ESTES guidelines: acute mesenteric ischaemia.

PURPOSE: Acute mesenteric ischaemia (AMI) accounts for about 1:1000 acute hospital admissions. Untreated, AMI will cause mesenteric infarction, intestinal necrosis, an overwhelming inflammatory response and death. Early intervention can halt and reverse this process leading to a full recovery, but the diagnosis of AMI is difficult and failure to recognize AMI before intestinal necrosis has developed is responsible for the high mortality of the disease. Early diagnosis and prompt treatment are the goals of modern therapy, but there are no randomized controlled trials to guide treatment and the published literature contains a high ratio of reviews to original data. Much of that data comes from case reports and often small, retrospective series with no clearly defined treatment criteria. METHODS: A study group of the European Society for Trauma and Emergency Surgery (ESTES) was formed in 2013 with the aim of developing guidelines for the management of AMI. A comprehensive literature search was performed using the Medical Subject Heading (MeSH) thesaurus keywords "mesenteric ischaemia", "bowel ischaemia" and "bowel infarction". The bibliographies of relevant articles were screened for additional publications. After an initial systematic review of the literature by the whole group, a steering group formulated questions using a modified Delphi process. The evidence was then reviewed to answer these questions, and recommendations formulated and agreed by the whole group. RESULTS: The resultant recommendations are presented in this paper. CONCLUSIONS: The aim of these guidelines is to provide recommendations for practice that will lead to improved outcomes for patients.

The effects of obstructive jaundice on the brain: An experimental study.

BACKGROUND/OBJECTIVE: The study aims to evaluate the alterations in the brain due to oxidative stress and lipid peroxidation resulting from obstructive jaundice. METHODS: Forty-one Wistar albino rats were used in this study. Simple laparotomy was performed in the sham group (n = 5). In the remaining 36 rats, the common bile duct (CBD) was found and ligated. They were divided into six groups. Group I, Group II, and Group III were sacrificed at the 3(rd), 7(th), and 14(th) day of ligation, respectively. In Group Id, Group IId, and Group IIId ligated bile ducts were decompressed at the 3(rd), 7(th), and 14(th) day, respectively. One week after decompression these rats were also sacrificed and samples were taken. RESULTS: After the CBD ligation, serum levels of bilirubin and malondialdehyde were found to be increased progressively in parallel to the ligation time of the CBD. After decompression these values decreased. In electron microscopy evaluation, the damage was found to be irreversible depending on the length of the obstruction period. In Group II, the damage was mostly reversible after the internal drainage period of 7 days. However in Group III, the tissue damage was found to be irreversible despite the decreased values of oxidative stress and bilirubin. CONCLUSION: Ultrastructural changes in brain tissue including damage in the glial cells and neurons, were found to be irreversible if the CBD ligation period was >7 days and did not regress even after decompression. It is unreliable to trace these changes using blood levels of bilirubin and free radicals. Therefore, timing is extremely critical for medical therapies and drainage.

Effect of erythropoietin on oxidative stress and liver injury in experimental obstructive jaundice.

BACKGROUND: To evaluate the time-dependent effects and pathophysiological mechanism of erythropoietin (Epo) on oxidative stress and liver injury resulting from obstructive jaundice in common bile duct-ligated rats. METHODS: Wistar Albino rats were divided into 5 groups, each including 8 rats. The sham group underwent laparotomy only, while the Non-Epo-3 and Non-Epo-7 groups underwent common bile duct ligation and were sacrificed 3 and 7 days, respectively, after the operation. The Epo-3 and Epo-7 groups underwent common bile duct ligation and Epo treatment and were sacrificed 3 and 7 days, respectively, after the operation. Blood and tissue samples were collected from all groups for the determination of oxidative injury and hepatocellular damage. Serum total and direct bilirubin levels, alkaline phosphatase, reduced glutathione (GSH), nitric oxide (NO), malondialdehyde (MDA) and white blood cell counts were measured. RESULTS: Significantly higher NO and MDA levels were found in Non-Epo groups than Epo groups. Significantly lower GSH levels were found in the Non-Epo-7 group than the Epo-7 and sham groups. Hepatocellular damage was also found to be reduced in Epo groups. CONCLUSIONS: In the present model, while common bile duct ligation increased oxidative injury and hepatocellular damage, treatment with Epo attenuated oxidative injury and hepatocellular damage by decreasing NO and increasing GSH.

