Location of the appendix at the third trimester of pregnancy: A new approach to old dilemma.

The aim of this study was to determine the location of the appendix at the third trimester of pregnancy as there are conflicting results in literature. Distances from the base of the appendix were measured intra-operatively to the anterior iliac spine (A), symphysis pubis (B) and the xyphoid process (C). The same measurements were taken from McBurney's point on the abdominal wall (A1, B1 and C1). In the allocated 21 pregnant and 18 non-pregnant women, distance A and B were 10.3 ± 0.9 cm and 18.3 ± 3.2 cm in pregnant and 6.7 ± 0.9 cm and 13.2 ± 0.9 cm in non-pregnant women (p < 0.001), respectively. Distance C was shorter in pregnant women (14.7 ± 2.5 cm vs. 23.8 ± 1.9, p < 0.001). Conversely, distance C1 was longer in pregnant women (30.3 ± 3.0 vs. 24.8 ± 5.1 cm, p = 0.004). This study provides evidence that the appendix moves cranially late in the course of the pregnancy. Therefore, McBurney's point cannot be used as a reference point to localise the appendix at the third trimester of pregnancy.

Enterostomy closure site hernias: a clinical and ultrasonographic evaluation.

BACKGROUND: Parastomal hernia with a reported incidence of up to 50% is a major problem after ostomy formation. Hernias at the closure site may be a problem after the closure of the enterostomy. In this study, in addition to physical examination, we used ultrasonography (USG) in order to find the true incidence of ostomy closure site and laparotomy incisional hernias. METHODS: We examined patients with closed enterostomy sites by both physical examination and USG for the detection of hernias. Risk factors for hernia formation, such as age, gender, body mass index (BMI), ostomy type, and surgical site infections, were determined. RESULTS: The evaluation of 31 patients with ostomies resulted in a 32% incidence of closed ostomy site hernias when patient medical history, physical examination, and ultrasonographic examination were used together. With physical examination and USG, incisional hernias at the laparotomy incision were found in 58% of cases. USG was able to detect hernias which were not clinically evident at the ostomy closure site and the laparotomy wound. BMI, age, gender, ostomy type, and surgical site infection did not have a significant effect on hernia formation. CONCLUSION: Ostomy closure site and laparotomy incisional hernias are important clinical problems with a high incidence after ostomies are closed. Closure of the enterostomy site should be regarded as a hernia repair rather than a simple fascial closure. USG is a valuable clinical tool in combination with physical examination for the detection of minor defects.

Different kinds of reactive oxygen and nitrogen species were detected in colon and breast tumors.

Several studies have shown the involvement of reactive oxygen species (ROS; O2*-, hypochlorite, hydroxyl radical, hydrogen peroxide) in carcinogenesis. With certain pathologies, nitric oxide (NO) is formed and can interact with superoxide radical (O2*-) resulting in the propagation of the highly reactive species, peroxynitrite. In order to study the molecular mechanisms underlying the ability of reactive oxygen and nitrogen species (RONS) to mediate carcinogenesis, we have measured ROS, NO, and peroxynitrite content of cancerous tissues obtained from colon and breast carcinoma cases by chemiluminescence technique. All ROS were significantly increased in cancerous colon tissues with hypochlorite making the most important contribution and suggesting the role of inflammatory cells. NO was also increased and the peroxynitrite concentration was higher in cancerous samples. For breast carcinoma cases, only O2*- was significantly increased. Hypochlorite was not detected excluding the contribution of inflammatory cells. NO concentrations were not significantly different, therefore, ROS might originate by change in the redox state of the tissue.

The effect of hyperthermic preconditioning on the immune system in rat peritonitis.

