Do different abdominal incision techniques play a role in wound complications in patients operated on for gastrointestinal malignancies ? "Scalpel vs. electrocautery".

BACKGROUND: Despite the studies of animals that demonstrate better wound healing after abdominal incisions with the use of a scalpel rather than electocautery, clinical experience does not confirm these findings. The purpose of this study was to compare the early postoperative and late-term wound complication rates between the scalpel and electrocautery in patients with gastrointestinal malignancies undergoing midline abdominal incisions. METHODS: Patients undergoing midline abdominal incisions for gastrointestinal malignancies were randomly divided into two groups according to the method used to perform the incisions: scalpel or electrocautery. Complications were investigated, diagnosed and compared in the early postoperative and late-term follow-up periods. The independent samples, chi-square, and Student's t tests were used for statistical analysis. RESULTS: Two hundred and eighteen patients were included to this study, of whom 97 (44.5%) were in the scalpel group and 121 (55.5%) in the electrocautery group. Both groups were similar with respect to their demographic, operative and postoperative characteristics. The analysis revealed no significant statistical differences in consideration of the incidences of either wound infection in the early postoperative period or incisional hernia in the late-term follow-up period between these two study groups (p > 0.05). CONCLUSIONS: Scalpel and electrocautery are similar in terms of early postoperative and late-term wound complications when used to perform midline abdominal incisions. Therefore, the choice of method remains a matter of the surgeon's preference.

Diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in children and adolescents: experience in a single institution.

INTRODUCTION: Experience in the use of endoscopic retrograde cholangiopancreatography (ERCP) for the investigation and treatment of pancreaticobiliary disorders is relatively limited in children. This report reviews the experience in a single institution with pediatric ERCPs and documents the indications, success rate, diagnostic and therapeutic yields, complications, and the impact on patient management. PATIENTS AND METHODS: The data of all consecutive patients aged < or = 18 years who underwent ERCP procedures between the years 1997 and 2007 were retrospectively identified through a computer database search. The database prospectively recorded the indications, findings, therapies, and complications. RESULTS: During the study period, 32 ERCP procedures were performed in 28 children with a median age of 13 (range 8 - 18) years. ERCPs were performed for biliary pathology in 21 (75 %) and for pancreatic pathology in 7 (25 %) patients. The most common biliary indications were suspected choledocholithiasis and postoperative bile leaks. Hydatid disease was the most common diagnosis that yielded bile leaks. The pancreatic indications were recurrent pancreatitis and traumatic pancreatic duct disruption. Cannulation of the desired duct was successful in all procedures. An endoscopic sphincterotomy, stone/sludge removal or a stent placement was performed in 20 (63 %) procedures. According to the long-term follow-up, avoidance from any further surgical interventions was achieved in 11 (65 %) children, in whom ERCP was undertaken as a therapeutic intervention. The complication rate was 6 % with the development of mild self-resolving pancreatitis in one patient and stent occlusion in another. CONCLUSIONS: ERCP in the pediatric population has a high success rate, both as a diagnostic tool and for therapeutic interventions, provided it is performed by experienced endoscopists. The delicate delineation of the anatomy by ERCP and its therapeutic potential make it absolutely superior to other less invasive tools such as magnetic resonance cholangiopancreatography.

Massive lower gastro-intestinal bleeding due to small bowel diverticula. A report of two cases.

Gastro-intestinal bleeding from the small bowel is a rare entity. It is difficult to determine the source of bleeding because of the unavailability of routine small bowel endoscopy. The most common reasons for bleeding from the small bowel are tumours, arteriovenous malformations and inflammatory bowel diseases. Diverticula of the small bowel are very uncommon. We present two cases of gastro-intestinal bleeding due to small bowel diverticula. Both of them were diagnosed on laparotomy. One had a short segment of small bowel, with six diverticula, which was resected. The second case had a long segment of small bowel with multiple diverticula. This patient was treated by isolating and excising the bleeding diverticulum. Haemodynamically unstable lower gastro-intestinal bleeding mandates exploratory laparotomy. Mesenteric angiography and Tc 99 labelled erythrocyte scintigraphy can detect the bleeding site. Intra-operative endoscopy can be performed safely via an enterotomy and can localize the bleeding site.

