Outcomes of Laparoscopic Versus Open Liver Resection: A Case-control Study With Propensity Score Matching.

BACKGROUND: This study aimed to evaluate the perioperative outcomes of patients with benign and malignant liver lesions scheduled for laparoscopic and open surgery using a propensity score-matched approach to analyze additional cofactors influencing outcomes. PATIENTS AND METHODS: In this study, we retrospectively reviewed 270 patients who underwent laparoscopic or open liver resection at our institute between October 2016 and November 2021. Patients were divided into open and laparoscopic liver resection groups and compared according to the intention to treat principle. In the purification process for the nonrandom nature of the study, a matching analysis was performed at a 1:1 case-control ratio. The PS model included selected data on body mass index, additional data on the American Society of Anesthesiology score, cirrhosis, lesion <2 cm from the hilum, lesion <2 cm from the hepatic vein or inferior vena cava, and type of neoadjuvant chemotherapy. RESULTS: The operation time and 30- and 90-day mortality rates were similar between the groups. The average length of hospital stay was 11 days in the open surgery group and 9 days in the laparoscopic surgery group after matching ( P =0.011). The 30-day morbidity rate was statistically different between the groups before and after matching, favoring the laparoscopic group ( P =0.001 and 0.006, respectively). After the propensity score-matched approch, the open group's Pringle time was shorter than that of the laparoscopic group. The total operative time was longer in the laparoscopic than in the open surgery group. This did not change after matching (300 vs. 240 min). CONCLUSIONS: Laparoscopic surgery is a feasible and safe treatment option for patients with liver tumors, with promising results in terms of morbidity and hospital stay.

Management of Biliary Complications in Liver Transplant Recipients with Duct-To-Duct Anastomosis: A Single-Center Experience.

BACKGROUND: The aims of this study were to investigate biliary complications in liver transplant recipients with choledochocholedocho stomy anastomosis, to identify the risk factors for the development of such complications, and to evaluate the success of endoscopic approaches in liver transplant recipients. METHODS: Between January 2013 and May 2021, a total of 238 patients with liver diseases underwent liver transplantation: 174 recipients undergoing choledochocholedochostomy anastomosis were included in the analysis. RESULTS: Their median age was 54.0 years. The median posttransplant follow-up period was 29 months. Hepatitis B virus infection (33%) was the most common indication for liver transplantation. Most patients (87%) received living donor liver transplantation. The overall prevalence of posttransplant biliary complications was 31%. Anastomotic biliary strictures were the most common biliary complications (72%), followed by biliary leakage (13%). The median time between endoscopic retrograde cholangiography and liver transplantation was 4 months, with a mean of 3 ± 1.6 sessions. Endoscopic retrograde cholangiography-guided drainage and balloon dilation with or without stent placement was the most common treatment modalities for recipients with biliary strictures. The overall success rate of endoscopic treatment modalities was 83.3%, with 65% of the recipients exhibiting complete biochemical and endoscopic responses. The response did not differ significantly between living donor liver transplantation and cadaveric donor liver transplant recipients (P > .05). Three recipients required revision surgery for biliary complication repair. Six patients died due to biliary sepsis. CONCLUSION: Biliary stricture and leakages were the most common biliary complications after liver transplantation. Endoscopic treatment was successful in most recipients.

Surgical Drains After Laparoscopic Donor Nephrectomy: Needed or Not?

BACKGROUND Routine placement of prophylactic drains after laparoscopic donor nephrectomy has been suggested and has become common practice in some centers. However, there is a lack of evidence proving the surgical benefits of routine drain placement in laparoscopic donor nephrectomy. Here, we assessed the effect of surgical drain placement on recovery, length of hospital stay, and complication rates of live kidney donors. MATERIAL AND METHODS This retrospective study included all live donor nephrectomies performed at a single institution from January 2010 to January 2017. Surgeries were performed by 2 surgeons; one routinely placed a closed suction drain after LDN whereas the other did not. Patients operated on by these 2 surgeons were enrolled in either the drain or no drain group. Demographic data, preoperative and postoperative creatinine levels, estimated blood loss (EBL), surgical time, surgical complications, and length of hospital stay were compared. RESULTS The study included 272 patients. Three were converted to open donor nephrectomy and were excluded (1.1%). Among the 269 patients, 156 (57.9%) had surgical drains and 113 (42.1%) did not. Mean surgical time, estimated blood loss, and duration of hospital stay did not significantly differ between groups. Postoperative complications were encountered in 17 of the patients, but the overall complication rate did not differ between patients with vs. those without surgical drains. CONCLUSIONS There was no significant difference between the drain and no drain groups in terms of length of hospital stay, complication rates, or postoperative creatinine levels. Thus, placement of a surgical drain in the setting of an LDN is not justified based on our single-center experience.

