The relationship between patellar volume and trochlear volume in patients with patellofemoral instability.

AIM: To investigate a possible relationship between both the volume and morphology of the patella and the volume of the trochlea in trochlear dysplasia (TD). MATERIALS AND METHODS: Eighteen patients with TD and 18 controls were evaluated retrospectively in two groups using computed tomography (CT). Patellar morphology was evaluated with the standard measurement methods described in the literature. Additionally trochlear sulcus volume (TV) and patellar volume (PV) were measured quantitatively using the three-dimensional volume-rendering method. The relationship between patella dimensions and volume and trochlea volume was evaluated. RESULTS: The length of the medial patellar facet (lMP), patellar width (PW), TV and PV were significantly lower in the patient group. When compared according to Dejour types, PW was statistically significantly lower than the control group in those with high-grade and those with low-grade dysplasia. A positive correlation was found between the TV and PV in both groups (patient group: r=0.583 p=0.011; control group: r=0.485 p=0.042). CONCLUSIONS: PV and the TV are related. Therefore, PV can be used as a determining parameter in the evaluation of TD. This technique can also be used for prosthesis construction and more accurate surgical planning.

Posterior fixation of type IV humeral capitellum fractures with fully threaded screws in adolescents.

PURPOSE: Humeral capitellum fractures comprise approximately 1% of all elbow fractures. In this study, we examined the clinical, radiographic, and functional outcomes following operative stabilization of Bryan and Morrey type IV fractures of the capitellum in adolescents. We applied headless cannulated screws in a posteroanterior direction without damaging the articular cartilage surface of the fractures. METHODS: Eight adolescent patients (six male, two female) with a mean age of 15 ± 2.1 years (range 13-18 years) were treated for type IV (McKee) humerus capitellum fractures. In the preoperative radiological evaluation, anteroposterior and lateral radiographs and computed tomography (CT) images were performed. A lateral surgical approach was used, and cannulated fully threaded headless screws were applied in a posteroanterior direction as fixation materials in the fracture reduction. The Mayo Elbow Performance Score was used in the evaluation of elbow joint functions. RESULTS: Patients were followed up for a mean of 24.6 months. Fracture union was achieved at a mean of 5 ± 0.92 weeks (range 4-6 weeks). The mean elbow extension flexion arc was 135° ± 13.47° (range 110°-150º) and the mean pronation supination arc was 156° ± 4.43° (150°-160°). In one patient, there was nonconformity in the humerus trochlea and in another patient, there was keloid formation on the surgical scar. All patients attained excellent results according to the Mayo Elbow Performance Score. CONCLUSIONS: In the treatment of type IV capitellum fractures in adolescents, open reduction with a lateral surgical approach and fixation using posteroanterior directed, cannulated, fully threaded, headless screws is a reliable method to achieve a pain-free functional elbow joint.

Promoter hypermethylation-mediated down-regulation of RUNX3 gene in human brain tumors.

BACKGROUND: The Runx family proteins, including RUNX3, are tissue-restricted transcription factors and play role in neuronal development and tumorigenesis. RUNX3 has an important role in glioblastoma (GBM) tumorigenesis because of its promoter hypermethylation. AIM: We aimed to evaluate the methylation-mediated expression regulation of RUNX3 gene in brain tumors. PATIENTS AND METHODS: Cases of meningiomas WHO grade III (3), anaplastic astrocytomas (3), diffuse astrocytoma (3), and GBM (12) were recruited into this study. Real-time quantitative PCR was performed for analyses of DNA promoter methylation and analyses of methylation-mediated expression status of RUNX3 gene was performed by real-time quantitative RT-PCR. RESULTS: There was no significant difference between methylated and unmethylated quantitative ratio of RUNX3 gene promoter region and also no significant difference in relative ratio of RUNX3 gene expression in brain tumor groups. Methylated and unmethylated ratio in anaplastic astrocytoma, diffuse astrocytoma, GBM, meningioma (WHO grade III) and in all groups were; 1.44, 1.09, 1.51, 1.52 and 1.43, respectively. One allele was found methylated necessarily. No methylation was detected in one case of GBM group and one case of anaplastic astrocytoma group. There was no unmethylated promoter in one of the GBM cases. There were significant differences between relative ratio of RUNX3 gene expression and methylated/unmethylated ratio rates for all cases (p = 0.001) and GBM groups (p = 0.041). CONCLUSION: This study overemphasized the RUNX3 gene importance in brain tumors, due to the existence of at least one methylated allele.

miR-17 in imatinib resistance and response to tyrosine kinase inhibitors in chronic myeloid leukemia cells.

