[Factors affecting morbidity in urgent repair of abdominal wall hernia with intestinal incarceration in adults]. / Intestinal inkarserasyon için acil karin duvari fitik onarimi yapilan eriskinlerde morbiditeyi etkileyen faktörler.

BACKGROUND: The aim of this study was to investigate factors that affect morbidity in adults with incarcerated intestinal hernia of the abdominal wall. METHODS: 124 patients with a mean age of 61 ± 13.87 years (73 males) underwent emergency surgery for incarcerated intestinal hernia between March 1999 and March 2008. The median duration of the hernia was 5 years (0.1-30). Type and duration of hernia, accompanying diseases, surgical procedure, and operation-related complications were retrospectively evaluated. RESULTS: Twenty-five patients (20%) had complications. Twelve patients (10%) had surgical site infection and 10 patients (8%) had septic complications. Four patients (3%) died in the postoperative period. Out of 40 patients developing strangulation, 18 underwent bowel resection. The only independent variable concerning bowel resection other than inguinal hernia was found to be ventral hernia (p=0.039). There was no statistical significance between duration of hernia and incarceration and complications. The rate of complications was significantly high in the patients with accompanying diseases (p<0.001). The relation between age and complications was also significant (p=0.034). Multivariate analyses showed high ASA scores as the only independent variable for development of complications (p<0.001). CONCLUSION: Patients with comorbid diseases and high ASA scores should be informed about the elevated risk of complications, and scheduled surgery before the development of incarceration should be recommended.

Traumatic lumbar hernia: report of a case.

Traumatic lumbar hernias are very rare. Here, we present a case of secondary lumbar hernia. A 44-year-old man sustained a crushing injury. On admission, ecchymotic, fluctuating swelling was present on his left flank with normal vital signs. Subcutaneous intestinal segments were revealed at his left flank on abdominal CT. Emergency laparotomy revealed a 10-cm defect on the left postero-lateral abdominal wall. The splenic flexure was herniated through the defect. Herniated segments was reduced, the defect was repaired with a polypropylene mesh graft. There was also a serosal tear and an ischemic area 3mm wide on the splenic flexure and was repaired primarily. The patient had an uneventful recovery. Most traumatic lumbar hernias are caused by blunt trauma. Trauma that causes abdominal wall disruption also may cause intraabdominal organ injury. Abdominal CT is useful in the diagnosis and allows for diagnosis of coexisting organ injury. Emergency laparotomy should be performed to repair possible coexisting injuries.

Effect of manual bowel decompression (milking) in the obstructed small bowel.

BACKGROUND: Mechanical intestinal obstruction is a frequently encountered problem in general surgery. One of the frequently used techniques for surgical decompression, so-called milking, is to caress the intestinal contents cephalad into the stomach or caudally into the colon. The aim of our study was to examine the functional, morphologic, and microbiologic effects of manual bowel decompression (milking) in the obstructed small bowel. METHODS: Six rats in the milking (M) group (obstructed and decompressed manually), 6 in the control (C) group (obstructed only), and 5 rats in the sham (S) group (laparotomy and evisceration) underwent surgery. Muscle contractility, gastrointestinal dye transmission, histopathologic changes of ileum, and bacterial translocation were analyzed. RESULTS: The contractile response of intestinal segments to acetylcholine was significantly less in group M compared with those of groups C and S (P < .05). The maximal contractile response to acetylcholine also was significantly lower in group M (P < .05). There was no statistically significant difference between the groups regarding the sensitivity of cholinergic receptors. Frequency of peristaltic movements, progression of Evans blue dye, histopathologic variables, and the quantitative evaluation (colony-forming units/gram of tissue) of isolated bacteria were not different among the groups. However, Escherichia coli in group M and Klebsiella spp in group S were the main isolated bacteria. CONCLUSIONS: Although it reduces muscle contractility, a milking procedure in an intestinal obstruction model does not cause peristaltic deterioration, histopathologic or inflammatory changes, or alterations in the degree of bacterial translocation.

Laparoscopic management of gallbladder duplication.

Gallbladder duplication is a rare condition. Because laparoscopic cholecystectomy is the primary treatment modality for the diseased single gallbladders, it should be the choice of treatment for double gallbladders. However, preoperative imaging methods may be unsatisfactory for the correct diagnosis. As a result, incomplete resections may be performed. Intraoperative cholangiography should be performed in suspected cases to prevent inadvertent injury to the biliary system. In this report, we present a symptomatic patient with double gallbladders with separate cystic ducts in whom the gallbladders were successfully resected as a single specimen by laparoscopic means. The pitfalls of diagnostic modalities and surgical strategy are discussed in the context of the available literature.

Adhesion molecules as prognostic markers in pancreatic adenocarcinoma.