OBJECTIVE: To assess whether hyperthermic (HT) preconditioning prevents the lethal effects of peritonitis by acting on the immune system. DESIGN: Prospective, controlled, experimental study. SETTING: Laboratory and animal facility of the university. MATERIALS: Adult male Sprague-Dawley rats. INTERVENTIONS: In the HT groups animals were subjected to hyperthermia (42 degrees C, 15 min) and 8 h later peritonitis (P) (n = 14) was induced. In the normothermic (NT) groups, animals were subjected to normothermia (38 degrees C, 15 min) and 8 h later peritonitis (n = 14) was induced. Each group had a corresponding sham laparotomy group (n = 14). Six rats from each group were allowed to live 7 days for survival. In the control group (n = 4), rats were not anesthetized or heat treated. MEASUREMENTS AND RESULTS: Sixteen hours after peritonitis and laparotomy, rats were killed. Blood was taken to measure the percentage of CD(4)(+), CD(8)(+), CD(4)(+)CD(56)(+), CD(8)(+) CD(11 b)(+), NK(+), B cells and the level of tumor necrosis factor. Grading of peritonitis and the measurement of free oxygen radicals in the peritoneal fluid were undertaken. All rats in the HT + P and sham laparotomy groups survived for 7 days, while in the NT + P group two rats died in 7 days. HT decreased the severity of peritonitis and increased the free oxygen radicals in the peritoneal fluid; however, the difference did not reach statistical significance. HT prevented the decrease in CD(4)(+) and B cells and the increase in CD(11 b)(+). CONCLUSIONS: HT may have a protective role in sepsis by reducing the severity of peritonitis. A causal relation between hyperthermia and an improved immune system seems possible.

Captopril prevents the oxidative damage to proteins after renal ischemia reperfusion injury: role of endothelin-1.

Ischemia reperfusion (I/R) injury is one of the leading cause of the transplanted organ loss. In this experimental study, we investigated the effect of captopril on endothelin and eicosanoid release in I/R injury of the kidney. Rats were subjected to 60 min ischemia and 60 min of reperfusion of the left kidney in control and captopril groups. Tissue protein oxidation products, PGE2 and LTB4 levels and plasma endothelin-1 (ET-1) like activity were determined in sham operated, control and captopril groups. There were no differences in the LTB4 levels among the groups. ET-1 and PGE2 levels and protein oxidation products increased in the control group when compared with the sham. Captopril further increased both PGE2 and ET-1 concentrations and prevented protein oxidation. The increased ET-1 concentrations in the captopril treated group may imply the protective role of endothelin as the significant increase in protein oxidation products was reversed by captopril infusion. This has led us to believe that captopril might be useful in preventing I/R injury of the kidney. Also the release of endothelin from the vascular endothelium is increased by captopril and may be mediated by PGE2.

The effects of prostacyclin analogue ZK 36374 and thromboxane synthetase inhibitor UK 38485 on mesenteric ischemia in guinea pigs.

The effects of ZK 36374, a prostacyclin analogue and UK 38485, a thromboxane synthetase inhibitor were studied in guinea pigs after performing mesenteric arterial occlusion. In this study, while ZK 36374 significantly lowered the alkaline phosphatase and creatine phosphokinase values two hours after mesenteric arterial occlusion when compared with the control group (p less than 0.005), UK 38485 did not induce any change. In guinea pigs, when given together, ZK 36374 and UK 38485 lowered the enzyme levels to preligation values and the difference was nonsignificant (p greater than 0.1). The histopathologic investigation of the small intestine after giving ZK 36374 and UK 38345 together revealed minimal changes. These findings stress the importance of preserving the PGI2 levels in the PGI2/TXA2 ratio in preventing the increase of lysosomal enzyme levels and histopathologic changes after mesenteric arterial occlusion in guinea pigs.

Does PGE2 act as a mediator for endothelin release?