New technique for inguinal hernia repair.

We compared a new fascia transversalis based hernioplasty with mesh repair techniques which leave the fascia transversalis intact. We prospectively randomized 180 consecutive patients with inguinal hernia to undergo one of the three hernia repair techniques. Hernias were repaired either by using the new fascia transversalis repair-Coskun's hernia repair (FTR), based on the plication of fascia using continuous sutures and followed by a second layer of interrupted or continuous sutures between inguinal ligament and conjoint tendon to distribute the tension, or one of the two mesh repair techniques: anterior (Lichtenstein) or posterior (preperitoneal) repair. Parameters such as age, sex, hernia cause, operation time, type of anesthesia, surgeon's seniority, complications, hospital stay and follow-up were evaluated. Recurrence rates were determined through clinical examination. Effect of prostatism, co-morbid disease, operation time, complications and Nyhus type of hernia on recurrences were also analysed. Most patients in each group were operated on under general anesthesia (78% vs. 80% vs. 85% for FTR, Lichtenstein, and preperitoneal repair, respectively) and by surgeons in training (average 78%). Patients were followed up for a median of 36 months. FTR had less complications and an acceptable time for operation whereas preperitoneal repairs needed more seniority, longer operation time, and caused more complications. There were only 3 (1.6%) recurrences, none in the FTR group and two the in Lichtenstein group during first postoperative year. There was no recurrence in preperitoneal repair group. All patients with recurrences had an operation time longer than 60 min and were operated on by surgeons in training. Two patients with recurrences had prostatism symptoms and chronic cough. We conclude that the new FTR is as effective as mesh repair (either anterior or posterior) with an acceptable rate of recurrences, fewer complications, and that it can be performed by the surgeons in training.

The evaluation of the peak flow velocity and cross-sectional area of the femoral artery and vein following totally extraperitoneal vs preperitoneal open repair of inguinal hernias.

BACKGROUND: Both totally extraperitoneal (TEP) and preperitoneal (PPOR) approaches involve the placement of prosthetic material preperitoneally. As the prosthetic material overlies the femoral artery and vein, we aimed to assess its effect on the velocity and the diameter of the artery and vein, using colour Doppler ultrasonography in both approaches. METHODS: Eighty patients with unilateral groin hernia were prospectively randomised to have either TEP repair (n = 40) or PPOR (n = 40). All patients underwent colour Doppler ultrasound study 6 months after the procedure, and all patients were followed up for 5 years to evaluate real recurrence rates. RESULTS: Our study revealed that neither mean diameter nor mean flow velocity is changed by the insertion of the mesh preperitoneally. Change was only observed in the peak systolic femoral arterial blood velocity, which was significantly decreased in the PPOR group. We also found that no patient in this study developed a clinically significant deep-vein thrombosis during 6 months of follow-up. CONCLUSIONS: It is concluded that the insertion of a prosthetic mesh during TEP or PPOR does not influence the mean peak flow velocity and the cross-sectional area of the vessels in the inguinal region and can be used safely for open and laparoscopic preperitoneal approaches.

Comparison of the effects of continuous and intermittent portal triad occlusion (PTO) in rats.

