Social accountability: A national framework for Turkish medical schools.

PURPOSE: To define recommendations to the medical schools in Turkey about social accountability which meets the local needs. METHODOLOGY OF THE STUDY: The Association of Evaluation and Accreditation of Medical Education Programs (TEPDAD-Turkey) Social Accountability working group planned a study to determine national recommendations for social accountability of medical schools in two-stages. Delphi technique was used to develop the recommendations and finalize the recommendations in the first stage in which 61 members from 30 different institutions participated. Qualitative analysis was used for open questions in the first round and quantitative analysis for the data which is collected with a rating scale in the second and third rounds of the Delphi study. In the second stage, the recommendations were reviewed and finalized in a consensus workshop in which 68 members from 39 different institutions participated. RESULTS: In the Delphi study 63 recommendations were classified under five themes: the health needs of the society, health service delivery, institutional structure and management, educational program and implementation and development and evaluation of social accountability. In the consensus workshop, the 63 recommendations were evaluated and of which 54 of 63 recommendations were agreed upon. CONCLUSION: A national framework has been developed by including a wide range of experts from different institutions for the social accountability of medical schools in Turkey. Developing recommendations in a local context will enhance the conceptualization of the recommendations of social accountability in the medical schools. As an accreditation body embedding the principles in the national standards will have a further impact on this process.

RE-AIMing COVID-19 online learning for medical students: a massive open online course evaluation.

BACKGROUND: Clinical training during the COVID-19 pandemic is high risk for medical students. Medical schools in low- and middle-income countries (LMIC) have limited capacity to develop resources in the face of rapidly developing health emergencies. Here, a free Massive Open Online Course (MOOC) was developed as a COVID-19 resource for medical students working in these settings, and its effectiveness was evaluated. METHODS: The RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework was utilized to evaluate the effectiveness of MOOC in teaching medical students about COVID-19. The data sources included the student registration forms, metrics quantifying their interactions within the modules, students' course feedback, and free-text responses. The data were collected from the Moodle learning management system and Google analytics from May 9 to September 15, 2020. The research team analyzed the quantitative data descriptively and the qualitative data thematically. RESULTS: Among the 16,237 unique visitors who accessed the course, only 6031 medical students from 71 medical schools registered, and about 4993 (83% of registrants) completed the course, indicating high levels of satisfaction (M = 8.17, SD = 1.49) on a 10-point scale. The mean scores of each assessment modules were > 90%. The free-text responses from 987 unique students revealed a total of 17 themes (e.g., knowing the general information on COVID-19, process management of the pandemic in public health, online platform use, and instructional design) across the elements of the RE-AIM framework. Mainly, the students characterized the MOOC as well-organized and effective. CONCLUSIONS: Medical students learned about COVID-19 using a self-paced and unmonitored MOOC. MOOCs could play a vital role in the dissemination of accurate information to medical students in LMIC in future public health emergencies. The students were interested in using similar MOOCs in the future.

Dexamethasone effects on vascular flow and organ injury in septic mice.

BACKGROUND: To demonstrate the effects of low-dose dexamethasone treatment on mesenteric artery blood flow, oxidative injury, vascular reactivity, and survival in Swiss albino mice with intra-abdominal polymicrobial sepsis accomplished by cecal ligation and puncture (CLP). METHODS: Mice were allocated to CLP + saline, CLP + dexamethasone, sham + saline, and sham + dexamethasone subgroups to evaluate blood flow, organ injury, and vascular response to consecutive phenylephrine administrations at 24, 48, and 72 h. Survival rates were also evaluated in a different group of mice. Dexamethasone (1 mg/kg/d) and saline (4 mL/kg/d) were administered intraperitoneally to mice 2 h after CLP or sham procedure, whichever appropriate, and repeated once a day until evaluation time at 48 and 72 h. Relaparotomy was performed at the concerned time and mesenteric blood flow was measured, and liver, lung, and peritoneum samples were obtained. Alteration in mesenteric blood flow response to intravenous phenylephrine injections was recorded at the related time intervals in different mice groups. Survival group was followed up by 7-d administration of dexamethasone or saline for 18 d. RESULTS: The significant fall in mesenteric blood flow after CLP ameliorated with dexamethasone treatment at 48 and 72 h. Dexamethasone also diminished the malonyl dialdehyde level, which is an indicator of organ injury raised after CLP, at 24 h in liver, lung, and peritoneum samples. Dexamethasone therapy has significantly enhanced the vascular response to phenylephrine injections at all doses; however, no change was observed in survival rates. CONCLUSIONS: Low-dose dexamethasone has beneficial effects on mesenteric blood flow and organ injury in experimental sepsis models.

