Clinical determinants of suppurative cholangitis in malignant biliary tract obstruction.

BACKGROUND: The purpose of this study was to find the factors predicting the supurative cholangitis in malignant biliary tract obstruction. METHODS: During the period of 1992-2003, 107 patients were operated on for malignant obstruction of the biliary tract. Obstructions were due to gall bladder cancer (n = 4), cholangiocarcinoma (n = 21) or periampullary tumor (n = 82). Sixteen patients were found to have suppurative cholangitis at laparotomy. Among the patients with suppurative cholangitis, eight were males and eight were females with a mean age of 62 (range 42-85) years. The chi-square analysis and student-t test were employed for correlation of individual risk factors with cholangitis. Stepwise logistic regression analysis was then used to identify independent risk factors. RESULTS: Only seven patients with supurative cholangitis (43.8 %) had the Charcot's triad of symptoms and one had the Reynold's pentad. Six of 16 patients survived postoperatively and were discharged from hospital while nine patients died during the first hospital admission. There were five cases of death due to biliary sepsis, two cases of anastomotic leakage, one acute renal failure, and one case of intra-abdominal hemorrhage and sepsis. Multivariate logistic regression analysis showed that a number of variables can serve as independent predictors of suppurative cholangitis, namely the fever, leukocytosis, high bilirubin level and ERCP performed in preoperative period. CONCLUSION: Identification of these risk factors may be worthwhile in the early diagnosis and treatment of the disease. Fever, high bilirubin level, leukocytosis and ERCP performed in the preoperative period were independently associated with suppurative cholangitis (Tab. 3, Ref. 20).

Reasons patients present to the emergency department might change during epidemics and be a valuable component of a disease surveillance system.

We hypothesize that the frequency of reasons patients present to the emergency department will change during epidemics and might be a valuable component of a disease surveillance system. We found support for this hypothesis over a two-year period with high frequency days of fever clustering during two periods of increased hospital influenza activity, but not during any other period during the two-years. This methodology appears to be superior to the previous use of triage nurses defining patients with symptom complexes. Such a system could result in online monitoring, be independent of the medical personnel (use of admission secretary), and might be able to identify various epidemics including increased hospital disease activity due to bio-terror attacks, influenza, and food poisoning. This would have important implications for limiting the spread of disease and for the acute planning of distribution of medical resources. Studies are warranted in various settings to determine whether or not changes in the daily frequencies of reasons patients present to the ED will allow identification of epidemics.

Intrabiliary rupture of a hepatic hydatid cyst: associated clinical factors and proper management.

HYPOTHESIS: The prediction of an intrabiliary rupture of a hepatic hydatid cyst using associated clinical factors is important for early diagnosis and proper management. DESIGN: Case series of patients with hepatic hydatid cysts treated between January 1, 1992, and January 1, 2000, in a single institution. SETTING: A tertiary care teaching hospital. PATIENTS: The clinical findings in 116 patients with a hepatic hydatid cyst were reviewed. Of the 116 patients, 24 (21%) had a cyst-biliary communication: 15 (13%) had an occult rupture, and 9 (8%) had a frank rupture. MAIN OUTCOME MEASURES: The following variables were analyzed as potential predictors of an intrabiliary rupture: age, sex, type and duration of symptoms, findings on physical examination, leukocyte count, liver function test results, serologic test results, suggestive ultrasonographic findings, ultrasonographic cyst features (type, diameter, number, and localization), and whether the cyst is primary or recurrent. RESULTS: The independent clinical factors for the presence of an occult rupture were a history of nausea and vomiting (P = .004), alkaline phosphatase level greater than 144 U/L (P = .004), total bilirubin level greater than 0.8 mg/dL (>13.5 micromol/L) (P< .001), and cyst diameter greater than 14.5 cm (P< .001) in multivariate analysis. Multivariate analysis also showed that history of jaundice (P< .001), jaundice found on physical examination (P = .05), cyst diameter greater than 10.5 cm (P = .009), a type IV cyst (P< .001), and suggestive ultrasonographic findings (P< .001) were the independent clinical predictors for the presence of a frank intrabiliary rupture. Patients with cyst-biliary communications had increased morbidity rates (13 [54%] of 24 patients vs 13 [14%] of 92 patients; P< .001) and longer mean postoperative hospital stays (13.7 vs 9.4 days; P = .03) compared with others. CONCLUSION: Clinical predictors should be considered for early diagnosis and proper management of intrabiliary ruptures in patients with hepatic hydatid cysts.