Endoscopic diagnosis and management of complications following surgery for gallstones.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is increasingly being performed for therapeutic purposes. This report reviews our experience in an attempt to determine the role and efficacy of ERCP in the management of postoperative complications following surgery for gallstones. METHODS: This study analyzes ERCP records of 418 patients performed in a single referral center after a surgery for gallstones, in the period from December 1991 to June 2000. RESULTS: A total of 451 endoscopic procedures were performed for 418 patients. The primary operations which required ERCP and were included in the study were laparoscopic cholecystectomy (n = 161, 38.5%), choledocholithotomy and T-tube drainage (n = 157, 37.5%), open cholecystectomy (n = 82, 19.6%), choledochoduodenostomy (n = 14, 3.3%), and cholecystostomy (n = 4, 1%). Procedure was carried out successfully in 403 patients (96.4%), whereas a proper endoscopic diagnosis was not achieved in 15 (3.5%). Retained biliary stones (without any associated abnormality) were found in 163 (38.9%), ductal injuries in 44 (10.5%), biliary strictures in 21 (5.0%), papillary stenosis in 36 (8.6%), cystic stump leak (with or without retained stones) in 30 (7.1%), leak from T-tube tract (with/or without retained stones) in 20 (4.8%), and unsuspected malignancies in 18 (4.3%). A sole diagnostic cholangiography was obtained in 63 patients (15.0%). Patients were managed by debris or stone extraction in 169 (40.4%), endoscopic sphincterotomy (ES) in 145 patients (34.6%), stent insertion in 19 (4.5%), or dilatation in 2 (0.4%). Overall successful stone removal rate was 97.4%. Thirty-nine patients with normal cholangiographic findings underwent ES for the relief of presenting signs and symptoms. ERCP-related morbidity was 13.6%. CONCLUSIONS: The need for ERCP is rising, especially for stones retained after cholecystectomies. Endoscopy offers safe and effective methods in the treatment of bile leaks, unless associated with major ductal injuries. ES is a reasonable method for treating papillary stenosis and some post-cholecystectomy pain or symptoms.

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.

False aneurysm of the hepatic artery after laparoscopic cholecystectomy.

PURPOSE: A rare complication of laparoscopic cholecystectomy is defined: iatrogenic injuries to hepatic artery system which may evolve to pseudoaneurysms in the late postoperative period. This rare phenomenon may be overlooked and pose a challenge to surgeons. MATERIAL AND METHODS: We will describe three cases with iatrogenic pseudoaneurysms after laparoscopic cholecystectomy. The onset of symptoms and the course of the disease was not uniform. Diagnosis was made after a considerable delay. In the first case, a small, uncomplicated extrahepatic pseudoaneurysm was successfully treated with coil embolization. The second patient who had an intrahepatic pseudoaneurysm with multiple injuries to the common bile duct and portal vein, did not survive despite surgical and endovascular interventions. In the latter, surgical treatment for a large pseudoaneurysm that had ruptured into the liver parenchyma was successfully conducted. Review of the literature reveals fifty-four more cholecystectomy-related pseudoaneurysms. The site of injury was the right hepatic artery in 61% of the cases and the presenting symptom was upper gastrointestinal bleeding (haemobilia) in two-third of the patients. Embolization was performed in 82% of the cases, and surgery was undertaken in the remaining 18%. CONCLUSION: Pseudoaneurysm is an uncommon complication of laparoscopic cholecystectomy. Prompt attention is necessary since the lesion has a high risk of rupture. Embolization is the first line of treatment and surgery is reserved for more complex injuries and cases with life-threatening rupture of the aneurysm.

A case of protrusion of an intraperitoneal chemotherapy catheter through rectum.

Bowel penetration of an intraperitoneal catheter occurred in a patient who had received a course of uncomplicated intraperitoneal chemotherapy for a persistent ovarian carcinoma. One month after the termination of chemotherapy, she presented with protrusion of a catheter through anus. At operation, the catheter was removed, the rectum was repaired primarily, and a cytoreductive surgery was performed.

[The role of peritoneal lavage in treatment of penetrating abdominal injuries]. / Die Rolle der Peritoneallavage bei der Behandlung der penetrierenden Bauchverletzungen.

Preventing negative laparotomies is one of the most challenging problems in the management of penetrating abdominal injuries. The term "selective laparotomy" has been therefore introduced and has found an ever increasing acceptance. The peritoneal lavage is a useful tool in patient selection for laparotomy but the main problem is where to set the boundary between a positive and a negative peritoneal lavage. The manipulation of this boundary leads to significant changes in the sensitivity and specificity of the peritoneal lavage. Here we are presenting 162 consecutive cases of penetrating abdominal trauma and discussing our methods of evaluation and management.

[Blunt diaphragmatic rupture in children]. / Stumpfe Zwerchfellrupturen im Kindesalter.

The incidence of traumatic diaphragmatic hernia due to blunt trauma, an uncommon injury in children, has been increased with the increase in automobile and pedestrian accidents. During a 5 year period, 9 patients 3-14 years of age, with acutely ruptured diaphragms following blunt trauma were treated in our institution. Diaphragmatic injury was detected within 6 hours of admission to the hospital. In 2 patients the diagnosis was suggested by upright chest X-ray. In the remaining 7 patients, the diaphragmatic ruptures were diagnosed at laparotomy performed for hemiperitoneum diagnosed by peritoneal lavage. At initial evaluation hypotension was present in all but one patient. Intraabdominal organs were herniated through the diaphragmatic defect in 3 patients. All patients had associated extraabdominal injuries and 90% had associated intraabdominal injuries. The diaphragmatic tear was repaired via abdomen in all patients and all defects were closed primarily. The mortality rate was 33.3%. Early deaths were attributable to hemorrhage and severe head injury, the single late death to sepsis and progressive multiorgan-failure.