Effects of dexamethasone on ischemia reperfusion injury following pringle maneuver.

BACKGROUND/AIMS: Hepatic ischemia reperfusion injury induced by Pringle maneuver leads to bacterial translocation, endotoxemia and apoptosis. Our aim was to compare the effects of low and high dose dexamethasone pretreatment on antioxidant enzyme activities, bacterial translocation, endotoxemia and apoptosis, following Pringle maneuver. METHODOLOGY: Thirty-two rats were randomized into four groups; sham, control and two treatment groups; low dose dexamethasone (0.1 mg/kg) and high dose dexamethasone (1 mg/kg). In the treatment groups dexamethasone was administered intraperitoneally one hour before Pringle maneuver. Twenty-four hours after closing rats' abdomen, re-laparotomy was performed and tissue samples were taken from the mesenteric lymph nodes, liver, ileum and spleen and 1 mL of blood was drawn from the aorta. Bacterial translocation, endotoxemia, apoptosis and enzyme activities of G6PD, 6-PGD, GR, GST, GPx and CAT were evaluated. RESULTS: Low dose dexamethasone significantly decreased bacterial translocation to mesenteric lymph nodes, and reduced liver and enterocyte apoptosis, whereas high dose dexamethasone caused only a significant reduction in enterocyte apoptosis (p<0.05). Dexamethasone both in low and high doses significantly reduced the decrease in antioxidant enzyme levels (p<0.05). CONCLUSIONS: Low dose dexamethasone pretreatment caused constructive therapeutic effects after Pringle maneuver, whereas these effects were seen partially with a high dose.

Determinants of postoperative infection after laparoscopic cholecystectomy.

BACKGROUND/AIMS: The aim of this study was to evaluate the effect of antibiotic prophylaxis on the development of infectious complications in laparoscopic cholecystectomy. METHODOLOGY: A total of 208 patients undergoing elective laparoscopic cholecystectomy were randomized, double-blinded into one of two treatment arms: 1) cefazolin 1 g intravenously after induction of anesthesia and 2) no prophylactic antibiotics. The patients were followed-up for infectious complications for 30 days at the out-patient clinic. The data collected included age, sex, body mass index, ultrasonography findings, accompanying diseases, perforation during surgery, stone spillage, operation time, port of gallbladder delivery, suture material used for skin closure, preoperative and length of postoperative hospitalization, bile culture, pathology of the gallbladder, serum biochemical findings including alanine aminotransferase, aspartate aminotransferase, gammaglutamyl transpeptidase, bilirubin, alkaline phosphatase and glucose. RESULTS: Overall rate of infection was 3.36%. Four out of 105 patients who received antibiotics and 3 out of 103 patients who did not receive antibiotics developed infection. The difference was not statistically significant. Obesity and closing the skin with nylon sutures were found to be associated with increased rate of infectious complications. CONCLUSIONS: Cefazolin prophylaxis in low risk patients has no effect on postoperative infection rate in laparoscopic cholecystectomy.

Metacognitive awareness and self-regulated learning skills of medical students in different medical curricula.

AIM: The aim of this study was to investigate the acquisition of metacognitive awareness and self-regulated learning skills in medical schools using different curricular models. METHODS: The study was carried out in four medical schools implementing different curricular models. Eight hundred and sixty two medical students took part in the study and two scales (self-regulated learning perception scale--SRLPS and metacognitive awareness inventory--MAI) were used. Cronbach's alpha was 0.93 for the MAI, and 0.88, 0.91, 0.83, and 0.76 for the four dimensions of the SRLPS. RESULTS: There were no statistically significant differences in MAI scores according to gender, curricular language, or previous exposure or not to a learner-centered method during secondary school, but the differences in scores according to the phase and curricular model were found to be significant. With regard to SRLPS total scores, no difference was found according to gender, but significant differences were found according to phase, curricular language, and curricular model. MAI and SRLPS scores of students from the medical school using a learner-centered curriculum were higher than the other schools' students. CONCLUSION: This study suggests that students who experience a learner-centered curriculum, such as PBL during their medical education demonstrate improved metacognitive awareness and self-regulated learning skills.