PURPOSE: In this study we examined the expression levels of miR-17 which possesses oncogenic activities through downregulation of CDKN1A, p21 and E2F1 tumor suppressor genes, in imatinib sensitive and resistant chronic myeloid leukemia (CML) cells. On the other hand, we also determined the expression levels of miR-17 in response to tyrosine kinase inhibitors imatinib, nilotinib and dasatinib used for the treatment of CML. METHODS: The expression profiles of miR-17 were analysed by Stem-Loop reverse transcription (RT) polymerase chain reaction (PCR). RESULTS: The results revealed significant increase in the expression levels of miR-17 in imatinib sensitive and resistant cells compared to peripheral blood mononuclear cells (PBMCs). On the other hand, significant decrease was observed in miR-17 levels in response to imatinib, nilotinib and dasatinib. CONCLUSION: These results may imply that miR-17 can be used for diagnosis and treatment of CML.

Association of osteopontin and tumor necrosis factor-α levels with insulin resistance in obese patients with obstructive sleep apnea syndrome.

OBJECTIVE: The aims of this study were to compare the tumor necrosis factor (TNF)-α and osteopontin levels, to identify the relationship between insulin resistance (IR) and osteopontin levels in obese patients with and without obstructive sleep apnea syndrome (OSAS). METHOD: The study population included 62 obese patients (35 males, 27 females) with OSAS and was compared with 26 obese patients (16 males, 10 females) without OSAS as a control group. Polysomnographic evaluation, spirometric tests and arterial blood gas sampling were performed on the obese patients with OSAS. Plasma levels of TNF-α and osteopontin were measured by enzyme-linked immunosorbent assays during the process. IR was estimated using the homeostasis model assessment (HOMA). RESULTS: Mean plasma levels of fasting glucose, insulin, HOMA, liver function test, hematocrit, leukocyte, TSH, free T4, fibrinogen, TNF-α, and osteopontin were similar in the 2 groups. In patients with OSAS, mean osteopontin levels were positively correlated with mean fasting insulin levels (r=0.306, p=0.01), HOMA (r=0.299, p=0.01), apnea-hypopnea index (r=0.377, p=0.03) and Epworth Sleepiness Scale (r=0.299, p=0.01). However, mean TNF-α levels were negatively correlated with Epworth Sleepiness Scale (r=-0.298, p=0.01) in the patients with OSAS. CONCLUSIONS: It was observed that TNF-α and osteopontin levels showed no difference between obese patients with and without OSAS. However, osteopontin levels increased with fasting insulin, IR, OSAS severity, and daytime sleepiness.

Methylation of the p16INK4A promoter is associated with malignant behavior in abdominal extra-adrenal paragangliomas but not pheochromocytomas.

Pheochromocytomas and abdominal extra-adrenal paragangliomas are related to endocrine tumors of the sympathetic nervous system. Studies in animal models have shown that inactivation of the products of the cyclin dependent kinase inhibitor 2A (CDKN2A) gene locus, p16INK4A and p14ARF, promotes the development of pheochromocytoma, especially in malignant form. The present study evaluated the involvement of CDKN2A in human pheochromocytomas and abdominal extra-adrenal paragangliomas from 55 patients. Promoter methylation was assessed using quantitative Pyrosequencing and methylation-specific PCR, and mRNA expression was measured by quantitative real-time PCR. For p16, western blot analysis and sequencing were also performed. succinate dehydrogenase complex subunit B (SDHB) sequencing analysis included extra-adrenal paragangliomas, all tumors classified as malignant, and cases diagnosed at 30 years or younger. The p16INK4A promoter was heavily methylated in a subset of paragangliomas, and this was significantly associated with malignancy (P<0.0043) and SDHB mutation (P<0.002). p16INK4A mRNA expression showed moderate suppression in malignant cases (P<0.05). In contrast, very little p14ARF promoter methylation was seen and there was no significant difference in p14ARF expression between tumors and normal samples. The p16 protein expression was reduced in 16 tumors, and sequence variations were observed in four tumors including the missense mutation A57V and the single nucleotide polymorphism (SNP) A148T. The results suggest that p16INK4A, and not p14ARF, is a subject of frequent involvement in these tumors. Importantly, hypermethylation of the p16INK4A promoter was significantly associated with malignancy and metastasis, and SDHB gene mutations. This finding suggests an etiological link and could provide a clinical utility for diagnostic purposes.