Live Donor Assessment Tool (LDAT): A Turkish validity and reliability study.

BACKGROUND/AIMS: Psychosocial and psychiatric evaluations are crucial components of the assessment of a live donor candidate. The Live Donor Assessment Tool (LDAT) was developed for this purpose. This study aims to evaluate the validity and reliability of the Turkish version of LDAT. MATERIALS AND METHODS: 132 live kidney or liver donor were referred to assess their psychosocial/psychiatric appropriateness for donation and were randomized for clinical evaluation as usual or with LDAT. The internal consistency of LDAT was measured by Chronbach's alpha coefficient. Inter-rater reliability was measured by using Spearman's correlation coefficient. The potential validity of LDAT was assessed by comparing LDAT scores to clinical decisions. The Mann-Whitney U test was used to compare LDAT scores across two clinically classified groups (acceptable/declined). Logistic regression was performed using LDAT scores to predict the clinical decision. RESULTS: The Turkish version of LDAT items demonstrate good internal consistency (α=0.773). Inter-rater reliability of LDAT demonstrated strong correlation (ICC=0.72). LDAT scores differentiated the accepted/declined groups, and strongly predicted the clinical decision. With a cut-off score of 60.5, LDAT was found to have high sensitivity and specificity. CONCLUSION: The Turkish version of LDAT was found to be a valid and reliable tool. LDAT could be an appropriate tool to assess live donor candidates.

The impact of two arterial catheters, different in diameter and length, on postcannulation radial artery diameter, blood flow, and occlusion in atherosclerotic patients.

PURPOSE: Arterial cannulation is a common intervention in anesthesia practice. However, the success rates and complications of radial arterial cannulation with 20-G or smaller catheters in patients with atherosclerosis have been underevaluated. The aim of this prospective randomized study was to compare the efficacy of and complications with 20- and 22-G catheters for radial arterial cannulation in atherosclerotic patients. METHODS: Thirty patients with atherosclerosis, American Society of Anesthesiologists (ASA) III-IV, undergoing general anesthesia were enrolled in the study. Radial artery cannulation was performed in group 20G (n = 15) with a 20-gauge (20 x 1.1 x 33 mm; flow, 61 ml.min(-1)) catheter and in group 22G (n = 15) with a 22-gauge (22 x 0.9 x 25 mm; flow, 36 ml.min(-1)) catheter. Radial artery systolic blood flow (SBF) and radial artery diameter (RAD) were assessed by a Doppler ultrasound probe before cannulation and 24 h after decannulation for vascular complications. The number of puncture attempts, arterial blood gas samples, and manual flushes; total heparinized solution consumption; duration of cannulation; decannulated radial arterial systolic blood flow; postcannulation RAD; and vascular complications such as occlusion, hematoma, pseudoaneurysm, bleeding, and thrombosis were noted. The Mann Whitney U-test, chi(2) test, and one-sample t-test were used. Values are expressed as medians and quartiles and P < 0.05 was considered as significant. RESULTS: The number of puncture attempts was greater in group 20G (range, 1 to 4) than in group 22G (range, 1 to 2; P = 0.02). In group 20G patients, postoperative RAD was larger than preoperative RAD (P = 0.02) and postoperative SBF was lower than preoperative SBF (P = 0.03). In group 22G patients postoperative SBF was higher than preoperative SBF (P = 0.03), while there was no significant difference between preoperative and postoperative RAD. The occlusion rate of atherosclerotic radial arteries was 6% with the 22-gauge catheter and 26% with the 20-gauge catheter (P = 0.02). CONCLUSION: A 22-gauge catheter for radial arterial cannulation in patients with atherosclerosis provides unchanged postcannulated radial artery diameter, decreases postcannulation complications, and improves the first-attempt success rate.

Is There a Correlation with Pre-donation Kidney Volume and Renal Function in the Renal Transplant Recipient?: A Volumetric Computed Tomography Study.