BACKGROUND/AIMS: It has previously been shown that prolonged ischemia of the liver had a mortal course and a method of intermittent occlusion of the hepatic pedicle was defined in order to minimize the damage to the liver. The present experimental study aimed to compare the effects of continuous and intermittent occlusion of the hepatic pedicle on the liver by measuring serum lactate, serum MDA malondialdehyde and glutathione levels and by evaluating the histologic changes in the liver tissue. METHODOLOGY: Thirty male Wistar albino rats weighing 300 +/- 50 g were divided into three groups of ten animals. Group 1 underwent a sham operation. Animals in group 2 underwent continuous portal triad occlusion (PTO group) for 30 minutes following laparotomy. The remaining ten animals in group 3 underwent intermittent occlusion consisting of 10 minutes of occlusion followed by 10 minutes of reperfusion for a total period of 30 minutes of ischemia. Blood samples were collected at the 1st and 6th postoperative hour for analytical evaluation. After sacrificing the animals, liver samples were obtained for histologic evaluation. RESULTS: The serum lactate levels were significantly higher in both portal triad occlusion groups than in the control at the 1st hour. While lactate levels also increased at the 6th hour in the continuous PTO group, it decreased to the level of control values in the intermittent PTO group. The difference between continuous and intermittent groups was also significant. Despite the unchanged malondialdehyde levels in the control group, malondialdehyde levels were significantly increased at the first and sixth hour in both PTO groups and the levels were also significantly higher than control values. Malondialdehyde levels of intermittent PTO groups at the first and sixth hour were both significantly lower than continue PTO groups. Whole blood glutathione levels were not changed in control groups with time, levels increased significantly in both PTO groups. Glutathione levels were higher than control values in both PTO groups at the first hour. While it turned to its basal value in intermittent PTO groups at the 6th hour, it was still significantly higher in the continuous PTO group. When both PTO groups were compared, glutathione levels were found to be significantly higher in the continuous group both at the first and sixth hour than in the intermittent PTO group. Histopathologic evaluation also showed that there was less damage in the intermittent PTO group than in the continuous PTO group. CONCLUSIONS: Our results show that continuous portal triad occlusion resulted in significant oxidative stress and cell damage as confirmed by increased serum lactate and blood malondialdehyde levels. The blood glutathione levels are increased due to a greater requirement in response to increased oxidative stress induced by portal triad occlusion. It is also confirmed that intermittent portal triad occlusion is safer as it causes less oxidative stress and cell damage so that its use is strongly suggested whenever portal triad occlusion is required.

Factors influencing mortality in spontaneous gastric tumour perforations.

Spontaneous perforation of gastric cancer is a serious complication with a very high incidence of mortality. In order to evaluate the prognostic factors influencing mortality in patients with gastric tumour perforations and to clarify the optimal surgical treatment, the records of patients at one centre during a 5-year period were evaluated retrospectively. Between 1995 and 2000, 14 patients with perforated gastric cancer were operated on in the Emergency Surgical Unit of a Turkish Hospital. This figure represents 3% of all the patients with gastric cancer who were treated during the same period. The hospital mortality was 36% in patients with perforations. The duration of symptoms suggesting perforation and the presence of pre-operative shock were predictive factors of mortality. It was concluded that those patients with pre-operative shock and delayed diagnosis should be treated with extra caution to decrease mortality. Perforation and peritonitis must be treated initially and elective radical surgery delayed.

Does splanchnic ischemia occur during laparoscopic cholecystectomy?