Laparoscopic myotomy for oesophageal achalasia--adding an antireflux procedure is not always necessary.

Laparoscopy is the access of choice for functional surgery of the gastroesophageal junction, and oesophagocardiomyotomy, as the conventional surgical treatment of achalasia, is one of the favourable indications for laparoscopic surgery. Laparoscopic anterior myotomy technique is highly effective and secure for relieving dysphagia with minimal risk of gastroesophageal reflux. Fifteen patients with the diagnosis of achalasia were treated with laparoscopic anterior face oesophagocardiomyotomy without a concomitant antireflux procedure. There was not any perioperative complication and no procedure was converted to open operation. Oesophageal cineradiography, manometry and 24-h pH monitoring were repeated postoperatively. Manometry showed a significant reduction of the resting tone (48-34.4 to 18-3.2 mmHg), and patients were free of symptoms for reflux and dysphagia at the follow-up between 8 and 96 (median 42) months. Only one patient needed pneumatic dilation, 1 year after the operation for mild dysphagia, and one patient had moderate reflux, which was managed by medication. Thanks to minimal invasive technique of laparoscopic surgery and intraoperative endoscopy, oesophagocardiomyotomy can safely be performed in a length needed without dividing lateral and posterior phrenoesophageal ligamentous attachments. Consequently, adding an antireflux procedure routinely is not necessary. We advocate laparoscopic anterior oesophagocardiomyotomy alone as the first-line treatment for achalasia.

Vagotomy without gastric drainage laparoscopic or thoracoscopic approach.

BACKGROUND/AIMS: This article describes the surgical techniques and preliminary results of a prospective trial of videoendoscopic bilateral truncal vagotomy without a drainage procedure in a series of selected patients with chronic non-obstructive intractible duodenal ulcer. METHODOLOGY: Video laparoscopic and videothoracoscopic truncal vagotomy of chronic duodenal ulcer in 32 patients has been successfully performed in the Department of Surgery, Istanbul Medical Faculty Hospital. These patients undergoing bilateral truncal vagotomy (BTV) without a drainage procedure were chosen with selective indication regarding the absence of pyloric obstruction and presence of hyperacidity. Endoscopic pyloric balloon dilatation (PBD) was performed at the same stage with vagotomy only for 20 patients as a prospective trial. The results of acid secretory tests and endoscopic control were studied. RESULTS: All the patients tolerated pure truncal vagotomy well under strict follow-up with semiliquid diet and promotility medication started 24 hours after surgery. The mean decrease in secretory tests for basal acid output (BAO) and peak acid output (PAO) were 70.6% and 79.5%, respectively. Endoscopic controls, 2 months after the operation, showed healing ulcers in patients who were able to be followed-up. One patient who had partial pyloric stenosis and was operated by BTV and PBD, required a drainage procedure in spite of repeated pyloric dilatation. During the mean follow-up period of 26 months (range: 10-46), the only symptom was moderate diarrhea in 4 patients, which became well with medical treatment or spontaneously. CONCLUSIONS: Videoendoscopic truncal vagotomy seems to be an alternative treatment regimen for the management of chronic duodenal ulcer in a group of selected patients, as a simple, surgeon independent and efficient procedure. Instead of routine addition of a drainage procedure after truncal vagotomy, which may improve the morbidity, observation of the patient after truncal vagotomy with dietary caution supplementary to prokinetic medication may be the chosen method in some patients.

Laparoscopic esophagomyotomy without an antireflux procedure for the treatment of achalasia.