PURPOSE: The aim of this study is to determine the correlation between the predonation computed tomography (CT)-based calculated kidney volume and post-transplant renal function in recipients of renal transplants and to compare two different CT techniques. MATERIAL AND METHODS: The study group is comprised of 55 paired living kidney donor-recipients transplants. The total parenchymal renal volumes were calculated by using two CT-based techniques (3-dimensional renal volume [3DRV] and voxel-based volume calculation). Post-transplant creatinine and estimated glomerular filtration rate (eGFR) levels for the recipients at hospital discharge and sixth month were obtained. We tested the association with eGFR and creatinine by adjusting the renal volume to body weight and body mass index. For the creatinine levels above 1.5 mg/dL at discharge, a threshold value for renal volume-to-weight ratio on receiver operating characteristic curve (ROC) analysis and odds ratio (OR) were calculated. RESULTS: The renal volumes adjusted to weight were found to be moderately correlated with eGFR and creatinine levels at discharge (r = 0.51 and r = -0.54 for voxel-based calculation; r = 0.52 and r = -0.52 for 3DRV calculation, P < .001, respectively) and at sixth month (r = 0.55 and r = -0.58 for voxel-based calculation; r = 0.51 and r = -0.54 for 3DRV calculation, P < .001 respectively). A threshold value of 1.84 mL/kg was calculated for parenchymal volume-to-recipient weight ratio on ROC analysis (AUC±SE, 0.760 ± 0.078, P = .008). The likelihood of creatinine elevation above 1.5 mg/dL was found to be nine times greater for smaller renal volume-to-recipient weight ratios (OR = 9.6; 95% CI, 1.8-50.6) CONCLUSIONS: Predonation renal volume adjusted to recipient weight may estimate the renal function at discharge and 6 months after transplantation.

Challenges of pancreas transplantation in developing countries, exploring the Turkey example.

Pancreas transplantation significantly improves the quality of life for people with type 1 diabetes, primarily by eliminating the need for insulin and frequent blood glucose measurements. Despite the growing numbers of solid organ transplantations worldwide, number of pancreas transplantations in the developing countries` remain significantly low. This difference of pancreas transplantation practices was striking among the participating countries at the 1st International Transplant Network Meeting which was held in Turkey on 2018. In this meeting more than 40 countries were represented. Most of these counties were developing countries located in Africa, Middle East or Asia. The aim of this article is to identify the challenges and limiting factors for pancreas transplantations in these developing countries, by exploring the Turkish example. The challenges faced by the developing countries are broadly classified in four categories; wait-listing, donor pool, team work and follow up. Under these categorical titles, issues are further discussed in detail, giving examples from Turkish practice of pancreas transplantation. Additionally, several solutions to these challenges have been proposed- some of which have already been undertaken by the Turkish Ministry of Health. With the insight and methods presented in this article, pancreas transplantation should be made possible for the potential recipients in the developing countries.

Therapeutic Effect of Plasmapheresis and Intravenous Immunoglobulin in Recipients of Kidney Transplant With High Panel-reactive Antibody Levels: A Single-center Experience.

OBJECTIVE: High panel-reactive antibody (PRA) levels limit patients' access to kidney transplantation from potential living donor candidates and decrease renal graft survival by causing acute antibody-mediated rejection (AAMR). In this article, we report our experiences about the efficiency of plasmapheresis (PP) and intravenous immunoglobulin (IVIG) in reduction of serum PRA levels in candidates for renal transplantation and in patients with AAMR. METHODS: We examined retrospectively 47 patients with high PRA levels (18 for desensitization (DS) and 29 with AAMR) at Ankara University. The reduction in PRA class 1 and PRA class 2 levels before and after the PP, IVIG, and rituximab or eculizumab therapy were evaluated. RESULTS: In the DS group, mean reduction in PRA class I ± SD was 28.0 ± 9.10 to 22.1 ± 8.14 (P <.05), and mean reduction in PRA class II ± SD was 40.3 ± 6.89 to 32.2 ± 5.68 (P < .05). In the AAMR group; mean reduction in PRA class I ± SD was 23.9 ± 9.56 to 17.8 ± 8.64 (P > .05), and mean reduction in PRA class II ± SD was 28.1 ± 8.37 to 26.7 ± 7.96 (P > .05). In total, mean reduction in PRA class I was 25.7 ± 6.66 to 19.7 ± 6.00 (P < .01). Mean reduction in PRA class II was 33.8 ± 5.93 to 29.2 ± 4.96 (P > .05). In the DS group, 3 (16.7%) patients were treated with rituximab. In the AAMR group, 9 (31.0%) patients were treated with rituximab, and 1 (5.5%) patient received eculizimab.In the DS group, the mean follow-up period in years ± SD was 5.06 ± 3.01 and no patient had graft loss. In the AAMR group, the mean follow-up period in years was 5.06 ± 2.74 and 6 (33.3%) patients had graft loss with acute rejection. CONCLUSIONS: PP and IVIG treatment provide significant reduction in PRA levels and can be used in DS protocols.