Intestinal obstructions: what has changed so far?

The aim of this study is to evaluate the changing factors related to surgery in intestinal obstruction. The surgical records of patients who were operated for intestinal obstruction at Hacettepe University Medical School during the years 1980-1985 and 2000-2005 were evaluated retrospectively. There were 92 patients in group I and 185 patients in group II. The cause of intestinal obstruction was adhesions in 41.30% of the patients in group I and tumors in 45.95% of the patients in group II (P = 0.0001). Patients with peritoneal carcinomatosis constituted 3.26% of the patients in group I and 27.03% of the patients in group II (P = 0.0001). Abdominal computed tomography was not used in the first group and was used in 60.54% of those in the second group (P = 0.0001). Complications were seen in 40.54% of patients in the second group and in 26.08% of patients in the first group (P = 0.01). During the past 20 years, changes have occurred that were related to causes, diagnostic tools, and nutritional support for patients undergoing surgery for intestinal obstruction. Despite these changes, no changes in length of hospital stay or mortality have been reported. Intestinal obstruction due to peritoneal carcinomatosis seems to be a growing problem.

[Effects of autologous and homologous blood transfusion on TNF-alpha levels and survival in an intraabdominal infection model]. / Otolog ve homolog kan transfüzyonunun karin içi enfeksiyon modelinde TNF-alfa düzeyleri ve sagkalima etkisi.

BACKGROUND: Autologous blood transfusion is one of the approaches used for prevention of the undesirable immunomodulatory effects of homologous blood transfusion that can cause an increase in cancer recurrence and surgical site infections. On the other hand, the benefits of autologous blood transfusion in that respect are not yet clearly identified. In this experimental study, we investigated the differences in effects of autologous and homologous blood transfusion on tumor necrosis factor (TNF)-alpha levels and survival in an intraabdominal infection model in rats. METHODS: A total of 92 Sprague-Dawley rats were used in the study. Forty-four of those rats were divided into autologous and homologous transfusion groups, and intraabdominal infection was instituted by cecal ligation puncture method on the 7th day after blood transfusion. Blood samples were taken at the 90th minute and at 6-hour intervals after cecal ligation puncture and were used for measurement of TNF-alpha levels by ELISA method. In the remaining 48 rats, survival was investigated within the first week of cecal ligation puncture. RESULTS: Our results revealed significantly depressed TNF-alpha levels in the homologous blood transfusion group, but with respect to survival, no difference was detected between the groups. CONCLUSION: Based on these findings, we concluded that autologous blood transfusion decreases transfusion-related immunomodulation but does not cause a decrease in mortality due to intraabdominal infection.

Effects of honey as a scolicidal agent on the hepatobiliary system.

AIM: To examine the effects of 10% diluted honey, which has been shown to be scolicidal, on the liver and biliary system and determine whether it could be used as a scolicidal agent in the presence of biliary-cystic communication. METHODS: Thirty Wistar-Albino rats were divided into two groups. Honey with 10% dilution in the study group and 0.9% saline (NaCl) in the control group were injected into the common bile ducts of rats through a 3-mm duodenotomy. The animals were sacrificed 6 mo after the procedure. Histopathological, biochemical, and radiological examinations were performed for evaluation of side effects. RESULTS: At the end of the sixth month, liver function tests were found to be normal in both groups. The tissue samples of liver and ductus choledochus of the honey group showed no histomorphologic difference from the control group. No stricture on the biliary tree was detected on the retrograde cholangiograms. CONCLUSION: According to these results, we concluded that 10% diluted honey could be used as scolicidal agent safely in the presence of biliary-cystic communication.

Effect of peritoneal lavage on TNF-alpha, IL-1beta, and IL-6 levels and mortality in intraabdominal infections.

The mortality rate of intra-abdominal infections is high, and new prognostic factors are being investigated. Tumor necrosis factor alpha (TNF-alpha), interleukin (IL)-1beta, and IL-6 are among these factors. Intraoperative peritoneal lavage is part of surgical treatment for intra-abdominal infection. The aim of this study is to investigate the effect of peritoneal lavage on TNF-alpha, IL-1beta, and IL-6 levels and mortality when the source control has or has not been established. Eighty-five rats were divided into control, cecal ligation and puncture, and cecal ligation and puncture with excision groups. The effect of peritoneal lavage on TNF-alpha, IL-1beta, and IL-6 levels and mortality could not be shown in this study.