To investigate the effect of iloprost (ZK 36374) and thromboxane synthetase inhibitor UK 38485 on endothelin release by the intestinal vascular endothelium after ischemia/reperfusion (IR) injury, five experimental groups were formed. The groups consisted of sham, control, iloprost treated (ILO), UK 38485 treated (TSI), and iloprost + UK 38485 treated (ILO + TSI) groups. The last three groups received the corresponding agents and then the superior mesenteric artery was clamped for 30 min followed by 90 min reperfusion. Endothelin levels in the portal blood and malondialdehyde (MDA), prostaglandin E2 (PGE2) and leukotriene C4 (LTC4) levels in the intestinal tissue were determined. The MDA levels increased significantly in the control group and this increase was reversed in ILO, TSI, and ILO + TSI groups, the two drugs together showing a synergistic effect in preventing lipid peroxidation. The changes in the LTC4 levels were not significant among the groups. The increased endothelin levels in the control group were reversed in ILO and TSI groups but these two agents did not have a synergistic effect. Increased PGE2 levels were reversed with iloprost but neither UK 38485 nor the combination of the two agents was effective in decreasing PGE2 levels. It is concluded that endothelin release after mesenteric IR injury is relatively unrelated to lipid peroxidation and the lipoxygenase pathway. The cylooxygenase pathway has a direct effect on endothelin release and PGE2 may act as a mediator.

The effect of Iloprost (ZK 36374) on isolated and transplanted pancreatic islet cells.

Several methods have been described for the prolongation of survival of isolated and transplanted islet cells. To investigate the effect of a stable prostacyclin analogue, ZK 36374 (Iloprost) on isolated and allotransplanted islet cell function, we studied 6 groups of rats: Group 1 (n = 7) animals underwent pancreatectomy and their islets were isolated and cultured by standard techniques. Group 2 (n = 8) animals were treated the same, except for the addition of Iloprost to the culture solutions. Group 3 (n = 7) animals were treated as group 1, but the isolated islets were transplanted to the subcapsular space of the left kidney of group 5 (n = 7) animals. Group 4 (n = 8) animals were treated as group 2, and the isolated islets were transplanted to group 6 (n = 8) animals. The insulin levels in the culture media obtained in group 1 and 2 were measured. In groups 5 and 6 blood glucose levels were measured and intraperitoneal glucose loading tests were performed. Histological examination was performed for both isolated and transplanted islets. The results showed that both insulin levels and histologic evaluation were better for group 2 than group 1. Animals in group 6 reached normoglycemia on the fifth day following transplantation while it was the ninth day for group 5. The intraperitoneal glucose loading test was tolerated better by group 6 animals. We conclude that Iloprost may be responsible for the improved results which seem to be due to its cytoprotective effect.

The effect of iloprost and NDGA in ischemia reperfusion injury in rat liver.

In this study, the effects of iloprost (ZK 36374) and NDGA on warm ischemia and reperfusion injury in rat liver were investigated. Rats were given isotonic saline (control group), iloprost 25 micrograms/kg i.v. (group II) just before warm ischemia or NDGA 10 micrograms/kg i.v. (group III) 5 min before reperfusion or the same drugs were given together (group IV). Serum SGOT, SGPT, and LDH values and tissue malondialdehyde (MDA), glutathione (GSH), prostaglandin (PG)E2, and leukotriene (LT)C4 levels were determined after ischemia-reperfusion injury. Histopathologic examination of the liver was carried out under the light microscope. The serum SGOT, SGPT and LDH levels improved significantly in groups II, III, and IV when compared with the control group (p < 0.05). There was a significant decrease (p < 0.05) in tissue MDA levels and significant increase (p < 0.05) in tissue GSH levels in group I, when compared with group IV and the control groups. The values did not differ significantly in group IV when compared to controls. The LTC4/PGE2 ratio was low and histologic findings were worse in group III. In conclusion, iloprost was found to be beneficial in preventing the ischemia-reperfusion injury in the rat livers. NDGA, either by direct toxic effect or by shifting the arachidonic acid metabolism to the cyclooxygenase route, was not found to be as effective. Iloprost and NDGA did not exert a synergist effect.