Urinary retention after elective cholecystectomy.

BACKGROUND: There are few reports about urinary retention rate after elective cholecystectomy. We designed a prospective study to assess the problem. METHODS: A total of 121 female and 19 male patients were included in the study with a prospective study protocol. Laparoscopic cholecystectomy was performed in 107 patients and open cholecystectomy in 33 patients. RESULTS: Neither gender nor age affected rate. Postoperative micturition difficulty developed in 10 patients. Of these patients, 9 could void with helping measures, and only 1 needed catheterization. Only 1 patient who underwent laparoscopic surgery required catheterization (0.7%). The open approach caused a higher incidence of postoperative micturition difficulty than did the laparoscopic approach (15.2% versus 4.7%; P = 0.04). Only large amounts of perioperative fluid administration and meperidine use had statistically significant effects on micturition problems. CONCLUSIONS: Urinary retention is a rare complication after elective cholecystectomy. Helping measures are very effective and should be tried before inserting a urethral catheter.

A risk score for conversion from laparoscopic to open cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy has become the standard operative procedure for cholelithiasis, but there are still some patients requiring conversion to open cholecystectomy mainly because of technical difficulty. Our aim was to develop a risk score for prediction of conversion from laparoscopic to open cholecystectomy. METHODS: Preoperative clinical, laboratory, and radiologic parameters of 1,000 patients who underwent laparoscopic cholecystectomy were analyzed for their effect on conversion rates. Six parameters (male sex, abdominal tenderness, previous upper abdominal operation, sonographically thickened gallbladder wall, age over 60 years, preoperative diagnosis of acute cholecystitis) were found to have significant effect in multivariate analysis. A constant and coefficients for these variables were calculated and formed the risk score. RESULTS: Overall 48 patients required conversion to open cholecystectomy (4.8%). These patients had significantly higher scores (mean 6.9 versus -7.2, P <0.001). Increasing scores resulted with significant increases in conversion rates and probabilities (P <0.001). Ideal cut-off point for this score was -3; conversion rate was 1.6% under -3, but 11.4% over this value (P <0.001). CONCLUSIONS: Conversion risk can be predicted easily by this score. Patients having high risk may be informed and scheduled appropriately. An experienced surgeon has to operate on these patients, and he or she has to make an early decision to convert in case of difficulty.

A prognostic score for gastric cancer.

BACKGROUND: Scoring systems are generally used for predicting prognosis in the intensive care unit, but there is no score being used frequently for predicting prognosis in gastric cancer. The aim of this study was to develop a prognostic score for gastric cancer patients. METHODS: Demographic, clinical, laboratory, radiologic, histopathologic data, and operative findings for 128 patients who had curative or palliative resection for gastric cancer were analyzed for their effect on overall and disease-free survival. Ten variables-invasion depth of tumor, node status (American Joint Committed on Cancer, 1992), metastasis, node status (Union Internationale Contre le Cancer, 1997), metastatic lymph node ratio, resectability, tumor location, extent of lymphadenectomy, Borrmann type, Lauren type-that have independent significant effect or borderline significance on both overall and disease-free survival according to multivariate analysis were chosen. Coefficients were calculated for these variables by using Cox regression analysis, and thus the Prognostic Score for Gastric Cancer (PSGC) was designed. All patients were scored using the PSGC and also staged clinically (AJCC 1992) and histopathologically (AJCC 1992 and UICC 1997). RESULTS: Patients were grouped according to their scores: group 1, patients with scores 20 to 50 (probability of 5-year overall survival 50% to 95%); group 2, patients with scores 51 to 80 (probability of 5-year overall survival 10% to 50%); and group 3, patients with scores 81 and higher (probability of 5-year overall survival <10%). Overall survival and disease-free survival decreased significantly with increasing scores. The association of PSGC and staging systems with survival was analyzed by stepwise logistic regression and Cox regression analyses. PSGC was proved to have the most significant association with overall and disease-free survival. CONCLUSIONS: Inclusion of more variables in PSGC seems to make it superior than staging. It is easy to adapt PSGC to different patient populations, which may make it accepted as a practical and useful scoring system in clinical practice.