Mitochondrial lipid peroxides and antioxidant enzymes in colorectal adenocarcinoma tissues.

Lipid peroxide levels and superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), and glutathione transferase (GST) activities were investigated in mitochondrial fractions obtained from tumorous and nontumorous colorectal tissues of fourteen patients with colon and rectum cancer. Histopathological evaluations, including type, stage, necrosis and lymphocyte infiltration were also performed for each patient. The activities of SOD, GSH-Px and GST were increased significantly, but lipid peroxide levels remained unchanged in mitochondria obtained from tumors compared to adjacent normal tissues of subjects with colorectal cancer. When the patients were grouped according to their histopathological evaluation, such as type, stage, necrosis and lymphocyte infiltration, no relationship was observed between the histopathological results and the mitochondrial lipid peroxidation or antioxidant enzyme activities.

Effects of octreotide on healing of intestinal anastomosis following small bowel obstruction in rats.

PURPOSE: Octreotide is an analog of somatostatin, with the same biologic effects but a longer half-life than somatostatin. The purpose of this experimental study was to search the effects of octreotide on the healing of bowel anastomosis and to observe the anatomic and physiologic changes in the obstructed bowel. METHODS: Two groups of ten male Wistar albino rats (average weight, 250 grams) were used in this study. One group was the octreotide group, and the other was the control group. In both groups, the basal diameters of jejunum were measured before ligation of the bowel 20 cm from the duodenum. Octreotide was administered subcutaneously (7 micrograms/kg/day, in two equal doses) in the first group, and the same volume of saline was used in the control group. Diameters of the obstructed segments were measured, and sodium and potassium levels, obtained from the luminal fluid of the obstructed bowel, were recorded 48 hours following the first operation. Dilated segments were resected, and end-to-end intestinal anastomoses were performed. In rats sacrificed on the fourth and seventh days following the second operation, bursting pressures of the anastomotic and hydroxyproline levels in tissue samples taken from the anastomosis were measured. RESULTS: The diameter of the obstructed bowel increased significantly in the control group (P < 0.05). Sodium and potassium losses were significantly less in the octreotide group (P < 0.001 for sodium; P < 0.01 for potassium). In histopathologic examination, ischemic changes were more evident in the control group (P < 0.05). Anastomotic bursting pressure differences were not significant on the fourth postoperative day (P > 0.05), but differences were significant on the seventh postoperative day (P < 0.05). Anastomotic tissue hydroxproline synthesis on the fourth and seventh postoperative days of the octreotide and control groups did not show significant difference (P > 0.05). CONCLUSION: In this experimental model, it appears that octreotide attenuates the ischemic changes and electrolyte losses in the obstructed bowel.

Serum lipids and apolipoprotein concentrations and plasma fibronectin concentrations in renal transplant patients.

In those cases where hypertriglyceridaemia was present before renal transplantation, it persisted after transplantation, and hypercholesterolaemia also developed. We studied serum lipid, lipoprotein, and apolipoprotein concentrations and plasma fibronectin concentrations in 57 renal transplantation patients and 29 healthy controls. We concluded that atherosclerosis in renal transplantation patients might be related to alterations in the constitutions of lipoproteins and apolipoproteins, but fibronectin synthesized by vascular endothelial cells seemed not to be associated with the atherosclerotic process.

[The role of diagnostic laparoscopy in treatment of penetrating injuries of the lower thoracic wall and anterior abdominal wall]. / Die Rolle der diagnostischen Laparoskopie bei der Behandlung von penetrierenden Verletzungen des unteren Brustkorbs und der vorderen Bauchwand.

Penetrating injuries of the lower thoracic wall and anterior abdominal wall cause difficulties in the decision for laparotomy. For gunshot wounds laparotomy without further investigations is in most cases justified, but in other penetrating traumata one should use every diagnostic modality to prevent unacceptably high negative laparotomy rates. We performed diagnostic laparoscopy (DL) on 39 patients with penetrating injuries of the anterior abdominal wall and/or lower thoracic wall. Of these 39 patients, 25 had negative and 14 positive results. We had only one false-negative finding. No false-positive result occurred. We think that DL is a very reliable diagnostic tool which requires a relatively high technology.

[Blunt kidney injuries in children]. / Stumpfe Nierenverletzungen im Kindesalter.