Nitric oxide and endothelin relationship in intestinal ischemia/reperfusion injury.

Gastrointestinal mucosal blood flow is dependent on a balanced release of vasoactive substances from endothelium. Nitric oxide (NO) may increase the flow by vasodilatation and/or antiaggregation whereas endothelin (ET) may decrease it by vasoconstriction and aggregation. NO and ET may have counterbalancing effects on each other in tissue damage. In order to test this hypothesis, in this study on rats, L-arginine to increase NO levels and N(G)-nitro-L-arginine methyl esther (L-NAME) to decrease NO levels have been used in an intestinal ischemia/ reperfusion (I/R) injury model and portal vein ET response was evaluated. Lipid peroxidation product measurements and chemiluminescence (CL) studies were also carried out in ileal tissue samples. Intestinal I/R injury caused an increase in portal venous ET levels with levels of 9.4+/-0.5 fmol/ml in sham operation and 14.8+/-1.6 fmol/ml in I/R group. ET level of L-NAME-sh group was lower than that of sham-operated group and also ET level of L-NAME-I/R group was lower than that of I/R group. This yielded the conclusion that inhibition of NO synthesis decreases portal venous ET levels in this model. Increased NO production by L-arginine caused increased ET levels in sham operated groups but this effect was not observed in I/R injury state. This study also showed that inhibition of NO synthesis has a protective role by reducing the reperfusion damage in this model. It is likely that NO and ET have a feedback effect on each other both under physiologic conditions and I/R injury.

Scientific publications at a Turkish medical school.

The authors studied the scientific publishing trend for 1991 to 1998 at Turkey's Marmara University School of Medicine. Although publications increased both in real numbers and in ratios per faculty member, most were not original, peer-reviewed articles. Mere quantity of publications cannot accurately reflect a school's research reputation.

Preoperative albendazole treatment for liver hydatid disease decreases the viability of the cyst.

OBJECTIVE: Although in experimental models the efficacy of albendazole has been demonstrated, more clinical data are required. In this study, the effect of preoperative albendazole treatment was investigated in patients with liver hydatid cysts. DESIGN: This is a prospective non-randomized study. METHODS: In this study, the viability was assessed by the gross appearance of the cyst and intracystic pressure (ICP). The study consisted of 70 patients with 89 liver hydatid cysts in two groups. The patients in the first group (n = 29) received 10 mg/kg albendazole orally for 3 weeks before surgery. Thirty-five cysts were evaluated in this group. The second group (n = 41) with 54 liver hydatid cysts received no preoperative treatment. RESULTS: In the first group receiving preoperative albendazole, 20 cysts were viable and 15 non-viable. The median ICP was 21 (range 8-56) cm H2O in viable and 0 (range 0-8) cm H2O in non-viable cysts. In the second group, 43 cysts were viable and 11 non-viable. The median ICP was 35 (range 8-75) cm H2O in viable and 0 (range 0-2) cm H2O in non-viable cysts. The ICP values of viable cysts in the first group receiving preoperative albendazole were significantly lower (P < 0.05). The number of non-viable cysts was also significantly higher in the group treated with preoperative albendazole (P < 0.05). CONCLUSION: Albendazole in this study has proved to be effective in decreasing the viability of liver hydatid cysts when given for 3 weeks preoperatively.

The effect of thermal injury on gastric emptying in rats.

Gastric distension and gastrointestinal discomfort are common complications of burn injuries. This study was designed to examine the effect of thermal injury on the emptying rate of liquids in conscious rats fitted with stainless steel cannulae in the body of the stomach. In rats with partial-thickness burns emptying of the hyperosmolal saline was found to be delayed (P < 0.5) with respect to control only during the chronic phase of injury. However, full-thickness burns delayed hyperosmolal saline emptying in both acute and chronic phases, together with delayed saline emptying in the acute state. Thermal injury did not influence the gastric emptying of peptone and acid solutions, which activate different pathways to delay gastric emptying. Delayed gastric emptying of hyperosmolal solutions may be explained by increased sympathetic and opiatergic nervous activities, resulting in reflex relaxation of gastric smooth muscle.