Core Professionalism Education in Surgery: A Systematic Review.

BACKGROUND: Professionalism education is one of the major elements of surgical residency education. AIMS: To evaluate the studies on core professionalism education programs in surgical professionalism education. STUDY DESIGN: Systematic review. METHODS: This systematic literature review was performed to analyze core professionalism programs for surgical residency education published in English with at least three of the following features: program developmental model/instructional design method, aims and competencies, methods of teaching, methods of assessment, and program evaluation model or method. A total of 27083 articles were retrieved using EBSCOHOST, PubMed, Science Direct, Web of Science, and manual search. RESULTS: Eight articles met the selection criteria. The instructional design method was presented in only one article, which described the Analysis, Design, Development, Implementation, and Evaluation model. Six articles were based on the Accreditation Council for Graduate Medical Education criterion, although there was significant variability in content. The most common teaching method was role modeling with scenario- and case-based learning. A wide range of assessment methods for evaluating professionalism education were reported. The Kirkpatrick model was reported in one article as a method for program evaluation. CONCLUSION: It is suggested that for a core surgical professionalism education program, developmental/instructional design model, aims and competencies, content, teaching methods, assessment methods, and program evaluation methods/models should be well defined, and the content should be comparable.

Liposome-mediated intraperitoneal interleukin 10 gene transfer increases survival in cecal litigation and puncture model of sepsis.

Interleukin 10 (IL-10) has been considered to alleviate the inflammatory cytokine response in various models of sepsis. Although being regarded as a key immunomodulator molecule to be beneficial for the treatment of sepsis, recombinant IL-10 treatment is limited by efficacy and tolerability. We tested a novel approach and conducted i.p. liposomal IL-10 gene transfer 24 h before the cecal ligation and puncture in mice and observed 75% mortality at the end of the 7th day. The mortality was 100% in the group where the gene transfer was not performed. The transgene expression is observed mainly in the endothelium in all vital organs. The results demonstrate the advantageous role of de novo IL-10 synthesis in early stages of sepsis and suggest the beneficial impact of gene transfer approach to recombinant protein infusions.

In vivo characterisation of parathyroid lesions by use of gamma probe: comparison with ex vivo count method and frozen section results.

OBJECTIVE: In this study we hypothesized that if timing of gamma probe-guided parathyroidectomy were individualized according to an optimal-time-to-surgery technique, in vivo characterization of parathyroid lesions would be possible. We compared our findings with an ex vivo counting method ("20% rule") and frozen section results. STUDY DESIGN AND SETTINGS: Thirty-five patients who were referred for surgical treatment of hyperparathyroidism were studied. Maximum parathyroid to thyroid sestamibi uptake ratio (UR(max)) was measured by use of preoperative dynamic scintigraphy. The interval between sestamibi injection and UR(max) was defined as the optimal time to surgery. On the day of surgery, the patients received the same dose of sestamibi and were taken to the operating room at UR(max) as determined by preoperative scintigraphy. Intraoperative in vivo gamma probe counts from parathyroid lesions were compared with in vivo contralateral background thyroid counts (in vivo/Bkg) and to ex vivo parathyroid counts relative to postexcision background of the adjacent normal tissue (ex vivo/Bkg). RESULTS: A total of 70 excised lesions were evaluated. In vivo/Bkg counts obtained from parathyroid adenoma were significantly different from parathyroid hyperplasia (z = -3.093, P = 0.002) and other lesions (z = -3.958, P = 0.0001). By receiver operating characteristic curve (ROC) analysis, we found the cutoff value for the in vivo/Bkg counts ratio to be 103% to differentiate parathyroid adenoma from hyperplasia with a sensitivity, specificity, and accuracy of 82.5, 65, and 74.4%, respectively. On the other hand, sensitivity, specificity, and accuracy of the ex vivo/Bkg method to differentiate parathyroid adenoma from hyperplasia with a cutoff value of 34.7 was found to be 70.8%, 60%, and 65.9%, respectively. The difference between the accuracy of these 2 tests was not significant statistically (P = 0.137). Sensitivity of frozen section to differentiate parathyroid adenoma and hyperplasia was 76.2% and 33.3%, respectively. CONCLUSIONS: Patient-specific optimal protocol for timing of sestamibi injection together with in vivo/Bkg method is a useful alternative method in guiding the surgeon to differentiate parathyroid adenoma from parathyroid hyperplasia and other tissues and may help surgeons' decisions during the operation. Combined use of in vivo/Bkg and ex vivo/Bkg methods may give more accurate results than frozen section.

