Sequential analysis of single-center experience of living donor kidney transplants with several vascular anastomosis techniques

Background and aim: Vascular variations of grafts are handled with various reconstruction techniques in renal transplantation. We aimed to analyze the effects of these reconstruction techniques and sites on patient/graft outcomes. Materials and methods: Renal transplantation cases at the Transplantation Unit of the General Surgery Department, Istanbul Uni- versity Cerrahpasa Medical Faculty between January 1st, 2000 and December 31st, 2012 were analyzed retrospectively. Postoperative duplex ultrasound results, urea-creatinine reduction rates, and complications were evaluated. Results: There were 228 living-donor transplantation cases evaluated. For single-renal-artery living-donor transplantations, there were 45 end-to-side external iliac artery, 15 end-to-side internal iliac artery, 152 end-to-end internal iliac artery, and 3 end-to-side common iliac artery anastomoses performed. In cases with double-arteries, 3 had end-to-side external iliac artery anastomoses, and 10 had end- to-end internal iliac artery anastomoses. No statistically significant differences were found between reconstruction techniques with regard to complications or urea-creatinine reduction rates. Conclusion: Internal, external, and common iliac arteries can be safely used for anastomoses. The presence of more than one renal artery creates no short or long-term problems when a side-to-side anastomosis is initially performed.

Integrating the new systemic treatment landscape and surgical therapy in hepatocellular carcinoma.

The treatment landscape of hepatocellular carcinoma has evolved rapidly within the last decade. Minimally-invasive techniques have reached a new level of safety, affording surgeons to pursue more aggressive treatment strategies to ultimately improve oncological outcomes. These procedures have been increasingly applied to treat patients with more progressed tumors and in select case even patients with advanced stage disease confined to the liver. Concomitantly, a dramatic increase in research into immunotherapy has altered the treatment paradigm in advanced disease stages, where the emerging treatment regimens can provide durable responses in a subset of the patient population for whom prognosis is dramatically improved. These treatments are now tested in early-stage disease to address the pressing unmet need of high recurrence rates after resection and in intermediate stage to complement the proven efficacy of intraarterial embolization in delaying progression. This review provides an in-depth discussion of these trends and describes how the treatment landscape has already changed and which impediments remain.

Hepaticojejunostomy with the "Hand-Fan" technique.

A standard hepaticojejunostomy technique might be difficult to perform, especially when the bile duct is small and located deep in the liver hilum. Herein we present a new procedure, the Hand-Fan technique, that was used to enhance the exposure and ease the performance of these challenging anastomoses. Thirty-one patients who had had hepaticojejunostomy with this technique for bile duct injury and other benign biliary pathologies from July 2004 to June 2011 were included into the study. Median postoperative hospital stay was 7 days (6-25 days) and median follow-up time was 33 months (2-84 months). Liver function tests revealed that the blood bilirubin levels of the patients were normalized after hepaticojejunostomy. Follow-up showed that there were no signs of clinical recurrence or impaired bile flow. The Hand-Fan technique considerably facilitates challenging hepaticojejunostomies. Surgeon's comfort is exceptional and the clinical results are satisfactory.

Acute pancreatitis: It can be the first sign of silent gallstones.

Objectives: The management of asymptomatic cholelithiasis is controversial. Silent gallstones are generally assumed to cause complications after at least one episode of biliary colic. The ratio of those silent stones that had initially caused, -or were diagnosed as the etiological agent of- acute pancreatitis has not been reported in the literature yet. Our study was designed to investigate the ratio of asymptomatic cholelithiasis in acute biliary pancreatitis cases. Material and Methods: One hundred and seventy-one patients of 305 cases, who were followed up with the diagnosis of acute biliary pancreatitis, were identified retrospectively. Demographic specifications, laboratory findings and clinical progressions of the patients were inspected. Clinical histories were detailed by phone calls. Gallstones were radiologically detected in 85 out of 171 cases. Those patients were divided as symptomatic and asymptomatic. Clinical findings and follow-ups were evaluated by "Chi-square" test. Results: In the study group, 80% of the patients were asymptomatic (n= 68) and 16.47% of the patients (n= 14) had complicated pancreatitis. Regarding the severity of the clinical course, being symptomatic or not was not identified as a significant factor (p= 0.108). In regard of creating symptoms, the size of the stone was not significant (p= 0.561) and obtained no prediction about the clinical severity of the pancreatitis (p= 0.728). Conclusion: Asymptomatic cholelithiasis patients had a major percentage in acute biliary pancreatitis cases. The "wait and see" approach should be re-evaluated for silent gallstones in prospective trials.

Biliary cysts in adults: Cerrahpasa experience.