Outcomes of Canakinumab Treatment in Recipients of Kidney Transplant With Familial Mediterranean Fever: A Case Series.

Familial Mediterranean fever (FMF) is an important and preventable cause of chronic kidney disease due to secondary amyloidosis. Although colchicine is the first-line therapy in patients with FMF with 60% to 65% complete remission rates, 5% to 10% of patients are colchicine-resistant and 5% to 10% of them are intolerant to the therapy. Anti-interleukin-1 agents, such as anakinra and canakinumab, are safe and efficient therapeutic options in patients with colchicine resistance or intolerance. However, the data on management of these targeted agents is limited in recipients of kidney transplant (RKT). In this case series, we aim to share our experience on canakinumab therapy of 4 RKTs with FMF-related amyloidosis, who were followed up in our clinic between 2010 and 2017. All of the 4 patients with end-stage renal disease were colchicine- resistant and on other alternative therapies, which provided poor disease control. For efficient control of secondary amyloidosis, canakinumab therapy was initiated in 1 of the patients before the renal transplant, and for the remaining patients after renal transplant. Any serious adverse effect, development of proteinuria, or graft dysfunction has not been observed in any of the patients. Under the canakinumab treatment, complete clinical responses, prevent typical familial Mediterranean fever attacks with fever and arthritis and abdominal pain, normalized serum amyloid A and C-reactive protein levels were achieved in all patients. Canakinumab treatment is a safe and effective therapeutic option for RKTs with FMF who are resistant or intolerant to colchicine and anakinra.

Long-term Results of Kidney Transplantation in Patients With Familial Mediterranean Fever and Amyloidosis.

INTRODUCTION: Amyloid A amyloidosis is most commonly caused by familial Mediterranean fever (FMF) in Turkey. Amyloidosis secondary to FMF is an important cause of end-stage renal failure, and kidney transplantation (KT) in these cases can be complicated, with long-term results oftentimes inferior compared with organ transplant in patients without FMF. The present study aims to show the long-term results of patients with secondary amyloidosis caused by FMF undergoing KT . METHODS: We enrolled 27 patients with a history of FMF amyloidosis undergoing KT and a control group of 614 patients undergoing KT between 2005 and 2018 at Ankara University Medical School. All data were recorded retrospectively from patients files. RESULTS: Twenty-two patients (81.5%) were treated with triple immunosuppressive therapy consisting of mycophenolate mofetil, tacrolimus, and a steroid; 5 patients (18.5%) were treated with tacrolimus, azathioprine, and prednisolone. Acute cellular rejection was seen in 3 patients (11.1%), and acute cellular- and antibody-mediated rejection occurred in 1 patient (3.7%). During the follow-up period, graft loss due to acute cellular rejection was observed in only 1 patient. One patient was lost to follow-up.

Maintenance Immunosuppressive Treatment of Renal Transplant Recipients in the Critical Care Unit.