Management of main bile duct injuries that occur during laparoscopic cholecystectomy.

The introduction of laparoscopic cholecystectomy in surgical practice resulted with an increased incidence of bile duct injuries and required new classification systems. This article presents six cases of major bile duct injuries that occurred in our first 1,000 laparoscopic cholecystectomies. Four female and two male patients (ages, 36-71 years) were detected to have major bile duct injuries. Laparoscopic dissection was difficult because of acute inflammation in four patients and fibrosis in two patients. These six cases were between laparoscopic cholecystectomies 26 and 377 performed by the operating surgeons. Three of the patients had type E2 injury according to the Strasberg classification: one detected intraoperatively and the other two postoperatively. All were treated with Roux-en-Y hepaticojejunostomy. The other three patients had type D injuries: two realized intraoperatively and one postoperatively. Two of these injuries were repaired primarily over a T-tube. The remaining patient, whose injury was realized intraoperatively, underwent nasobiliary drainage postoperatively. Only one patient had a complication associated with a trocar injury to the liver parenchima during the first operation. A hepatic abscess and external biliary fistula developed, which were treated conservatively. At this writing, all the patients are well and without problems after 2.5 to 6 years of follow-up evaluation. Difficulties in laparoscopic dissection because of severe inflammation or fibrosis resulted in injuries to our patients. We can underscore the fact that experience may not always protect from complications, and that conversion to laparotomy might have prevented some of these injuries. Patients with a minor injury and a controlled leak can be treated by a combination of surgical and endoscopic or radiologic techniques. The treatment plan must be individualized for every patient, depending on the injury type, presentation, and condition of the patient.

Practical recommendations for the prediction and management of common bile duct stones in patients with gallstones.

BACKGROUND: Approximately 10% of patients with symptomatic gallstones may have associated common bile duct stones (CBDS). However, the predictive value of noninvasive tests as well as the preoperative diagnosis and management of CBDS have not been well defined. The aim of this study was to define an accurate and simple model for the prediction and management of CBDS. METHODS: A prospective database containing 986 cholecystectomies performed from 1994 through 1999 was evaluated. Univariate analysis using the Pearson chi-square test was performed to determine the factors significantly related to the presence of CBDS. Then logistic regression analysis was performed for multivariate analysis to discover independent predictors. RESULTS: Of the 986 patients in this study, 48 (5%) had CBDS. Of the 48 patients with choledocholithiasis, 22 (46%) were men and 26 (54%) were women. The mean age was 55.3 years (range, 16-87 years). As a result of multivariate analysis, abdominal ultrasonographic findings suggestive of CBDS (common bile duct diameter exceeding 8 mm or visible stones), total bilirubin, and gamma glutamyl transpeptidase levels above normal were the independent predictors of CBDS in patients age 70 or younger. On the other hand, an elevated bilirubin level was found to be the single independent factor related to CBDS in the elderly. CONCLUSIONS: For patients with gallstones, suggestive ultrasonographic findings in those younger than 71 years and elevated direct or total bilirubin level in those older than 70 years are the most valuable and practical predictors of CBDS, and thus are the proper indications for preoperative endoscopic retrograde cholangiography.

Risk factors resulting in conversion of laparoscopic cholecystectomy to open surgery.