Trauma, primarily due to traffic accidents, is the most common cause of death in childhood. In the context of abdominal trauma, the probability of injuries to urinary organs in children is higher than in adults. Peritoneal lavage and use of the CRAMS scale have proved to be reliable methods for assessment and planning of therapy for traumatised children. When it comes to treatment for splenic rupture, efforts should be made to preserve the greatest possible amount of splenic tissue to prevent post-splenectomy sepsis.

The impact of various suture materials on experimental colorectal carcinogenesis.

Local tumor recurrence following restorative surgery for colorectal cancer may occasionally result from the promotion of a neoplastic lesion in a zone of proliferative instability adjacent to the anastomosis. This study was designed to determine the influence of various suture materials on experimental colorectal carcinogenesis. A total of 72 rats were divided into six groups, four of which were subjected to colotomy and repair using catgut, silk, polyglactin (PG), or stainless steel. The fifth group was given a sham procedure and the sixth group served as a control. Methylnitrosourea was administered rectally to all the animals, at a dose of 4 mg/kg/week for 20 weeks. The mean number of tumors per rat was significantly higher in the PG group than in the other groups. The mean tumor size was found to be significantly larger in each of the suture material groups than in the sham group. A tendency for tumor occurrence to develop at the anastomosis rather than at the other colon sites was seen in the PG group. These results indicate that PG has an adverse effect on local tumor occurrence in experimental colorectal carcinogenesis.

Could honey have a place in colitis therapy? Effects of honey, prednisolone, and disulfiram on inflammation, nitric oxide, and free radical formation.

BACKGROUND/AIMS: The purpose of this study was to investigate the potential therapeutic roles of honey, prednisolone and disulfiram in an experimental model of inflammatory bowel disease. Another aspect of the study was to find out whether these substances have any effect on nitric oxide (NO) and free radical production. METHODS: After the induction of colitis with trinitrobenzene sulfonic acid in 64 male rats, physiological saline, honey, prednisolone and disulfiram enemas were applied to the rats once daily for 3 days (acute treatment groups) or 7 days (chronic treatment groups). Control groups received only saline enemas. Rats were killed on the 4th or 8th days and their colonic mucosal damage was quantitated using a scoring system. Acute and chronic inflammatory responses were determined by a mucosal injury score, histological examination and measurement of the myeloperoxidase (MPO) activity of tissues. The content of malonylaldehyde (MDA) and NO metabolites in colon homogenates was also measured to assess the effects of these substances on NO and free oxygen radical production. RESULTS: Estimation of colonic damage by mucosal injury scoring was found to be strongly correlated with the histologic evaluation of colon specimens. On the other hand, mucosal injury scores were not correlated with MPO, MDA or NO values. There were significant differences between the MPO results of chronic-control and chronic-honey groups, as well as chronic-control and chronic-prednisolone groups (p = 0.03 and p = 0.0007). The acute honey, prednisolone, and disulfiram groups had significantly lower MDA results compared to the acute control group (p = 0.04, p = 0.02, and p = 0.04). In terms of NO, there was no significant difference between the treatment and control groups. NO was found to have a strong relationship with MDA (p = 0.03) and MPO values (p = 0.001). On the other hand, MPO results were not found to be correlated with MDA values (p > 0.05). CONCLUSIONS: MPO activity is not directly proportional to the severity of the inflammation, but it may only determine the amount of neutrophil in the tissues. Inflammatory cells are not the sole intensifying factor in colitis. Therefore, mucosal injury scores may not correlate well with MPO activities. In an inflammatory state NO and MPO levels have a strong relationship, since NO is released from the neutrophils. In an inflammatory model of colitis, intrarectal honey administration is as effective as prednisolone treatment. Honey may have some features in the treatment of colitis, but this issue requires further investigation. Honey, prednisolone and even disulfiram also have some value in preventing the formation of free radicals released from the inflamed tissues. Prednisolone may also have some possible benefits in the inhibition of NO production in colitis therapy.

[Percutaneous endoscopic gastrostomy in the ICU]. / Yogun bakim ünitesinde perkutan endoskopik gastrostomi.

Aspiration pneumonia due to gastroesophageal reflux is a frequent complication in ICU. The most commonly chosen method for long-term enteral access is gastrostomy and this method also reduces the risk of aspiration and shortens the hospital stay. We evaluated 31 patients in whom PEG was performed between 1997-98 in our unit. Indication of PEG was long-term ICU stay and coma which necessitate long term enteral nutrition. Mean age of our patients were 60.5((19.4). We evaluated the aspiration by clinical inspection. Aspiration and interruption of feeding was observed 1.57 ((1.43) times before PEG and 0.67 ((0.73) times after PEG. Further more positive tracheal aspirate culture were seen 3.14 ((1.95) times before PEG and 1.52 ((1.47) times after PEG.