A Ureteral Inguinoscrotal Hernia from a Pelvic Kidney.

A 74-year-old male patient with prostate cancer under remission was admitted with left inguinoscrotal swelling. He underwent scrotal ultrasound demonstrating a giant in-guinoscrotal hernia. Contrast-enhanced computerized tomography of the abdomen and pelvis demonstrated a left pelvic kidney associated with severe hydroureteronephrosis secondary to a ureteral inguinoscrotal hernia. Upon exploration with left inguinal incision, a paraperitoneal ureteral in-guinoscrotal hernia and a hypertrophic left spermatic cord were observed. The elongated and tortuous left ureter, being pulled down to the scrotum by the hernia, was released from the herniating tissues fullfilling left hemiscrotum. The ureter was tapered followed by ureteroureterostomy. The accompanying left spermatic cord was excessively elongated and curled, necessitating cordectomy. The hernia was repaired with prolene mesh after removal of herniating peritoneal tissue. This is a rare case of a paraperitoneal ureteral inguinoscrotal hernia of the left pelvic kidney.

Systematic review of studies investigating sentinel node navigation surgery and lymphatic mapping for gastric cancer.

Evolutions in minimally invasive surgical techniques and advances in sentinel node navigation surgery (SNNS) have had considerable impact on current insights into surgical treatment of gastric cancer. Extensive data on this method of surgical application have accumulated but have been principally derived from single-institute studies. Isosulfan blue and patent blue violet have been the most frequently used dye tracers in the past; however, indocyanine green has now is increasingly popular. The double-tracer method, where dye and radioisotope tracers are used together, seems to be more effective than any single tracer. Among newly emerging adjunct techniques and promising alternative in particular are infrared ray electronic endoscopy, florescence imaging, nanoparticles, and near-infrared technology. Hematoxylin and eosin (H&E) staining is still the method of choice for the detection of sentinel lymph node (SLN) metastases. Immunohistochemical staining can be used to support H&E findings, but the equipment costs of ultrarapid processing systems are currently slowing down their worldwide spread. We believe minimally invasive function-preserving resection of the stomach, together with lymphatic basin dissection navigated by SLNs, can represent the ideal approach for SNNS to detect clinically node-negative early gastric cancer, although this remains to be elucidated. Patients with cT3 or more advanced disease should still be treated by means of standard D2 dissection.

The effects of hyperbaric oxygen therapy on experimental colon anastomosis after preoperative chemoradiotherapy.

The aim of the present study was to investigate the effect of hyperbaric oxygen therapy (HBOT) on colon anastomosis after chemoradiotherapy (CRT). Sixty female Wistar-Albino rats were divided into 5 groups and underwent left colon resection and end-to-end anastomosis. CRT simulation was performed on 2 sham groups before the anastomosis, and 1 of these groups was administered additional postoperative HBOT. Two groups were administered CRT before the anastomosis, and 1 of them received additional postoperative HBOT. On postoperative day 5, all groups underwent relaparotomy; burst pressure was measured and samples were obtained for histopathologic and biochemical analysis. There was a significant weight loss in the CRT groups and postoperative HBOT had an improving effect. Significantly decreased burst pressure values increased up to the levels of the controls after HBOT. Hydroxyproline levels were elevated in all groups compared to the control group. Hydroxyproline levels decreased with HBOT after CRT. No significant difference was observed between the groups regarding fibrosis formation at the anastomosis site. However, regression was observed in fibrosis in the group receiving HBOT after CRT. Preoperative CRT affected anastomosis and wound healing unfavorably. These unfavorable effects were alleviated by postoperative HBOT. HBOT improved the mechanical and biochemical parameters of colon anastomosis in rats.

Rectus abdominus fascial sheath usage for crural reinforcement during surgical management of GERD: preliminary report of a prospective randomized clinical trial.

PURPOSE: Many materials are currently being used to reinforce the crural repair. Perforation, intensive fibrosis, and price are limiting the usage of these materials. Our purpose was to seek an alternative, cheap, always available, and inert material to use for cruroplasty reinforcement. METHODS: Twenty-four patients participated and were randomly divided into 2 groups (graft+laparoscopic Nissen fundoplication and laparoscopic Nissen fundoplication alone) with 12 patients in each group. Total operation time, postoperative dysphagia rate, dysphagia improvement time, postoperative pain, recurrence, and incisional hernia rate were compared. RESULTS: There was no difference in terms of study parameters between both groups except for the mean operation time. CONCLUSIONS: Autograft hiatoplasty seems to be a good alternative for crural reinforcement. It provides safe reinforcement, has the same dysphagia rates as meshless hiatoplasty, and avoids potential complications of redo surgery by minimizing extensive fibrosis. Furthermore, the rectus abdominus sheath is always available and inexpensive.

The use of single port surgery for polyps located in the rectum.