BACKGROUND: Laparoscopic cholecystectomy has become the standard treatment for symptomatic gallbladder diseases. However, there still is a substantial proportion of patients in whom laparoscopic cholecystectomy cannot be successfully performed, and for whom conversion to open surgery is required. METHODS: In this study, 1,000 laparoscopic cholecystectomies performed at Ankara Numune Hospital, Fourth Department of Surgery, from March 1992 to July 1999 were prospectively analyzed. The patients studied included 804 women (80.4%) and 196 men (19.6%) with a mean age of 43.8 years (range, 30-80 years). From the data collected, only factors available to the surgeon preoperatively were considered for analysis. These factors included age, gender, history of acute cholecystitis, jaundice or pancreatitis, previous abdominal surgery, obesity and concomitant disease, white blood cell (WBC) count, preoperative liver function tests, ultrasound findings of the gallbladder, preoperative endoscopic retrograde cholangiopancreatography (ERCP), and suspicion of common bile duct stones. Also we analyzed the case numbers as a measure of institutional experience. RESULTS: Of the 1,000 patients in whom laparoscopic cholecystectomy was attempted, 48 (4.8%) required conversion to open surgery. The most common reason for conversion was inability to define anatomy in patients with inflamed contracted gallbladder (n = 34). Significantly independent predictive factors for conversion were male gender, previous abdominal surgery, acute cholecystitis, thickened gallbladder wall on preoperative ultrasonography, and suspicion of common bile duct stones. CONCLUSIONS: An appreciation for the aforementioned predictors of conversion will allow appropriate planning by the patient, the institution, and the surgeon.

Radical surgery of colon cancers directly invading the duodenum, pancreas and liver.

BACKGROUND/AIMS: Adjacent organ invasion is observed in 5-12% of the colorectal cancers and is rarely faced with invasion of the duodenum, pancreas or liver. METHODOLOGY: We reviewed 4 patients with invasion of the duodenum, pancreas or liver or more than one at the same time, to emphasize the importance of aggressive radical procedures. RESULTS: Three patients underwent en bloc pancreaticoduodenectomy with right hemicolectomy, and one patient underwent en bloc pancreaticoduodenectomy with right hemicolectomy and 5th and 6th hepatic segments resection. Perioperative need for blood transfusion was 3-5 units. There was no postoperative morbidity and mortality, except for the patient who had a bile leakage which got well with medical treatment. Although malignant invasion was proved by pathologic evaluation, only one patient had lymph node involvement. While one patient was lost at the 8th postoperative month, 3 patients are living disease free within a range of 14-41 months. CONCLUSIONS: The chances of longer survival can be given to the patient by en bloc radical resections of locally advanced right colon tumors accompanied by invasion of duodenum, pancreas and liver, with low morbidity and mortality rates.

Factors affecting post-operative mortality in malignant biliary tract obstruction.

BACKGROUND/AIMS: Although malignant obstruction, itself, is a significant risk factor associated with post-operative mortality, factors affecting mortality in the surgery of malignant obstruction have not been thoroughly studied in the literature. METHODOLOGY: In order to identify independent risk factors which might be associated with an increase in post-operative mortality in patients with malignant biliary obstruction, 24 clinical and laboratory parameters in 52 patients undergoing biliary tract surgery were analyzed retrospectively. RESULTS: Simple regression revealed 24 factors with prognostic significance, but multivariate analysis detected only 3 factors with independent significance in predicting mortality (cholangitis, weight loss of 10 kg or more and operative or post-operative blood transfusion). The presence of 2 of these risk factors identified a group of patients with an 37% mortality rate. CONCLUSIONS: The results of this study show that the presence of pre-operative cholangitis, marked weight loss, and operative and post-operative blood transfusion are associated with high post-operative mortality. The major challenge is the prevention of cholangitis in high-risk patients, improvement of the nutritional status of the patients, and avoidance of unnecessary blood transfusions.

Effects of octreotide and a-tocopherol on bacterial translocation in experimental intestinal obstruction: a microbiological, light and electronmicroscopical study.