Objectives: Biliary cysts are biliary duct dilatations, with 20% of the cysts being diagnosed in adulthood. Abdominal pain, jaundice and palpable abdominal mass are defined as the classical triad. However, nausea, vomiting, fever, itching and weight loss are frequent complaints. There are several treatment options depending on the type of the cyst. This study aimed to share our experience with biliary cysts and contribute to the literature on this subject. Material and Methods: Thirty patients, who received treatment for biliary cyst from January 1981 to December 2018 at our clinic, were studied retrospectively. The patients were analyzed based on age, sex, type of the cyst, diagnosis and treatment methods, post-op follow up and complications. Results: Twenty-seven of the patients were females, and three were males. The patients were aged between 16 and 76 years, and the median age was 41.9 years. All patients presented with abdominal pain, which was accompanied by cholangitis in nine patients, nausea and vomiting in four patients, dyspepsia in three patients and palpable mass in one patient. According to the Todani classification, biliary cyst findings were consistent with Type I in 23 patients, Type V in three patients, Type IV in two patients, Type II in one patient and Type III in one patient. Conclusion: Diagnosis and treatment are complex in biliary cysts due to anatomical proximity and variations. Therefore, it would be beneficial to refer them to referral centers. Choice of treatment should be based on the type of the cyst.

Does taurolidine have any effect on liver regeneration and oxidation in the experimental hepatectomy model?

Objectives: Taurolidine is a bicyclic molecule produced by the natural amino acid taurine. Antibacterial, antiendotoxic and cytoprotective effects of taurolidine have been shown experimentally. Data on the effects of taurolidine on oxidative stress and hepatic regeneration are limited. The aim of the study was to evaluate the effect of taurolidine on hepatic regeneration and oxidative stress in rats undergoing partial hepatectomy. Material and Methods: Forty adult, male Wistar Albino rats were randomly divided into four equal groups: sham (S) group (n= 10), post-sham opera- tion taurolidine administered (ST) group (n= 10), partial hepatectomy (H) group (n= 10) and post-partial hepatectomy taurolidine administered (HT) group (n= 10). 100 mg/kg/day taurolidine was administered for seven days. Blood and liver tissue samples were collected on postoperative day seven. Liver tissue malondialdehyde, glutathione and Cu-Zn superoxide dismutase activity (SOD) were measured to assess oxidative stress. Binuclear hepato- cyte and Ki-67 antigen levels were measured to evaluate hepatic regeneration. Results: There was no difference between the groups for malondialdehyde, Cu-Zn superoxide dismutase and glutathione levels (p> 0.05). Binuclear nuclei levels were comparable between the H and HT groups (p= 0.06), while taurolidine decreased binuclear hepatocyte levels in the sham operated groups (p= 0.02). Taurolidine application decreased Ki-67 levels after partial hepatectomy (p= 0.001). Conclusion: Taurolidine may cause anti-regenerative effects after partial hepatectomy without causing oxidative damage.

Spontaneous intramural hematoma of the small intestine.

BACKGROUND: Spontaneous intramural hematoma of the small intestine is a rare clinical condition that may result in potentially serious complications. The purpose of this study was to present our experience with the diagnosis and management of spontaneous intramural hematoma of the small intestine. METHODS: The medical records of the patients with spontaneous intramural hematoma of the small intestine were retrospectively reviewed. Six patients were included in this study. RESULTS: Anticoagulation therapy and factor VIII deficiency were found to be responsible for the intramural hemorrhage in five patients (83%) and one patient, respectively. Acute abdominal pain followed by nausea and vomiting were the most common presenting symptoms. Abdominal computed tomography scan was diagnostic in five of the six patients. Four patients were followed up with conservative therapy. Surgical intervention was required in two patients due to acute abdomen. All patients were discharged from the hospital uneventfully. CONCLUSION: The patient's medical history, physical examination and radiological evaluation proved adequate for the diagnosis. Conservative therapy provides regression of the hematoma in most patients. Surgery should be reserved only for the complicated cases.

Fournier's gangrene: Five years' experience from a single center in Turkey.