BACKGROUND AND OBJECTIVES: Pancreatic adenocarcinoma is a highly aggressive cancer with high metastatic potential and therefore, a high mortality rate. Ezrin, radixin, moesin, and E-cadherin are transmembrane glycoproteins that regulate cell motility, migration, and metastasis. In this study, we investigated the relationship of ezrin, moesin, and E-cadherin expression with the clinicopathological features of pancreatic ductal adenocarcinoma. METHODS: Data including demographic features, size and grade of tumor, presence of perineural and lymphovascular invasion, and survival were obtained retrospectively from 46 patient records. RESULTS: No significant correlation was found among ezrin, moesin, and E-cadherin. Significant correlations were found between ezrin and the tomographic size of the tumor (P = 0.034) and resectability (P = 0.052). Moesin-stained tumors were found to have high lymphovascular (P = 0.030) and perineural (P = 0.036) invasion rates and a high histopathologic grade (P = 0.053). E-cadherin staining was correlated with perineural invasion (P = 0.003) but not with lymphovascular invasion (P = 0.334). Only moesin was correlated with survival in resected pancreatic adenocarcinomas and moesin-negative patients had longer survivals compared with moesin-positive patients (P = 0.021). CONCLUSIONS: We could not demonstrate a relation between ezrin and E-cadherin staining with survival. However, we found ezrin to be related to local tumor behavior, and moesin to be a potential prognostic molecule.

Retained surgical sponge (gossypiboma) after intraabdominal or retroperitoneal surgery: 14 cases treated at a single center.

BACKGROUND AND AIMS: The objective of this study was to present the etiology, clinical presentation, diagnosis, and management for 14 cases of gossypiboma [retained surgical sponge (RSS)] treated at a single center and to emphasize the importance of this potential complication. METHODS: Data for 14 cases of RSS treated between January 1999 and December 2004 were retrospectively assessed. The details of preoperative evaluation, demographic features, and operative findings were recorded. Use of, and findings from, abdominal x-ray, ultrasonography, computed tomography, magnetic resonance imaging, and upper-gastrointestinal endoscopy were also noted. RESULTS: In all cases, the RSS was surgically removed. Thirteen of the 14 patients were symptomatic, and the most frequent finding was nonspecific abdominal pain and intestinal obstruction. Four patients required urgent surgery because the sponges were causing intestinal obstruction or intraabdominal sepsis. Based on history, physical examination findings, and diagnostic imaging, RSS was diagnosed preoperatively in five of the patients. Postoperative complications, including surgical site infection and evisceration, occurred in five cases. CONCLUSION: RSS can lead to significant medical and legal problems between the patient and the doctor. RSS may be incorrectly diagnosed preoperatively, which can lead to unnecessary invasive diagnostic procedures and operations. Strict measures must be taken to prevent this complication.

Colonic obstruction due to rectal endometriosis: report of a case.

Although endometriosis is a common disease in women of childbearing age, intestinal endometriosis is unusual and may cause clinically significant complications. We report a 46-year-old woman with rectal endometriosis who presented with intestinal obstruction. She was operated on with a preoperative diagnosis of malignancy. The diagnosis of endometriosis was made only after histological examination of the resected specimen. Intestinal endometriosis has a diverse clinical spectrum, with nonspecific features in many patients. In female patients who have unexplained digestive complaints, endometriosis should also be considered in the differential diagnosis.

A new weighted scoring system for Subjective Global Assessment.

OBJECTIVE: Subjective Global Assessment (SGA) is a widely used and validated method for identifying and classifying malnutrition. Recently, in effort to assess nutritional status more accurately, quantitative systems have been devised in which scores are assigned for items or components of the SGA. In addition to validation of conventional SGA in our patient population, this prospective study investigated the association of a recently devised quantitative SGA (Q-SGA) method and an invented modified Q-SGA (MQ-SGA) scoring system with conventional SGA. METHODS: A total of 2197 patients was evaluated. Each subject was assessed for malnutrition by SGA, anthropometric measurements, and laboratory testing. The items of SGA were scored by assigning 1 point for each increasing severity level to obtain the Q-SGA score. In the invented MQ-SGA system, the items were entered into the logistic regression model and weighted scores were calculated according to the weighted effect of the SGA items. The efficiencies of Q-SGA and MQ-SGA were compared to predict malnutrition according to SGA. RESULTS: Eighty-nine percent of patients were classified as well nourished according to conventional SGA, whereas 27 patients (1.2%) were classified as severely malnourished. When patients were grouped according to binary SGA outcome (well nourished versus malnourished), receiver operating characteristics curve areas for the Q-SGA and MQ-SGA scores were 0.897 (95% confidence interval = 0.875-0.919) and 0.952 (95% confidence interval = 0.939-0.964), respectively. The cutoff points for Q-SGA and MQ-SGA were identified as 10 and 18, respectively. Although the sensitivity of these systems in identifying malnutrition were similar (90.0% and 90.9%, respectively), the specificity of MQ-SGA was greater than that of Q-SGA (85.6% versus 67.0%). CONCLUSIONS: The findings suggest that MQ-SGA outperforms Q-SGA in identifying malnutrition according to SGA. Future nutrition scoring studies need to take into account the weighted effects of items on outcome.