Developing and evaluating professionalism.

Professional behaviour, being one of the domains of professionalism, is an area of medical education that has long been of concern to medical educators. At Hacettepe University, our main goal is to have students become conscious of professional identity, values, responsibilities and the physician-patient relationship. We welcome our new students with an opening ceremony on their first day and two months later, the students start the course called "Health-Illness Concepts and Medical Professional Identity". Students are expected to discuss the subjects given to them as scenarios or arguments. The aim of our study is to determine whether the course leads to a positive change in students' attitudes, indicating the attainment of those attributes that reflect professionalism. On the first and the last days of the course, a questionnaire was delivered to the students. Any positive change in preferences between the two questionnaires is identified as an achievement of that attribute. As a result we found that in all of the seven attributes there were positive changes in the students' attitudes. Positive changes varied from 48% to 84% and all were statistically significant. Using more interactive techniques helped the students to make larger percentage changes in their awareness of these professional attributes.

Training of 'first-aid' trainers: a medical school example in Turkey.

OBJECTIVE: A student-oriented basic life support and first-aid training is practical to enlarge the number of qualified people in the field. In this study, we aimed to describe and discuss the training process of a group of medical students at Hacettepe University, School of Medicine and their assessment as basic life support and first-aid trainers. METHODS: A '6-hour' 'Training the Trainers' course was conducted and participants' demonstration and coaching skills were evaluated by using a 3-point scale (1 - needs improvement; 2 - competently performed; 3 - proficiently performed). In total, 31 students out of 45 volunteers were certified as trainers. RESULTS: All of the students proficiently performed 'explain the aim of the demonstration', 'motivate participants to use checklists', and 'motivate the participants to ask questions' for demonstraton skills. Similarly, they all got the maximum grade for 'answer the questions of the participant', 'discuss the coach role of the participant', 'apply the skills', and 'follow up with the participant by using the checklist' as steps of coaching skills. None of the skills within the checklists needed improvement for any of the candidates. CONCLUSION: Although there are limitations, we hope that our experience of the Training the Trainers course will be useful for readers to highlight the importance of skill-based peer education on a very important public health concern, especially for the developing countries.

Effect of dexamethazone on hepatic vascular response in experimental sepsis.

BACKGROUND: The aim of the present study was to evaluate the effect of dexamethasone-pretreatment on the hepatic artery and portal vein of septic rats, which were generated by lipopolisaccarides (LPS) intraperitoneal injection. METHOD: Thirty-six albino Wistar rats were used and constructed as LPS (n = 12), control (n = 12), dexamethazone-pretreatment (n = 6) and dexamethazone-control (n = 6) groups. Hepatic artery and portal vein rings were excised and placed in Krebs-Henseleit solution. Vessel rings were contracted with phenylephrine adding to the organ chamber in cumulative doses. Then the contraction-response curves were drawn. RESULTS: In the LPS group, phenylephrine evoked contractions were reduced in both hepatic artery and portal vein rings in comparison to the control group. In the dexamethasone-control group, phenylephrine-evoked contractions were increased but not significantly. Dexamethasone-pretreatment increased the phenylephrine-evoked contractions close to the values of control group for both types of rings. CONCLUSIONS: Dexamethasone pretreatment corrected the vascular hyporeactivity to phenyleprine in isolated portal vein and hepatic artery rings prepared from the LPS treated rats in experimental sepsis. This might have occurred as a result of inhibition of inducible nitric oxide synthase expression.

Clinicopathologic and radiopharmacokinetic factors affecting gamma probe-guided parathyroidectomy.