BACKGROUND: Is the present study aims to analyze demographic, clinical and surgical data of all patients with FG (Fournier's gangrene) admitted to a tertiary healthcare hospital in the largest city of Turkey. METHODS: This study included 35 patients with Fournier's gangrene, who were followed by the General Surgery, Plastic Surgery, and Urology Departments of Istanbul University Cerrahpasa Faculty of Medicine from January 2010 to January 2015. Demographic and clinical data, including gender, age, length of stay at the hospital, the underlying cause(s), number of debridement, predisposing factors, and surgical reconstructive data over 10 years were assessed and analyzed retrospectively. RESULTS: The mean age of the 35 patients was 58.14±12.71 years. Diabetes mellitus was present in 20 of the 35 (57.1%) patients. Twelve of the patients (34.2%) were hospitalized in the intensive care unit (ICU). Length of stay in the ICU was found to be significantly influenced by age, hematocrit level, FGSI and UFGSI (p=0.013, p=0.030 p=0.025 and p=0.002, respectively). CONCLUSION: Fournier's gangrene is a fulminant infection with a high mortality rate. Physical examination and anamnesis are quite important for the diagnosis of FG. DM is the most common comorbidity. Age, hematocrit level, FGSI and UFGSI scores affect the patients' length of stay in the ICU.

Surgical management of digestive system cancers during the coronavirus disease 2019 pandemic: review of general suggestions.

Since December 2019, the world has been battling the COVID-19 pandemic, and health workers are at the forefront of the fight. Surgeons also fulfill their duty; however, elective cases had to be postponed in order to use resources appropriately in the fight against coronavirus. Although benign elective surgical procedures can be postponed to a distant time during this pandemic, surgical interventions for urgent and life-threatening situations are mandatory to perform but the main uncertainty among surgeons is about cancer patients. In this paper, we aimed to present a suggestion to the surgeon about how to manage digestive system cancers during pandemic in the light of the published articles and guidelines.

Prognostic significance of the DNA-index in liver transplantation for hepatocellular carcinoma in cirrhosis.

OBJECTIVE: This study was conducted to evaluate the prognostic significance of the tumor DNA index in patients receiving liver transplantation for hepatocellular carcinoma (HCC) in cirrhosis. BACKGROUND: In patients suffering from HCC in cirrhosis, the current selection for liver transplantation does not optimally achieve the goal to simultaneously maximize the number of viable transplant candidates and reject the smallest number of those who could have benefited. This is the first report on the prognostic significance of the tumor DNA index. PATIENTS AND METHODS: From 1988 to 2007, liver transplantation for HCC in cirrhosis was performed in 246 consecutive patients. The DNA-index was determined by Feulgen staining and semiautomatical image analysis. Interpretation of DNA histograms followed the recommendations outlined in the European Society for Analytical Cellular Pathology consensus report on diagnostic DNA image cytometry. RESULTS: A DNA-index

Comparison of the electrothermal vessel-sealing system versus endoclip in laparoscopic appendectomy.

BACKGROUND: Various techniques have been used for the division of mesoappendix, such as endoloops, endoscopic linear cutting staplers, an electrothermal vessel-sealing system (LigaSure), the Harmonic Scalpel, clips, and bipolar coagulation. In the present study, LigaSure and an endoclip were compared in laparoscopic appendectomy (LA). MATERIALS AND METHODS: This study included patients who underwent LA for acute appendicitis at Istanbul University, Cerrahpasa Medical Faculty, Emergency Unit (Istanbul, Turkey) between May 2003 and April 2007. The patients were assigned to two groups according to the mesoappendix dissection device: LigaSure and endoclip groups. The main outcome measures (e.g., operating time, conversion rate, hospital stay, postoperative complications, etc.) were then compared. RESULTS: LA was performed in 280 patients with acute appendicitis. LigaSure and endoclips were used in 127 and 153 patients, respectively. The mean operative times were 41 and 54 minutes in the LigaSure and endoclip groups, respectively. Conversions to open rates were found to be 9.4% (12 patients) in the LigaSure and 11.1% (17 patients) in endoclip groups. No statistically significant differences regarding hospital stay or complications were found, whereas significant differences were observed in surgical time and conversion rate. CONCLUSION: The use of LigaSure facilitates the dissection of mesoappendix and shortens the operation time in LA. We believe that LigaSure is a safe, useful tool for mesoappendix dissection.

Selective laparoscopic adhesiolysis in the management of acute and chronic recurrent adhesive bowel obstruction.