Laparoscopic repair of bilateral morgagni hernia.

Morgagni hernias are rare and comprise approximately 3% of the congenital diaphragmatic hernias that are observed in 1 in 4800 live births. A 50-year-old female patient who complained of nonspecific chest pain radiating to the right arm for approximately 1 year presented. Chest x-ray revealed a right-sided paracardiac mass diagnosed Morgagni hernia by computerized tomography of the thorax. Laparoscopic exploration showed that the retrosternal hernia was actually a bilateral one. After reducing the contents of the hernial sacs, the defects were closed as a single defect with hernia stapler starting from each end and an appropriate sized polyprolene mesh was closed over the repair site. The patient did not have any symptoms of recurrence after 3 months. Recent advances in video-endoscopic surgery made it possible to perform repairs of these hernias less traumatic and more comfortable to the patients than the conventional transabdominal or transthoracic methods.

The effect of tissue adhesive, octyl-cyanoacrylate, on the healing of experimental high-risk and normal colonic anastomoses.

BACKGROUND: Tissue adhesives may be advantageous over sutures in colonic anastomoses because they do not result in potentially dangerous tight tissue approximation. METHODS: Ninety male Wistar-albino rats were used in the study. Excluding the 10 animals that constituted the control, the rest of the animals were divided in two groups: normal (N) and high-risk (HR). Only resection and anastomosis were done on half of the animals in each group. Octyl-cyanoacrylate was applied on the anastomosis of the other half of the groups. Anastomotic assessment was done at the third and seventh postoperative days. Gross anastomotic healing, mechanical strength, hydroxyproline deposition, and histopathological healing indices were used for the assessment. RESULTS: There was no difference in the third day and the seventh day groups regarding the gross healing parameters and hydroxyproline concentration. Similarly there was no difference between the third day groups in terms of mechanical healing (P = 0.669). However, the mechanical strength of the anastomosis assessed the seventh postoperative day was lower in groups in which octyl-cyanoacrylate was applied (P <0.001). Furthermore, inflammatory reaction, presence of necrosis, peritonitis, and exudate was pronounced in groups in which octyl-cyanoacrylate was applied. CONCLUSIONS: Application of octyl-cyanoacrylate to both normal and high-risk colonic anastomosis does not provide any benefit over conventional suturing at the early phase of the healing. However, octyl-cyanoacrylate seems to be detrimental at the late phase of the healing probably due to the ongoing intense inflammatory reaction.

Effect of drainage on postoperative nausea, vomiting, and pain after laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy is associated with a high incidence of postoperative pain, nausea, and vomiting. Pneumoperitoneum created during the operation and residual gas after the operation are two of the factors in postoperative pain and nausea. We studied the effects of a subdiaphragmatic gas drain, which is intended to decrease the residual gas, on postoperative pain, nausea, and vomiting after laparoscopic cholecystectomy. PATIENTS AND METHODS: Seventy patients were randomized into two demographically and clinically comparable groups: drainage and control. Postoperative pain, nausea, and vomiting were measured by verbal grading and visual analog scale 2-72 h postoperatively. Analgesic and antiemetic use and incidence of retching, vomiting and other complaints were also recorded. RESULTS: Subdiaphragmatic drain effectively reduced the incidence and amount of subdiaphragmatic gas bubble. The incidence and severity of nausea was lower in the drainage group at 72 h. Although severity of pain was lower at 8 and 12 h in the drainage group, the difference was not significant. There was also no difference between the groups in regard to analgesic and antiemetic use. CONCLUSIONS: Subdiaphragmatic drain offers only minor, if any, benefit on postoperative pain, nausea, and vomiting after laparoscopic cholecystectomy, and this effect is probably clinically irrelevant.

[Intraabdominal and intramural hemorrhage due to warfarin therapy]. / Warfarin'e bagli gelisen karin içi ve barsak duvari kanamalari.

BACKGROUND: The study investigated clinical, radiological findings and treatment methods used in patients who developed intraabdominal hemorrhage due to chronic warfarin use. PATIENTS AND METHODS: Eight patients receiving warfarin for cardiac valve replacement, pulmonary thromboemboli, and atrial fibrillation were admitted to our hospital. The patients had abdominal pain, nausea, and vomiting although there was no hematemesis and melena. RESULTS: Abdominal ultrasonography and computerized tomography identified the individuals' problems as intraabdominal hemorrhage (n=2), intestinal intramural and intraabdominal hemorrhage (n=2), bleeding into the sheath of the rectus abdominus muscle (n=1), subcapsular splenic hemorrhage (n=1), and bleeding due to ruptured ovarian cyst (n=2). CONCLUSIONS: Clinicians must be alert for intraabdominal bleeding in patients who are prescribed warfarin treatment. Abdominal ultrasonography and computerized tomography should be used to investigate all such cases of suspected hemorrhage. Blood and plasma replacements are first line of supportive treatment and surgery should be avoided if possible.