Surgical treatment of hepatic hydatid cysts.

Ninety-two surgical procedures were carried out in 82 patients with 92 hepatic hydatid cysts. The most common complication of the hydatid cyst was biliary rupture (17.3%) followed by infection of the cyst cavity (5.4%). Omentoplasty was carried out for uncomplicated cysts (38.0%) with a low morbidity (14.2%) and short hospital stay (mean 12.8 days). External tube drainage was carried out in 30.5% of patients. The morbidity rate was 67.8% and the mean hospital stay was 19.8 days. No single method can be recommended for the treatment of hepatic hydatid cysts but the choice of the surgical method must be made according to the complications of the cyst. Omentoplasty is the procedure of choice for uncomplicated cysts with a low complication rate and relatively short hospital stay. External tube drainage is recommended for infected cysts and a biliary drainage procedure must be added to external tube drainage for cysts with intrabiliary rupture.

How minimally invasive is laparoscopic cholecystectomy?

To determine the extent of surgical stress induced by open (n = 20) and laparoscopic (n = 20) cholecystectomy, postoperative serum cortisol, growth hormone, and insulin responses were determined for each group. The groups were similar regarding age, sex distribution, and duration of the surgical procedures. The open cholecystectomy group had significant elevations of serum cortisol, growth hormone, and insulin levels 8 h after surgery (p < 0.05). The increased cortisol and growth hormone levels returned to preoperative control values 48 h after surgery. In the laparoscopically operated group, although all hormones increased after surgery, only the increase in growth hormone was statistically significant (p < 0.05). Serum cortisol and growth hormone levels gradually returned to control values 48 h after surgery, but the increased serum insulin levels remained significantly high in both groups 24 and 48 h after surgery (p < 0.05). It is concluded that acute surgical stress induced by open cholecystectomy is more severe than that induced by laparoscopic surgery as reflected by serum hormone determinations. However, the hormonal convalescence rate was similar for both groups. It appears that laparoscopic cholecystectomy is "minimally invasive" concerning the hormonal responses.

Prospective multicentre trials in developing countries: willingness of surgeons to participate.

OBJECTIVE: To assess the feasibility of conducting a multicentre study among surgeons in Turkey. DESIGN: Prospective open multicentre study. SETTING: Teaching hospitals in Turkey. SUBJECTS: Surgeons working in 23 university and 15 state hospitals. INTERVENTIONS: Surgeons willing to participate were asked to look for the presence of Meckel's diverticulum in all patients undergoing laparotomy. MAIN OUTCOME MEASURES: To find out the number of surgeons willing to participate in the study and once they agreed to see how they fulfilled the requirements. RESULTS: 14 agreed to participate (12 from universities and 2 from state hospitals) and completed the study. A total of 2781 patient records were collected. University hospitals were more willing to participate than state hospitals (52% compared with 13%) but state hospitals contributed 20% of the patients. The number of patients contributed in the first and second halves of the study did not differ, reflecting no diminution of the enthusiasm. CONCLUSION: This study, with no financial support, showed that it is possible to conduct multicentre studies among surgeons in developing countries such as Turkey. Increased awareness of the importance of publication may have helped to obtain this result.

Sacrococcygeal hydatid cyst: another entity in the differential diagnosis of sacrococcygeal chordoma. Case report.

A case of hydatid disease of the sacrum with severe neurological symptoms, which was misdiagnosed preoperatively as a chordoma, is presented. The patient had significant improvement of the neurological symptoms after evacuation of the cyst. Sacral hydatid cysts must be considered in the differential diagnosis of sacrococcygeal chordoma.