HYPOTHESIS: The kinetics of technetium Tc 99m sestamibi (MIBI) in primary hyperparathyroidism are variable and affected by the cellular size of the abnormal glands, the parathyroid hormone levels, and the functional expression of P-glycoprotein (Pgp). The success of gamma probe-guided parathyroidectomy is closely related to the parathyroid-to-thyroid activity ratio at the time of surgery. Preoperative determination of maximum uptake ratio may improve the surgical outcome. DESIGN: Thirty-one patients with primary hyperparathyroidism attributed to a solitary parathyroid adenoma (27 patients) or multiglandular hyperplasia (4 patients) underwent dynamic MIBI imaging preoperatively. Maximum MIBI activity and activity elimination half-life in the abnormal parathyroid glands and thyroid glands were measured, and the maximum uptake ratio was calculated. After a second MIBI injection on the day of surgery, all patients underwent gamma probe-guided parathyroidectomy and cervical exploration. Timing of surgery after MIBI injection was individualized according to the optimal time to surgery (time to maximum uptake ratio), which was determined by preoperative scintigraphy. During surgery, the gamma probe was used to measure ex vivo counts of excised lesions and adjacent postexcision normal tissue (background). Image characteristics, MIBI kinetics, and gamma probe findings were correlated with gland volume, oxyphil cell content, Pgp expression, and serum parathyroid hormone levels. RESULTS: Probe localization of abnormal glands at maximum uptake ratio was successful in all patients. The volume of the parathyroid lesion ranged from 0.03 to 9.8 mL (median, 0.7 mL). Parathyroid maximum MIBI activity correlated with the volume of the gland (r = 0.54, P = .002) and serum parathyroid hormone level (r = 0.58, P = .001). No correlation between maximum MIBI activity and oxyphil cell content or Pgp expression could be demonstrated. Elimination half-life of MIBI from parathyroid inversely correlated with Pgp (r = -0.36, P = .05). The ex vivo lesion-background count ratio positively correlated with volume of the gland (r = 0.66, P = .001) and parathyroid hormone level (r = 0.48, P = .006). Ex vivo lesion counts and Pgp expression were negatively correlated (r = -0.37, P = .04). CONCLUSIONS: A strong relationship between volume of the parathyroid gland, serum parathyroid hormone levels, and MIBI uptake exists in primary hyperparathyroidism. Gamma probe-guided localization of abnormal gland(s) can be more successful if surgery is undertaken at maximum uptake ratio. High Pgp expression increases MIBI parathyroid clearance rate, decreases gamma probe counts, and may significantly alter the optimal time to surgery.

Lack of association between RNASEL Arg462Gln variant and the risk of breast cancer.

BACKGROUND: The RNASEL G1385A variant was recently found to be implicated in the development of prostate cancer. Considering the function of RNase L and the pleiotropic effects of mutations associated with cancer, we sought to investigate whether the RNASEL G1385A variant is a risk factor for breast cancer. PATIENTS AND METHODS: A total of 453 breast cancer patients and 382 age- and sex-matched controls from Greece and Turkey were analyzed. Genotyping for the RNASEL G1385A variant was performed using an Amplification Refractory Mutation System (ARMS). RESULTS: Statistical evaluation of the RNASEL G1385A genotype distribution among breast cancer patients and controls revealed no significant association between the presence of the risk genotype and the occurrence of breast cancer. CONCLUSION: Although an increasing number of studies report an association between the RNASEL G1385A variant and prostate cancer risk; this variant does not appear to be implicated in the development of breast cancer.

Surgical treatment of hydatid cysts of the liver in the era of percutaneous treatment.

BACKGROUND: Although surgery is the recommended treatment for liver hydatid disease, percutaneous treatment has been introduced as an alternative to surgery. No previous studies have been reported for patients who have not been suitable for percutaneous treatment and undergone surgery. The aim if this study was therefore to evaluate the patients who have liver hydatid disease and not suitable for percutaneous treatment and to determine the effectiveness of different types of surgical interventions in these patients. PATIENTS AND METHODS: Ninety-five patients who underwent operations for liver hydatid disease were retrospectively reviewed. All patients were radiologically evaluated before surgery for possible percutaneous treatment. Besides other related factors, conventional and radical surgical approaches were compared in terms of complication and recurrence rate. RESULTS: Overall complication and recurrence rates were 40% and 25%, respectively. Conventional surgical approaches and common bile duct exploration were significantly associated with an increased complication and recurrence rate. CONCLUSIONS: Selection of simple liver hydatid cysts for percutaneous treatment had led us to operate more difficult and complicated cases. It seems that routine use of endoscopic retrograde cholangiography in the preoperative period and more efforts to perform radical procedures are two major determinants in the successful treatment of theses complicated cases.