Various gastroenteric surgical procedures have been attempted laparoscopically. Laparoscopic esophagomyotomy (LE) with or without fundoplication, performed for achalasia, has gained popularity. In our clinic, LE (Heller's myotomy) was performed on six patients with achalasia. All patients underwent barium esophagography, endoscopy, and esophageal manometry for diagnosis. Extramucosal myotomy was started 6 cm above the cardioesophageal junction on the left anterolateral aspect of the esophagus and continued 1 cm below this area. Endoscopic control of the distal esophageal mucosa and the stomach was carried out under direct laparoscopic visualization following the completion of myotomy during the operation. LE was completed without complication in five patients. In one patient (16%), mucosal perforation occurred after myotomy during endoscopic control and was repaired with endostitches. There were no postoperative complications. The average hospital stay was 3 days. Three of the six patients agreed to 24-h pH monitoring, the results of which showed no evidence of reflux. All patients were completely symptom free in the postoperative period. The average preoperative lower esophageal sphincter pressure was 44 mm Hg, whereas in the early postoperative period and 6 months later, it was 11 mm Hg. There was no dysphagia or reflux esophagitis during the follow-up period (range 12 to 24 months). LE is associated with low morbidity and a high success rate, comparable with an open procedure, and can be done without an antireflux procedure.

Mesh infections after laparoscopic inguinal hernia repair.

Several complications like hematoma and seroma have been reported after laparoscopic inguinal hernia repair (LH). Sepsis due to infection of the patch is an uncommon complication. In this retrospective trial, we evaluated three male patients who developed postoperative mesh infection after LH by transabdominal preperitoneal patch (TAPP) technique in two institutions. Diagnosis was confirmed by clinical symptoms, signs, ultrasonography, and computerized tomography (CT), and definitive treatment was provided by removing the mesh. In the first case, mesh infection occurred 10 months after laparoscopic left inguinal hernia repair with TAPP for recurrence. The infection manifested itself as an external fistula at the drain site. The mesh was removed laparoscopically due to persistent suppuration. In the second case, mesh infection occurred 3 months after transabdominal preperitoneal hernia repair on the left. The patch was removed because of the persistent suppuration despite repetitive drainage and lavage. In the third case, mesh infection occurred in 15 days after transabdominal preperitoneal hernia repair on the right. External drainage was performed under CT guidance, but suppuration could not be stopped. Thus the mesh was removed. In three cases, infection could not be stopped after diagnosis despite drainage and antibiotic coverage, and then it was decided to remove the mesh. The meshes were removed under general anesthesia for the first two cases and under local anesthesia for the third one. During the follow-up period, no recurrences were noted. The mesh infections of these three cases, resistant to conservative treatment methods, completely disappeared after mesh removal.

Video endoscopic truncal vagotomies without gastric drainage.

The authors report 32 patients with chronic duodenal ulcer treated by bilateral truncal vagotomy (BTV) performed via laparoscopy or thoracoscopy. All cases were resistant to medical treatment and chosen with selective indication regarding endoscopic/radiologic and laboratory examination for absence of pyloric obstruction and presence of hyperacidity. Only one patient had partial pyloric stenosis preoperatively due to chronic duodenal ulcer. No drainage procedure was used after BTV, and an endoscopic pyloric balloon dilatation (PBD) was performed at the same time as vagotomy for 20 cases; 12 patients were followed without dilatation as a prospective trial. Semiliquid diet and promotility medication were started 24 h after surgery. All patients tolerated pure truncal vagotomy without any problem, except for two patients: one in whom open drainage procedure was required and one in whom PBD was performed. Basal acid output and peak acid output were measured the day before and 1 week after the operation. A mean decrease of hyperacidity was found: 70.6% for basal and 79.5% for peak acid output. Four patients suffered from moderate symptoms of diarrhea occurring intermittently and responded to medical treatment or recovered spontaneously. Median hospital stay was 4.8 days (range 3-10 days). Endoscopic control performed for 28 patients 2 and 6 months after the operation showed healing of the ulcer. But the patient who had partial pyloric stenosis and was operated on with BTV and PBD required an open drainage procedure (Jaboulay gastrojejunostomy) in spite of repeated PBD. There was no other gastropyloric outlet obstruction in this preliminary study with mean follow-up of 22 months (range 6-42 months).

Video thoracoscopic truncal vagotomies: technique and preliminary results.