BACKGROUND: In intensive care unit (ICU), although there is no standard protocol for maintenance of immunosuppressive (IS) treatments for the kidney transplant recipients (KTx), the dose and the number of IS drugs are decreased according to the center's experience. The aim of this study is to evaluate the changes in IS treatment during stays in the ICU and to evaluate the safety and results of this modification on the IS treatment in the ICU arbitrarily. METHOD: We evaluated retrospectively our kidney transplant recipients in ICU between 2012 and 2017. The immunosuppressive protocols and the results were taken from the ICU documents. RESULTS: A total of 31 (18 male, 13 female) patients were suitable for the analysis. They were all under the triple IS protocol including Tacrolimus (Tac) + Mycophenolate mofetil (MMF) + steroid before the admission. The reason for ICU admission were severe sepsis in all patients. In ICU, 16 patients (51.6%) died, and a total of 10 patients were lost with functional graft. Change in IS treatment is as follows: a total of the 23 patients (74.2%) were given only steroids, and 8 patients (25.8%) were changed from triple to 2 drugs. Acute kidney injury developed in 42% (13 patients) of the patients in ICU. CONCLUSION: In our study, we observed that life-threatening severe infections were the main cause of ICU admission in KTx. Reduction in IS treatments are common practice, and reduction to a single dose of steroid was the most frequently chosen IS treatment. Eighty percent of patients are discharged with reduction of steroid gradually. None of the patients developed acute rejection and permanent graft injury.

Effect of unilateral nephrectomy on urinary angiotensinogen levels in living kidney donors: 1 year follow-up study.

BACKGROUND: Urinary angiotensinogen (uAGT) has recently been proposed as a marker of kidney injury and activated intrarenal renin-angiotensin system. We investigated the effects of living donor nephrectomy on uAGT levels, blood pressure, estimated glomerular filtration rate, proteinuria and compensatory hypertrophy in the remaining kidney of living kidney donors. METHODS: Twenty living kidney donors were included in the study and followed for 1 year. uAGT levels were measured with enzyme-linked immunosorbent assay preoperatively and postoperatively at the 15th day, 1, 6 and 12 months. RESULTS: Four donors were excluded from the study due to lack of data. The mean baseline estimated glomerular filtration rate was 98 ± 15 ml/min/1.73 m². Serum creatinine, uAGT/creatinine, uAGT/protein levels were higher and estimated glomerular filtration rate was lower than baseline values at all time periods. Urinary protein/creatinine levels increased after donor nephrectomy, but after 6 months they returned to baseline values. Renal volume increased after nephrectomy, but these changes did not show any correlation with uAGT/creatinine, uAGT/protein, estimated glomerular filtration rate or systolic/diastolic blood pressures. uAGT/creatinine at 6 months and urinary protein/creatinine ratio at 12 months showed a positive correlation ( P=0.008, r=0.639). CONCLUSION: After donor nephrectomy, increasing uAGT levels can be the result of activation of the intrarenal renin-angiotensin system affecting the compensatory changes in the remaining kidney. The long-term effects of increased uAGT levels on the remaining kidney should be examined more closely in future studies.

Urothelial carcinoma of the allograft kidney developed in a renal transplant patient.

Renal transplantation is the best option in the treatment of end-stage renal disease However these patients are under the risk of developing malignancies particularly due to effects of immune supression. These malignancies tend to be more agressive compared to the general population. Here, we present a case of urothelial carcinoma develoing in the ureter of allograft kidney.

Quantitative viral load monitoring and cidofovir therapy for the management of BK virus-associated nephropathy in children and adults.

BACKGROUND: BK virus (BKV)-associated nephropathy (BKVAN) has been increasingly recognized as an important cause of renal transplant dysfunction. We report the role of quantitative viral load monitoring in the management of BKVAN. METHODS: We developed a real-time quantitative polymerase chain reaction (PCR) assay for BKV detection in urine and plasma. Four renal allograft recipients, including two children, with BKVAN were treated with low-dose cidofovir and followed prospectively. RESULTS: The PCR assay showed a detection limit of 10 viral copies with an intra-assay coefficient of variation of 19%. All four patients with BKVAN demonstrated intranuclear inclusions on allograft biopsy and a progressive rise in serum creatinine; three patients underwent multiple biopsies before the diagnosis of BKVAN was made. Three of the patients experienced a "viral syndrome" before the onset of renal dysfunction. One child also demonstrated an echogenic renal mass. All of the patients demonstrated strongly positive urinary PCR values (>100,000 copies/microL). BKV DNA was also detected in the plasma of three patients. All the patients were treated with intravenous low-dose cidofovir (0.25-1 mg/kg per dose, every 2-3 weeks, without probenecid). BK viruria resolved within 4 to 12 weeks (after 1-4 doses) of the cidofovir therapy, and all patients remain with stable renal function 6 to 26 months posttherapy. CONCLUSIONS: Quantitative PCR for BKV is a sensitive and reliable method for following the course of the infection in renal transplant patients. In addition, cidofovir therapy may be useful in the treatment of some of these patients, and its role needs to be investigated further.

