, the shaved dorsal skin of rats was exposed to boiling water for 12s to induce burn injury in a standardized manner. Twenty-four hours later, tissue samples from mesenteric lymph nodes (MLN), spleen, and liver were obtained under sterile conditions for microbiological analysis and ileum samples were harvested for biochemical analysis. In the burn group, the incidence of isolating bacteria in MLN, spleen, and liver specimens was significantly higher than other groups. NAC treatment prevented burn-induced BT in both pre- and post-burn groups. Thermal injury caused a significant decrease in glutathione (GSH) level, significant increases in malondialdehyde (MDA) and myeloperoxidase (MPO) activity at post-burn 24th hour. Treatment of rats with NAC significantly elevated the reduced GSH levels while decreasing MDA levels and MPO activity. These data suggested that NAC has a crucial cytoprotective role in intestinal mucosal barrier and preventive effects against burn injury-induced BT.

Total versus subtotal thyroidectomy for the management of benign multinodular goiter in an endemic region.

BACKGROUND: Because controversy still continuous to surround use of total thyroidectomy for the management of benign multinodular goiter, the present study aims to prospectively compare the safety and efficacy of total thyroidectomy with subtotal thyroidectomy. METHODS: A total of 200 consecutive patients with benign multinodular goiter were assigned to have either total thyroidectomy (n = 105) or subtotal thyroidectomy (n = 95) based on preoperative evaluation, intraoperative macroscopic findings and nodular dissemination. The patients with no healthy tissue or nodules localized in the dorsal part of the gland, which are usually left during normal subtotal resection, were assigned to the total thyroidectomy group. Demographic details, biochemical findings, indications for operation, operating time, specimen weight, complications and hospital stay were noted. RESULTS: There was no significant difference in the sex, hormonal status or duration of goiter between the two groups (P = 0.74, P = 0.59 and P = 0.59, respectively). The mean operating time was longer (148.52 min +/- 51.10 vs 135.10 min +/- 32.47, P = 0.03), and the mean weight of the specimens was greater (228.40 g +/- 229.91 vs 157.01 g +/- 151.23, P = 0.01) for total rather than subtotal thyroidectomy. Either temporary recurrent laryngeal nerve (RLN) palsy or hypoparathyroidism occurred in 10 (9.3%) or 12 (11.4%) of the patients undergoing total compared with six (6.3%) or nine (9.5%) of the patients undergoing subtotal thyroidectomy (P = 0.40 and P = 0.65, respectively). Either permanent RLN palsy or hypoparathyroidism was observed in one patient undergoing total thyroidectomy (P = 0.34 for each comparison). The mean hospital stay was longer in the total thyroidectomy group (2.24 days +/- 1.18 vs 1.89 days +/- 0.72 for subtotal thyroidectomy, P = 0.01). CONCLUSIONS: The present study shows that total thyroidectomy can be performed without increasing risk of complication, and it is an acceptable alternative for benign multinodular goiter, especially in endemic regions, where patients present with a huge multinodular goiter.

Effects of trapidil on the healing of colonic anastomoses in an experimental rat model.

BACKGROUND: Trapidil has various properties including vasodilatation, inhibition of lipid peroxidation and platelet aggregation as well as, and reduction of, the inflammatory response to injury. The aim of the present study was to investigate the effects of trapidil on dexamethasone-impaired colonic anastomotic healing in an experimental rat model. METHODS: Twenty-four Wistar rats underwent colonic transsection and primary anastomosis. Rats were divided into four groups of six: group 1 (G1), control; group 2 (G2) trapidil, 8 mg/kg per day intravenously; group 3 (G3) dexamethasone, 0.1 mg/kg per day intramuscularly; and group 4 (G4) dexamethasone 0.1 mg/kg intramuscularly and trapidil 8 mg/kg intravenously per day, for 1 week. Anastomotic bursting pressure, hydroxyproline level, histopathological grading, malondialdehyde and nitrite/nitrate levels were determined. RESULTS: Dexamethasone-impaired anastomotic healing was found to be improved by trapidil administration in terms of anastomotic bursting pressure and hydroxyproline content (P = 0.026, and P = 0.017). In addition, histopathological examination revealed an increase in fibroblast proliferation and collagen deposition (P = 0.004, and P = 0.015) and a decrease in leucocyte infiltration (P = 0.004). Moreover, serum nitrite/nitrate and malondialdehyde levels decreased when G3 was compared to G4 (P < 0.001, P = 0.38). CONCLUSIONS: Trapidil may improve the dexamethasone-impaired anastomotic healing due to its preventive effects on inflammatory response and lipid peroxidation in rats.

Effect of ornithine on the ileal histology, nitric oxide production and lipid peroxidation in LPS-induced endotoxemia.

Effect of ornithine which is known to inhibit L-arginine uptake via cationic amino acid transport system has been tested, and compared to aminoguanidine, an iNOS inhibitor in lypopolysaccharide (LPS)-induced endotoxemia in rats. Serum nitrite/nitrate and malondialdehyde (MDA) level have been measured, and ileal histology has also been examined. Endotoxin increased serum nitrite/nitrate and MDA levels from 15.7+/- 2.4 micromol/ml and 2.1 +/-0.2 nmol/ml to 23.1 +/- 1.0 micromol/ml and 5.2+/- 0.3 nmol/ml (both P<0.05), respectively. In addition, LPS caused ileal degeneration. L-ornithine (500 mg/kg) did not improve septic manifestations, i.e., serum nitrite/nitrate and MDA levels did not differ from those in endotoxemia. Neither does it have an improving action on ileal histology. However, higher dose of L-ornithine (2,500 mg/kg) lowered the increased level of nitrite/nitrate and MDA by LPS. Moreover, it restored ileal histology from grade 3 (median) to 0 (median) (P<0.05). On the other hand, aminoguanidine (100 mg/kg) normalized serum nitrite/nitrate and MDA levels but not ileal histology in endotoxemic rats. In conclusion, high dose of L-ornithine could improve endotoxemic parameters in LPS-treated rats.