BACKGROUND: Although it has been been shown that the elevation of abdominal pressure causes splanchnic ischemia, the pathophysiological changes that occur during laparoscopic cholecystectomy are still under investigation. Our aim was to evaluate the changes in nitric oxide (NO), malondialdehyde (MDA), and gastric intramucosal pH (pHi) during laparoscopic surgery to verify whether splanchnic ischemia had occurred. METHODS: Forty patients (11 men and 29 women) scheduled for cholecystectomy were randomly divided to undergo either open (OC) or laparoscopic cholecystectomy (LC). Repeated blood samples were collected for the measurement of NO and MDA concentrations. End-tidal carbon dioxide (ETCO2) levels were measured using a capnograph, and pHi was assessed using a tonometric nasogastric catheter. RESULTS: Although no significant change in pH was observed in the LC group during the procedure, it decreased significantly in the OC group and then returned to normal immediately after the procedure. ETCO2 did not change in the LC group but it increased in the OC group. Although it was not statistically significant, NO concentrations were slightly increased in the LC group. The same magnitude of increase was seen in MDA levels but it was not significant. Neither NO nor MDA levels changed in the OC group. CONCLUSION: LC has no adverse effects on gut perfusion. Even if the abdominal organs are hypoperfused during the procedure, compensates for this hypoperfusion so that it pulsatile NO secretion does not cause any harm. Since LC is a short procedure, the significance of these events for extended procedures still needs to be clarified.

Presentation and outcome of incarcerated external hernias in adults.

BACKGROUND: Incarcerated external hernias are the second most common cause of small-intestinal obstructions. The purpose of this study was to examine the presentation and management of incarcerated external hernia. METHODS: The records of 385 consecutive patients undergoing emergency surgical operation for incarcerated external hernias in a large volume teaching hospital between August 1996 and October 1999 were analyzed. The patients' ages ranged from 15 to 100 years (mean 55.1). There were more men than women (250 and 135, respectively), and 165 (42.9%) patients were over 60 years of age. Inguinal and umbilical hernias were encountered most frequently, in 291 (75.5%) and 48 (12.5%) patients, respectively. The intestine was resected in 53 patients, 31 of whom were over 60 years of age (58.5%). Two hundred fifty-two (84.9%) patients presented 48 hours or more from the onset of symptoms. Significant concomitant diseases were noted in 52 men and 19 women. RESULTS: The overall complication rate amounted to 19.5%, major complications 15.1%. The most serious postoperative complications were pulmonary and cardiovascular. Adult respiratory distress syndrome developed in 10 patients, and congestive heart failure developed in 14 patients. Postoperative mortality was 2.9%. Nine (81.8%) of the dead patients were older than 60. Nine (81.9%) of the dead patients were admitted to hospital more than 24 hours after incarceration. Mortality was high in patients with serious coexisting diseases whereas morbidity was linked with the duration of symptoms prior to admission. CONCLUSIONS: Older age, severe coexisting diseases, and late hospitalization were the main causes of unfavorable outcomes of the management of incarcerated hernias.

Corona mortis: an anatomic study in seven cadavers and an endoscopic study in 28 patients.

BACKGROUND: The corona mortis is defined as the vascular connections between the obturator and external iliac systems. While detailed information on the arterial anastomoses in corona mortis is available, a complete description of the venous system is lacking. Although the tiny anastomoses behind the pubic symphysis between the obturator and external iliac arteries have been described in classical anatomy textbooks, these texts neglect to mention that these anastomoses can be life threatening. Attention needs to be paid to these anastomoses between the arterial and the venous system located over the superior pubic ramus during laparoscopic procedures. METHODS: Fifty retroinguinal regions were dissected in seven cadavers and 28 patients. RESULTS: During the dissections, a venous anastomosis on the superior pubic ramus was a consistent finding in 96% of cases. This vein coursed vertically to the inferior border of the superior pubic ramus and connected to the obturator vein. Accessory branches of the obturator artery were observed in only 8% of the dissections. The tiny connections between the obturator and external iliac arteries are less important, since their diameter is <1 mm. CONCLUSIONS: We have termed the venous connection between the external iliac and obturator veins over the superior pubic ramus "the communicating vein". This structure forms the corona mortis. Surgeons dealing with direct, indirect, femoral, or obturator hernias need to be aware of these anastomoses and their close proximity to the femoral ring. In classical anatomy textbooks, a description of the veins that form corona mortis is found less often than descriptions of the arteries. Since a venous connection is more probable than an arterial one, its importance must be appreciated by surgeons in order to avoid venous bleeding.