BACKGROUND/AIMS: Bacterial translocation induced by intestinal obstruction is suggested to be due to increased intestinal luminal volume, leading to intestinal overgrowth with certain enteric microorganisms and intestinal mucosal damage. If this suggestion is true, maintenance of intestinal mucosal integrity by a cytoprotective agent, a-tocopherol, and inhibition of gastrointestinal secretions by octreotide should decrease the incidence of bacterial translocation and extent of mucosal injury due to intestinal obstruction. METHODS: Complete intestinal obstruction was created in the distal ileum of male Wistar Albino rats by a single 3-0 silk suture. The animals received subcutaneous injections of 1 ml of physiologic saline (group 1) (PS 24) and 1 ml of saline containing octreotide acetate (100 micrograms/kg) (group 2) (OC 24), at 0, 12 and 24 hours of obstruction. In group 3 (PS 48) and group 4 (OC 48), the rats were treated with subcutaneous physiologic saline (1 ml) and octreotide acetate (100 micrograms/kg), respectively, beginning at the time of obstruction and every 12 hours for 48 hours. The rats in group 5 (Toc 24), were pretreated with intramuscular a-tocopherol 500 mg/kg on day 1 and 8, and underwent laparotomy on day 9. A third dose of a-tocopherol was injected at the time of obstruction on day 9 and no treatment was given thereafter. We tested the incidence of bacterial translocation in systemic organs and circulation and evaluated the histopathological changes in all groups. RESULTS: Treatment with octreotide acetate was found to be ineffective in reducing the incidence of translocation, with no histopathological improvement. Mucosal damage scores, on the other hand, in the a-tocopherol group were statistically less than those in the octreotide and control groups (p < 0.05). Additionally, a-tocopherol treatment decreased the incidence of organ invasion with translocating bacteria, although this difference did not reach statistical significance. CONCLUSION: Octreotide acetate treatment in complete intestinal obstruction has no effect on the incidence of bacterial translocation. a-Tocopherol, on the other hand, has a cytoprotective effect on intestinal mucosa in intestinal obstruction which, in turn, is thought to decrease bacterial translocation when used in physiological doses and prophylactically.

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.

Effects on mortality of changing trends in the management of burned children in Turkey: eight years' experience.

This retrospective review of data from a single burn centre revealed a sharp decrease in the mortality associated with childhood burn. Between January 1998 and January 2006, 1035 children were admitted to our burn unit in Ankara. The overall mortality was 5.8%, falling from 23% between 1998 and 2000 to 5.6% between 2001 and 2005. Scalds were commonest among the younger and flame and electrical burns among the older children. Flame burns were associated with the largest burned body surface areas and highest mortality rates. Electrical burns remained a major health problem with significant amputation rates and lengths of hospital stay. Candidaemia was a mortal consequence of burn. Renovation of the unit with changes in the management of burn victims from conservative treatment to more up-to-date approaches were associated with improved outcomes.

Increased complaints of fever in the emergency room can identify influenza epidemics.

BACKGROUND: In developing countries, it may be easier to use the reasons why patients come to the emergency room (ER) instead of sentinel practices to identify influenza epidemics. METHODS: We studied the reasons why adult patients present to the ER in order to attempt to predict increased hospital activity as a result of influenza. The daily frequency of presenting symptoms during the 30 days of maximal influenza activity was compared to the other days of the study period (335 days). RESULTS: During the influenza period, more patients presented with fever, syncope or near syncope, cough, asthma attack, and paralysis than on the days outside of this period. On 50% of the days, eight or more patients presented with fever, an 8.36 (95% CI=4.6-15.19) higher frequency than during the rest of the year. During the subsequent year, days with excess presentations by patients with a principal complaint of fever predicted increased hospital activity due to influenza with no false-positive periods. CONCLUSIONS: We conclude that an increase in the number of patients presenting to the ER complaining of fever can identify increased hospital influenza activity.

Effects of vitamin A on immunological deficiencies in rats with obstructive jaundice.