Randomized clinical trial comparing laparoscopic totally extraperitoneal approach with open mesh repair in inguinal hernia.

The aim of this study was to compare laparoscopic totally extraperitoneal approach (TEP) repair with tension-free open mesh repair in inguinal hernia. One hundred thirty-four patients were allocated randomly to undergo TEP repair (n = 67) or open mesh repair (n = 67). Operative and postoperative outcomes were determined. The mean of operating time (49.67 +/- 14.11 vs. 56.64 +/- 12.32; P = 0.001), visual analog scale score (2.73 +/- 1.69 vs. 4.61 +/- 1.77; P = 0.001), hospital stay (1.8 +/- 0.7 vs. 2.7 +/- 1.6; P = 0.001), and duration of recovery (10.8 +/- 7.4 vs. 15.2 +/- 8.5; P = 0.001) was significantly less for TEP repair when compared with open mesh repair. The incidence of complications (13.4% vs. 16.4%; P = 0.631) and recurrence (2.9% vs. 5.9%; P = 0.407) was approximately equal in each group. Our results showed that laparoscopic TEP repair is superior to open mesh repair.

Chemopreventive effect of nonsteroidal anti-inflammatory drugs on the development of a new colorectal polyp or adenoma in a high-risk population: a meta-analysis.

BACKGROUND: Although many experimental, epidemiologic, and clinical studies have suggested that aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in reducing and preventing colorectal adenomas, randomized, controlled trials (RCTs) are still being carried out to obtain statistically reliable results. OBJECTIVE: The aim of this meta-analysis was to review long-term, prospective RCTs investigating the effect of NSAIDs on the relative risk (RR) for developing ≥1 new colorectal polyp or adenoma in a high-risk population. METHODS: We conducted a comprehensive search of MEDLINE, PubMed, and other electronic databases (including Inter-Science, Science Direct, Ebsco, Synergy, and Proquest) (key terms: nonsteroidal anti-inflammatory drugs, aspirin, colorectal, and polyps; years: 1974-2004) for English-language articles. Eligible studies were analyzed in terms of demographic data, adverse effects, and effect of NSAIDs on the RRs. RESULTS: Four long-term, prospective RCTs were used in the statistical analysis. A total of 2069 high-risk patients were enrolled; 1880 patients completed the studies, and 1127 were in active-treatment groups (aspirin 81-325 mg/d or sulindac 150-300 mg/d). Our meta-analysis of these studies revealed that the overall RR for developing ≥ 1 new colorectal polyp or adenoma was significantly reduced by using aspirin or other NSAIDs (RR = 0.809; 95% CI, 0.718-0.912). CONCLUSIONS: The results of this meta-analysis suggest that regular use of aspirin 81 to 325 mg/d or sulindac 150 to 300 mg/d for ≥1 year was associated with a decrease in the RR for developing ≥ 1 new colorectal polyp or adenoma to 0.80 (95% CI, 0.718-0.912) in patients at high risk.

Effects of trapidil on intestinal mucosal barrier function and bacterial translocation after intestinal ischemia and reperfusion in an experimental rat model.

BACKGROUND: Intestinal ischemia and reperfusion may be the primary triggers of mucosal barrier impairment, cytokine expression, and bacterial translocation (BT). Trapidil is a phosphodiesterase and platelet-derived growth factor inhibitor that reduces lipid peroxidation and inhibits the production of cytokines. OBJECTIVE: The goal of this study was to assess whether trapidil might protect the intestinal epithelial barrier by inhibiting lipid peroxidation and proinflammatory cytokines by testing the effect of trapidil on intestinal barrier function in an experimental ischemia/reperfusion (I/R) rat model. METHODS: Trapidil was used in a rat model of intestinal barrier dysfunction caused by intestinal ischemia for 40 minutes followed by reperfusion for 12 hours. To do this, the rats were randomized to 1 of 4 treatment groups, as follows: (1) sham surgery and saline administration (1 mL IV) (Sham group); (2) sham surgery and trapidil administration (8 mg/kg IV) (Sham+T group); (3) I/R and saline administration (1 mL IV) (I/R group); and (4) I/R and trapidil administration (8 mg/kg IV) (I/R+T group). Intestinal barrier function was assessed by histopathologic examination, blood malondialdehyde (MDA) level, and BT. RESULTS: The I/R+T group showed significantly less incidence of BT compared with the I/R group in the liver and reduced median colony count of translocated bacteria in mesenteric lymph nodes, liver, spleen, and peritoneum compared with the I/R group. Furthermore, the mean blood MDA level demonstrated that lipid peroxidation was significantly decreased in the I/R+T group compared with the I/R group. Histopathologic findings revealed that trapidil administration before reperfusion preserved intestinal mucosal integrity and inhibited the infiltration of inflammatory cells into the intestines. CONCLUSIONS: In this experimental study, a correlation seemed to exist between intestinal barrier dysfunction and BT. Intestinal barrier dysfunction may allow a large amount of bacteria to pass from the gut to distant organs. Trapidil treatment may inhibit BT by preserving intestinal barrier by inhibiting thromboxane A2, lipid peroxidation, proinflammatory cytokines, and stimulated prostacyclin. Future dose- and time-dependent studies will be helpful in revealing the effects of trapidil on BT.