Laparoscopic herniorrhaphy: preference rate among surgeons in Ankara, Turkey.

OBJECTIVE: To determine the surgeons' and the surgical residents' choice for inguinal hernia repair. DESIGN: A questionnaire study. SUBJECTS: One hundred and forty two respondents who work in surgical clinics as surgeons or residents. SETTING: University hospitals and non-academic teaching hospitals in Ankara, Turkey. MAIN OUTCOME MEASURE: The preference rates of open and laparoscopic hernia repairs for respondents' own inguinal hernias: "If you had an inguinal hernia, how would you prefer to have it repaired?" RESULTS: Only 14.1% of the respondents preferred a laparoscopic hernia repair. Eight of 63 residents (12.7%) and 12 of 79 surgeons (15.2%) chose laparoscopic technique for their own hernia (p=0.67). Personal laparoscopic herniorrhaphy experience significantly affected the choice. Among 118 respondents who had performed no laparoscopic hernia repair, only 12 (10.2%) preferred laparoscopic technique for their own inguinal hernias, whereas the preference rate rose to 33.3% in other 24 participants who had previously done laparoscopic hernia repair (p=0.03). The only independent variable in multivariate analysis was personal experience on laparoscopic herniorrhaphy (SE:0.33, Wald 11.73, Sig:0.0006). The majority of the respondents who preferred open hernia repair stated that it was a better known technique. Other common reasons for open repair were being better repair and the advantage of local anesthesia. Top three reasons for choosing laparoscopic hernia repair were less pain, short hospital stay and early return to normal activity. CONCLUSION: Majority of surgeons and residents still prefer open hernia repair.

Emergency hernia repairs in elderly patients.

BACKGROUND: Emergency hernia repairs comprise one of the most common procedures performed in elderly patients and also carry a high risk of mortality and morbidity. The aim of this study was to examine the factors that might have an influence on the outcome of emergency hernia repairs in elderly patients. METHODS: A review was made of 189 (120 male and 69 female) patients aged more than 65 years who underwent emergency hernia repair between December 1996 and January 2001 at the surgical emergency unit of our hospital. The patients' ages ranged from 65 to 100 years (mean 72.1). Concomitant diseases were present in 86 (45.5%) patients. Of 189 incarcerated hernias, there were 145 (76.7%) bowel obstructions and 91(48%) strangulations. Necrotic bowel was resected in 36(19%) patients. RESULTS: While overall mortality was 5%, it was found to be 19.4% after bowel resection. Major complications were observed in 48 (25%) patients. Mortality and morbidity were clearly linked with bowel resection. Coexisting cardiopulmonary diseases, misdiagnosis, American Society of Anesthesiologists class, and late admission were also found to be responsible for unfavorable outcomes. CONCLUSIONS: In elderly patients with external hernias early elective surgery should be preferred, and local anesthesia might be the best in order to avoid the increased risks of emergency hernia repairs.

Effect of CO(2) insufflation on bacteremia and bacterial translocation in an animal model of peritonitis.