Endoscopic treatment of biliary complications following liver transplantation.

BACKGROUND/AIMS: The aims of the present study were to review biliary complications following liver transplantation in a single-center experience, to identify the factors associated with biliary complications, and to evaluate the success of endoscopic and percutaneous treatment in such patients. MATERIALS AND METHODS: Between January 1994 and June 2010, a total of 176 patients with liver disease underwent liver transplantation; 119 recipients were included in this retrospective analysis. Median posttransplant follow-up period was 49 months. RESULTS: Mean age was 43.0±12.7 years. Living donor liver transplantation (LDLT) and deceased-donor liver transplantation (DDLT) were performed in 71 and 48 patients, respectively. Duct-to-duct anastomosis and Roux-en-Y hepaticojejunostomy were performed in 68 and 51 patients, respectively. The overall incidence of posttransplant biliary complications was 36%; anastomotic biliary strictures were the most common biliary complications (42%), followed by biliary leakage (28%). On logistic regression analysis, duct-duct anastomosis was the only risk factor associated with the development of biliary complications (Odds ratio (OR), 3.346; p=0.005). Endoscopic and percutaneous treatment was successful in the majority of patients (81%), and the remaining 19% recipients underwent surgery for biliary repair. Endoscopic retrograde cholangiopancreatography (ERCP) guided drainage and balloon dilatation with stent placement were the most common treatment modalities. CONCLUSION: Biliary complications were most frequent after liver transplantation; biliary strictures were the most commonly seen. The use of duct-to-duct anastomosis for biliary reconstruction is a risk factor for the development of biliary complications. Endoscopic and percutaneous treatment was successful in the majority of these patients.

Incidental gallbladder cancer diagnosed during or after laparoscopic cholecystectomy in members of the Turkish population with gallstone disease.

BACKGROUND/AIMS: Gallbladder cancer is a rare neoplasm. We report our experience with gallbladder cancer that was incidentally diagnosed during or after laparoscopic cholecystectomy performed for gallstone disease. MATERIAL AND METHODS: This study included all laparoscopic cholecystectomies due to gallstone disease undertaken from May 1999 to June 2010. Exclusion criteria were suspicion of malignancy and/or existence of gallbladder polyps detected with ultrasonography preoperatively. Patients with incidentally diagnosed gallbladder cancer were recorded, and the clinical and demographic characteristics of these patients were reviewed. RESULTS: Of 5,382 patients in whom laparoscopic cholecystectomy was attempted, 5,164 were included in this study. Incidental gallbladder cancer was found in five patients, with a mean age of 66.2 years. The histological tumor stages were adenocarcinoma in situ in one patient, pT1b in one patient, pT2 in one patient, and pT3 in two patients. Two patients who underwent laparoscopic cholecystectomy alone underwent no additional surgery because of the low stage of the tumors. The three remaining patients, whose laparoscopic cholecystectomies were converted to open surgeries, underwent cholecystectomy, excision of the liver bed and lymph node dissection. The overall median survival time was 32 months. CONCLUSION: The incidence of incidental gallbladder cancer has been reported to vary, up to 2.85%. In this single-center study, the rate of incidental gallbladder cancer was found to be 0.09%. Female gender and advanced age are demographic risk factors for gallbladder carcinoma. Although gallbladder cancer is well known for its poor prognosis, tumors that are incidentally diagnosed are often found at an early stage and have a better prognosis.

Laparoscopic fundoplication with prosthetic hiatal closure.

BACKGROUND: Despite the good results reported after laparoscopic fundoplication, failure is still a major problem. Hiatal disruption is one of the common patterns of anatomical failure. The aim of this study was to compare the results of suture repair of diaphragmatic crura with routine polypropylene mesh reinforcement in addition to suture repair. METHODS: A total of 551 patients who underwent laparoscopic fundoplication for gastroesophageal reflux disease between March 1998 and July 2004 were included into the study. Crural closure had been performed with simple primary suture repair alone between March 1998 and July 2002 (n = 335, group I), and mesh reinforcement of the hiatal repair was performed routinely thereafter (n = 176, group II). These groups were evaluated prospectively. RESULTS: We observed a significantly lower rate of recurrence in group II than in group I. After a 2-year follow-up, the rate of anatomic morphologic recurrence was 6.0% in group I and 1.8% in group II. Considering the recurrence rate, there was significant statistical difference. The overall recurrence rate in our series was 4.6%. There was no correlation between the size of the hernia and recurrence. No significant difference was found between groups regarding the rate of postoperative dysphagia. We have not observed any complications related to the use of polypropylene mesh in group II. CONCLUSION: The results of this study suggest that polypropylene mesh reinforcement increases the success rate for laparoscopic hiatal hernia repair without causing an additional complication burden. We propose routine use of mesh reinforcement in laparascopic antireflux surgery.