BACKGROUND: Laparoscopic adhesiolysis became popular in the last decade for the management of postoperative adhesive small bowel obstruction. This paper investigates the feasibility, effectiveness and safety of laparoscopy in this field; the details of a selective adhesiolysis were discussed as well. METHODS: The patients who underwent laparoscopic management of acute or chronic recurrent adhesive bowel obstruction were included into the study. The patients were managed according to a specific algorithm. If the conservative management has failed, selective laparoscopic adhesiolysis to the transition zone of distended /collapsed bowel was performed. Patients, who were suffering from chronic recurrent obstruction attacks and those who tolerated oral intake, underwent preoperative enteroclysis studies and selective adhesiolysis was performed according to imaging findings. Computerized tomography was performed in all cases to exclude other diagnoses. RESULTS: Thirty-one patients (22 female, 9 male) underwent laparoscopic adhesiolysis from January 1998 to June 2007. The mean age was 48 (range: 20-80). Enteroclysis--guided laparoscopic adhesiolysis was performed in nineteen patients. Twelve patients underwent laparoscopic adhesiolysis for acute obstruction. Enteroclysis was able to demonstrate the pathological adhesion or band in all of the patents who underwent this imaging technique. Conversion and complication rates were 9.6%. The entire patients tolerated well oral intake postoperatively except one who had underwent enteroclysis-guided adhesiolysis; the patient presented with transient subileus on postoperative day 34 and responded well to conservative management. Mean hospital stay was 4.1 days (range: 2-7). The patients are free of symptoms on their follow-up. CONCLUSION: Laparoscopy is feasible, safe and effective in postoperative adhesive disease. Laparoscopic adhesiolysis should be performed as selective as possible in acute and chronic cases. Enteroclysis is a helpful imaging modality for performing selective laparoscopic adhesiolysis in chronic obstruction.

Importance of knowledge of the management of traumatic dental injuries in emergency departments.

BACKGROUND: Hospital emergency departments (EDs) are confronted with managing dental emergencies of both traumatic and non-traumatic origin. However, the literature suggests inadequate knowledge of the management of traumatic dental injuries (TDIs) among medical professionals. The aim of this study was to investigate the knowledge and attitudes regarding management of TDIs among Istanbul ED physicians. METHODS: Surveys were distributed to emergency departments (ED) directors and their physicians. The survey contained questions about their characteristics and tested their knowledge of managing dental trauma. RESULTS: A total of 126 surveys (13 ED directors and 113 physicians) were returned and included in the analysis. ED physician's knowledge of the appropriate management of crown fractures and avulsion was generally good (p=0.221), but poor for luxation injuries (p=0.0001). Physicians were more likely to have a better knowledge about permanent teeth than about primary teeth (p=0.027). CONCLUSION: Education, monitoring, improved availability of resources, and disciplinary measures in cases of poor compliance are necessary to improve TDI management in hospitals, especially among physicians.

Intraoperative doppler ultrasound: a reliable diagnostic method in insulinoma.

A 44-year-old woman was admitted with obvious symptoms of hypoglycemia and Whipple's triad during a 6-month period. The glucose level was as low as 32 mg/dL and insulin/glucose ratio greater than 0.5 after fasting. Abdominal magnetic resonance imaging (MRI) studies revealed a pancreatic mass at the head, 2 cm in diameter that was not suggesting because of hypointensity. Selective angiography and somatostatin-receptor scintigraphy did not reveal insulinoma. During laparotomy the tumor was palpated on the ventral surface of pancreas and intraoperative ultrasound accurately localized it. Doppler ultrasound examination clearly revealed the hypervascularity of the tumor, which was suggesting an insulinoma. After the tumor enucleation, blood glucose level increased to normal ranges. Histopathological examination revealed benign, well differentiated neuroendocrine tumor, insulinoma. The postoperative recovery was uneventful and the patient is still symptom free during a follow-up period of 6 months. Doppler ultrasound may be a simple but efficient tool for the differential diagnosis of insulinoma. If the clinical symptoms and findings suggest clearly an insulinoma, intraoperative Doppler ultrasound examination seems to be a simple but the most sensitive diagnostic method.

Laparoscopy offers diagnosis and treatment in abdominal stab injuries.

PURPOSE: To assess the role of laparoscopy in the diagnosis and treatment of abdominal stab injuries (ASI). METHODS: Patients who underwent laparoscopic procedures due to ASI were included in the study. Hemodynamic instability, injuries to the posterior trunk, concomitant severe cranial injuries, and prior abdominal operations were considered as contraindication for laparoscopy. RESULTS: From January 1997 to March 2006, 88 patients underwent laparoscopic management of ASI. In 45 patients (51.1%), there was no intra-abdominal pathology requiring surgical intervention (nontherapeutic laparoscopy) and 5 patients in this group had no peritoneal penetration (negative laparoscopy). In another 25 patients (28.4%), laparoscopic treatment was performed (therapeutic laparoscopy), including bleeding control in liver, colonic, gastric, and diaphragmatic repairs and intra-abdominal bleeding control. Laparotomy was avoided in a total of 70 (79.5%) patients. In 18 patients (20.5%), laparoscopy was converted to laparotomy. There was no mortality, and except one missed small bowel injury nor perioperative morbidity in patients undergoing laparoscopy. In the laparotomy group, major complications were seen in 7 patients. CONCLUSIONS: Laparoscopy is safe and efficient in the management of ASI and should be more frequently considered as a therapeutic tool.