BACKGROUND: The widespread adoption of the laparoscopic approach has created some concern over the potential for increased risk of bacteremia and sepsis due to increased intraabdominal pressure in patients with intraabdominal infection and peritonitis. This study examines the effect of the CO(2) pneumoperitoneum on bacteremia and bacterial translocation. METHODS: New Zealand white rabbits were assigned into three groups of 10 animals. In group 1, 100 ml of sterile saline was infused into the peritoneal cavity under 10 mmHg CO(2) insufflation for 1 h. Group 2 received 100 ml of saline containing 10(9) CFU/ml (colony-forming units) E. coli strain 0163 and 10 mmHg CO(2) insufflation for 1 h. Group 3 received an identical bacterial inoculum, followed by a 10-cm midline laparotomy. Blood samples were taken for culture by cardiac puncture at various intervals during the experiment. At 6 h after being subjected to the experimental procedures, the rabbits were killed and their organs were cultured quantitatively for translocating bacteria. RESULTS: In group 1, neither blood nor organ cultures were positive, whereas in group 2 all blood cultures became positive in 1 h, and intraperitoneally infused bacteria translocated to the lung and kidney in all rabbits. In group 3, blood cultures became positive in 1 h, all but two of the rabbits had translocated bacteria in their lungs, and kidney samples from two of the rabbits were culture-positive. CONCLUSIONS: Our results indicate that both CO(2) pneumoperitoneum and laparotomy increase the incidence of bacterial translocation from the peritoneal cavity into the bloodstream. Thus, the risk of translocation to extraperitoneal organs such as lung and kidney is increased significantly by laparoscopy. Therefore, laparoscopic surgery should be avoided or used cautiously in the setting of acute peritonitis.

Intra-operative enteroscopy for obscure gastrointestinal bleeding.

Small bowel enteroscopy has been reported useful in the non-surgical evaluation of the small intestine in patients with obscure gastrointestinal bleeding but findings may be limited due to incomplete small bowel intubation and a lack of tip deflection. Intra-operative enteroscopy (IOE) is accepted as the ultimate diagnostic procedure for complete evaluation of the small bowel in these patients. Two patients with obscure gastrointestinal bleeding and deep anemia underwent IOE during surgical exploration. Angiodysplastic lesion with a diameter of 3 cm was found at jejunum in the first patient and segmental jejunal resection was performed. Enteroscopy showed red punctate lesions with a diameter of 1-3 mm located at proximal jejunum and extending to the ileum in the second patient. Total jejunal resection was performed. There was no recurrence of gastrointestinal bleeding during 36 months follow-up.

Laparoscopic versus open appendectomy: prospective randomized trial.

Although classic open surgery is simple, expeditious, and effective, it has some drawbacks, including wound sepsis, delayed recovery, operative difficulties, and possibility of unnecessary appendectomies for false appendicitis. The aim of this study was to assess the applicability and safety of laparoscopic appendectomy (LA) in a prospectively randomized trial. Seventy nonselective patients with suspected appendicitis were randomized to laparoscopic (n = 35, 17 male) or open appendectomy (n = 35, 15 male) and operated on an emergency basis. Operative findings, operating time, postoperative complications, and length of hospital stay were compared. We found that LA is associated with a shorter hospital stay, fewer postoperative complications, and better diagnostic accuracy, and it is recommended as the procedure of choice for the diagnosis and management of acute appendicitis.

Role of technetium tetrofosmin scintimammography in the diagnosis of malignant breast masses and axillary lymph node involvement: a comparative study with mammography and histopathology.

OBJECTIVE: To assess the role of Technetium-99m (99mTc) tetrofosmin scintimammography in the detection of breast cancer and involvement of axillary nodes. DESIGN: Open study. SETTING: General hospital, Turkey. SUBJECTS: 128 women who presented with masses in the breast. INTERVENTIONS: Scintimammography, standard mammography, and either excision or fine-needle aspiration biopsy to confirm the diagnosis. MAIN OUTCOME MEASURES: Sensitivity, specificity, and positive and negative predictive value of scintimammography compared with mammography. RESULTS: Sensitivity, specificity, and positive and negative predictive value (%) of 99mTc scintimammography were 95, 96, 97 and 92, respectively. The corresponding figures for standard mammography were 87, 26, 68 and 52. Scintimammography changed the 34 false positive mammograms into true negatives, at the expense of four false negatives. The sensitivity of scintimammography in detecting axillary lymph node metastases was 72% and specificity 100%. CONCLUSION: Scintimammography with 99mTc tetrofosmin seems to be of value in the detection of breast malignancy and axillary metastases. It may help to avoid unnecessary operations in patients whose mammograms do not give a definite diagnosis.