Prevention of surgical site infection after open prosthetic inguinal hernia repair: efficacy of parenteral versus oral prophylaxis with amoxicillin-clavulanic acid in a randomized clinical trial.

The aim of this prospective study was to compare the efficacy of oral versus parenteral prophylactic amoxicillin-clavulanic acid for preventing surgical site infection after open prosthetic mesh repair of inguinal hernia. A total of 480 inguinal-hernia patients were randomly assigned to two groups. Group I (n = 240) received 1.313 g oral amoxicillin-clavulanic acid 2 hours before operation, and group II (n = 240) received 1.2 g of the same drug combination intravenously approximately 30 minutes before surgery. Patients were examined four times during 1 year of follow-up (at 7-10 days, 4-6 weeks, 6 months, and 12 months postoperation), and data related to surgical site infections were collected. Seventy-two patients were excluded due to confounding factors during and after the operation. There were no statistically significant differences between group I (final n = 208) and group II (final n = 200) with respect to age, sex distribution, body mass index, American Anesthesiology Association grade, frequencies of different hernia types, duration of surgery, and the experience levels of the principal surgeon in the operations. One of the 208 (0.5%) patients in group I and 3 of the 200 (1.5%) patients in group II developed superficial surgical site infections (p > 0.05). None of the infections required mesh removal. There were no deep surgical site infections in either group, and there was one case of hernia recurrence in each group. For patients undergoing open prosthetic repair of inguinal hernia, oral amoxicillin-clavulanic acid is safe, significantly less costly, and equally effective in preventing surgical site infection as the same dose given parenterally.

The effect of hyaluronan-based agents on adhesion formation in an intraabdominal sepsis model.

Because of the technical difficulty during subsequent surgical intervention, adhesion remains the most important predictor of outcome in the staged procedures following emergent colorectal surgery. The aim of this study was to assess the long-term effects of hyaluronan (HA)-based adhesion barriers 3 months following the infectious insult to the peritoneal cavity. Wistar albino rats were divided into three sham and four infectious groups, each consisting of 20 rats. Sham groups consisted of a control group (I), which had undergone manipulation of the cecum in the first operation and saline irrigation following the cecal resection in the second operation; an HA-based bioresorbable membrane (BM) group (II), in which 20 x 20- and 35 x 25-mm pieces of HA-based bioresorbable membrane were placed over the cecectomy area and under the midline incision, respectively, with other conditions the same as for the control (I) group; and an HA-based solution (S) group (II), where HA solution was used as an irrigation solution, with other conditions the same as for the control group (I). Infectious groups consisted of a septic group (IV), which had undergone cecal ligation and puncture in the first operation and saline irrigation following the cecal resection in the second operation; a sepsis + HA-BM group (V), in which two sheets of membrane were applied, with other conditions the same as for the septic group (IV); a sepsis + HA-S group (VI), in which HA solution was used as an irrigation solution, with conditions otherwise the same as for the septic group (IV); and a sepsis + HA-BM + HA-S group (VII), where HA solution was used as an irrigation solution and two sheets of membrane were applied, with other conditions the same as for the septic group (IV). At the end of the 3-month period, mortality, septic complications, and intraabdominal adhesions (adhesion scores and adhesion tensile strength measurements) were recorded. Significantly denser adhesions were found in the septic group (IV) when compared to the others (P < 0.001). HA-S significantly reduced not only the incidence of adhesion but also the adhesion tensile strength in infectious groups (P < 0.001 compared to the sepsis group). However, HA-BM significantly reduced adhesion tensile strength only. Irrigation of the peritoneal cavity with HA-S may prove to be useful to shorten the reversal time period and decrease morbidity following staged procedures for intraabdominal sepsis.