BACKGROUND/AIMS: This report presents the technique and preliminary results of a prospective trial of videothoracoscopic bilateral truncal vagotomy without a drainage procedure in a series of selected patients having elective surgery for chronic non obstructive duodenal ulcer. MATERIAL AND METHODS: Videothoracoscopic truncal vagotomy was performed in six patients with chronic duodenal ulcer resistant to medical treatment. These patients undergoing neither a drainage nor a dilatation procedure supplementary to bilateral truncal vagotomy were chosen with selective indication regarding the absence of pyloric obstruction and presence of hyperacidity. The results of acid secretory tests and endoscopic control were studied. RESULTS: A Videothoracoscopic approach to truncal vagotomy was performed simply with a mean operation time of 42 min (35-80) providing all the advantages of minimally invasive surgery such as low morbidity and early recovery. The mean decrease of peak acid output was 77.4% and the ulcer healed without any gastric stasis symptoms or signs as compared with the endoscopic controls at the second month postoperatively. During the mean follow-up period of 26 months (3-38), the only symptom was moderate diarrhea which resolved spontaneously. CONCLUSION: Truncal vagotomy by videothoracoscopy as a simple, surgeon independent and efficient procedure seems to be an alternative treatment regimen for the management of chronic duodenal ulcer in a group of selected patients. Instead of routine addition of a drainage procedure after truncal vagotomy which may improve the morbidity, observation of the patient after truncal vagotomy with dietary caution supplementary to prokinetic medication may be the chosen method in today's circumstances.

[Reconstruction of the hypopharynx and cervical esophagus with free jejunal graft with double pedicle]. / La reconstruction de l'hypopharynx et l'oesophage cervical avec une greffe jéjunale libre à double pédicule.

Free jejunal graft autotransplantation for reconstruction of pharyngoesophageal defects was performed in 27 cases between 1983 and 1990. Of 27 cases, 26 patients who had carcinoma of hypopharynx underwent pharyngo-laryngo-cervical esophagectomy and interposition of free jejunal autograft. In one case who had a small and early-staged carcinoma of the cervical esophagus underwent resection of the cervical esophagus without laryngectomy and free jejunal autotransplantation in order to preserve the continuity of the alimentary tract. In the first 5 cases, the autografts interpositioned in the neck had single pedicle and were revascularized by one artery and vein, like the applications in the literature. Two fistulas and one necrosis were observed in these patients. In the following 22 patients a new model of free graft was applied. Jejunal graft prepared with double pedicles in abdomen was interpositioned in the neck with the microvascular anastomosis of the 4 vessels (two arteries and two veins) belonging to both pedicles. It was observed that the blood supply and vitality of the double pedicled jejunal graft was better comparing to the jejunal graft with single pedicle. Also, the feasibility of +4 degrees C continuous perfusion from the second pedicle protected the grafts from warm ischaemia. Only one case developed a fistula and no necrosis was observed in the 22 cases with double pedicled free jejunal autografts. These results suggested that application of double pedicled jejunal grafts reduces the risk of fistula and necrosis, despite the total operation time is 45-60 minutes longer.

The internal cavoatrial derivation for temporary vascular exclusion of the liver in the dog.

Vascular exclusion of the liver by clamping the hepatic pedicle and inserting an internal cavoatrial shunt allows bloodless hepatic surgery to be performed. The internal cavoatrial shunt performed on 30 dogs was studied to define its optimal hemodynamic characteristics. The internal diameter should measure half the caliber of the inferior vena cava and the total surface of the holes allowing blood flow to the shunt must be three times the internal caliber of the shunt. The aortic clamping associated with the clamping of the hepatic pedicle and the insertion of the internal cavoatrial shunt considerably diminishes the arterial blood pressure variations resulting from the splanchnic stasis. Administration of methylprednisolone (30 mg/kg) at the beginning of the experiment also plays a role in preventing alterations in the small intestine.

[Esophago-jejunostomy at the level of the neck for restoration of continuity in carcinoma of the esophagus (after esophageal resection or for palliative reasons) (author's transl)]. / L'oesophago-jéjunostomie au cou pour le rétablissement de la continuité dans le cancer de l'oesophage (après résection oesophagienne ou à titre palliatif).

A technic of esophago-jejunostomy in the neck is described which uses a Y loop, to which is given a further blood supply through the internal mammary vessels, united to the vessels of the transplanted loop through microsurgical anastomoses. This technic is used either for purely palliative reasons or when the esophageal tumour has become inoperable, or after esophagectomy as a procedure for reconstruction of the digestive tract.