OBJECTIVE: To investigate the ability of an immunostimulant, vitamin A, to reverse dysfunction of the mononuclear phagocyte system and impaired peritoneal neutrophil chemotaxis in rats with obstructive jaundice. DESIGN: Open laboratory study. SETTING: Medical School, Turkey. MATERIAL: 60 male Wistar-Albino rats. INTERVENTIONS: Two different experimental studies with 30 rats each were performed. Ten of the 20 rats in which the common bile duct was ligated and divided, were given vitamin A (vitamin A group) and the other 10 were given saline (saline group). Ten rats which underwent laparotomy with mobilisation of the common bile duct (sham group) were given saline. Rats in the vitamin A group were given 200 IU/g/day vitamin A and other groups of rats had an equal volume of saline intraperitoneally for 20 days. MAIN OUTCOME MEASURES: Function of the mononuclear phagocytic system was studied by the use of 99mTc sulphur colloid uptake, peritoneal neutrophil chemotaxis was measured by the Boyden chamber method, and liver function tests were studied 21 days after operation. RESULTS: Hepatic uptake of 99mTc sulphur colloid decreased, and lung uptake increased in the saline group compared with the sham and vitamin A groups (p < 0.05). Neutrophil chemotaxis was reduced in the saline and vitamin A groups compared with the sham group (p < 0.05). Serum aspartate aminotransferase and alanine aminotransferase activities and unconjugated bilirubin concentrations in the saline group were higher than in the vitamin A and sham groups (p < 0.05). CONCLUSION: Vitamin A stimulates mononuclear phagocytic function in jaundiced rats. It also improves liver function and may enhance peritoneal neutrophil chemotaxis.

Thyroxine prophylaxis after bilateral subtotal thyroidectomy for multinodular goiter.

In this study, we investigated the value of thyroxine administration to prevent recurrence after bilateral subtotal thyroidectomy for multinodular goiter. Patients that had benign multinodular goiter were operated on with the same surgical principles: ligation of both superior and inferior thyroid arteries on both sides, bilateral subtotal resection of thyroid gland including all visible nodules. On the 3rd postoperative day, the patients were divided into two groups: with 100 microgram 1-thyroxine daily (Thyroxine group) or no therapy (Control group). No recurrences were encountered among 40 patients followed up for 6 months and 20 patients for at least one year. One patient in the control group developed manifest hypothyroidism (5.3%). The mean TSH level of the control group was significantly higher than that of thyroxine group at 1st, 2nd, 3rd, 4th, 5th, 6th, and 12th months. At the end of the first year, the mean TSH level of the control group was four times that of the normal. On the other hand, the mean TSH level of the thyroxine group was within normal limits but not suppressed. In conclusion, we found that the pituitary-thyroid axis did not become normal spontaneously one year after thyroidectomy. Therefore, postoperative thyroxine administration seems to be of value, especially in endemic regions like Turkey.

Truncal ligation of the inferior thyroid arteries does not affect the incidence of hypocalcaemia after thyroidectomy.

OBJECTIVE: To assess the effect of truncal ligation of the inferior thyroid arteries during bilateral subtotal thyroidectomy on the incidence of hypocalcaemia after thyroidectomy. DESIGN: Prospective non-randomised study. SETTING: Teaching hospital, Turkey. SUBJECTS: 216 patients who had bilateral subtotal thyroidectomy for non-toxic nodular goitre between 1990 and 1996. INTERVENTIONS: The trunk of the each inferior thyroid artery was simply ligated during bilateral subtotal thyroidectomy. MAIN OUTCOME MEASURES: Clinical examination, and measurement of serum calcium, ionised calcium, and inorganic phosphate concentrations before and after operation. RESULTS: Four patients (2%) had low concentrations of total and ionised calcium during the postoperative period. On physical examination three of them had spasms of the facial nerve, as seen in tetany. They were given calcium supplements orally and their laboratory results returned to reference ranges within 180 days. No patients developed permanent hypocalcaemia. CONCLUSION: Truncal ligation of the inferior thyroid arteries during bilateral subtotal thyroidectomy has no effect on the incidence of hypocalcaemia after thyroidectomy.