Transanal endoscopic microsurgery is a minimally invasive technique for the treatment of rectal lesions which was introduced by Buess. In this report the first clinical experience of transanal endoscopic surgery was performed by a single incision laparoscopic surgical port adapted through the anal canal. In single port surgery, the single incision laparoscopic surgical port has to be stitched around anal orifice. There is no need to use a fixation apparatus. In transanal endoscopic microsurgery procedure, a rigid rectoscope 40 mm in diameter is introduced into the anus by stretching anal sphincter. A single incision laparoscopic surgical port can be disposed through the anal canal where there is no harmful cause because it is made an elastic. The dissection in the transanal endoscopic microsurgery procedure needs specific equipment to improve the surgery; however we could complete the surgical dissection using standard laparoscopic devices with articulated ones. The other factor makes single port surgery easier than transanal endoscopic microsurgery procedure is insufflation. It is easy and controlled way to be insufflated by a particular pump and cheaper than any insufflators. Furthermore, in the operating room, the patient's position on the table was not a limiting factor. As a conclusion, we report that for selected patients, single port surgery can be performed using a single incision laparoscopic surgical port as an adjusted surgical technique. It gives safe and feasible way to remove benign and malign polyps and tumors up to 20 cm in the rectum.

Is neopterin a diagnostic marker of acute appendicitis?

BACKGROUND: The diagnosis of acute appendicitis, even for experienced surgeons, can sometimes be complex. A delay in diagnosis increases the complication rate. This experimental study aimed to investigate the suitability and significance of neopterin as a marker for acute appendicitis. METHODS: The levels of neopterin were measured using an acute appendicitis animal model in 35 New Zealand male rabbits. They were divided into 5 groups as Group 1= control; Group 2= sham; and Groups 3 (12-hour); 4 (24-hour); and 5 (48-hour) (based on the elapsed time period before their appendectomies). The neopterin levels of each group were measured by neopterin enzyme immunoassay kit in blood samples (taken before the appendectomies in Groups 3, 4 and 5). RESULTS: For the diagnosis of acute appendicitis, the optimal cut-off point was 34.475 nmol/L. The probability of acute appendicitis was found to be 4.667 times higher when the neopterin level was greater than 34.475 nmol/L. CONCLUSION: This study was an experimental animal study; however, it provides valuable clues useful in clinical assessment. Neopterin seems to have great potential as a new diagnostic marker for the diagnosis of acute appendicitis.

Sentinel lymph node biopsy for gastric cancer: Where do we stand?

Development of sentinel node navigation surgery (SNNS) and advances in minimally invasive surgical techniques have greatly shaped the modern day approach to gastric cancer surgery. An extensive body of knowledge now exists on this type of clinical application but is principally composed of single institute studies. Certain dye tracers, such as isosulfan blue or patent blue violet, have been widely utilized with a notable amount of success; however, indocyanine green is gaining popularity. The double tracer method, a synchronized use of dye and radio-isotope tracers, appears to be superior to any of the dyes alone. In the meantime, the concepts of infrared ray electronic endoscopy, florescence imaging, nanoparticles and near-infrared technology are emerging as particularly promising alternative techniques. Hematoxylin and eosin staining remains the main method for the detection of sentinel lymph node (SLN) metastases. Several specialized centers have begun to employ immunohistochemical staining for this type of clinical analysis but the equipment costs involving the associated ultra-rapid processing systems is limiting its widespread application. Laparoscopic function-preserving resection of primary tumor from the stomach in conjunction with lymphatic basin dissection navigated by SLN identification represents the current paramount of SNNS for early gastric cancer. Patients with cT3 stage or higher still require standard D(2) dissection.

Use of vacuum-assisted closure (VAC™) in high-energy complicated perineal injuries: analysis of nine cases.

Our study reviewed nine patients who were treated with the VAC™ Abdominal Dressing System after suffering pelvic fractures and soft tissue loss after high-energy pelvic trauma. Between March 2008 and August 2009, our clinic treated nine patients with complicated perineal injuries from high-energy pelvic trauma with multiple irrigation and debridement procedures and broad-spectrum antibiotics. Protective ostomies were created for all nine patients. Required interventions were made for associated injuries, and VAC™ application was started. All patients were male, with an average age of 24·3 (range 21-32) years, and a mean injury severity score of 36·4 (range 16-59). Wound diameters ranged from 15 to 30 cm, and wound depths ranged from 5 to 25 cm. The injuries included one traumatic bilateral hemipelvectomy, and three unilateral and two bilateral lower extremity amputations. Intensive care unit length of stay averaged 12 (6-19) days, and average hospital length of stay was 44·12 (31-64) days. Beginning at an average of day 17 (±5·9 days) post-injury, wound cultures detected no bacterial colonisation. One patient died on the sixth day after injury from septic complications. Two patients' wounds were closed by primary closure, and six patients' wounds were closed by split thickness grafts after an average of 31·4 (17-50) days. Optimal treatment of high-energy perineal injuries requires early and extensive debridement and rich irrigation. The application of the VAC™ system as temporary coverage of large complex wounds in the pelvic region enhances wound healing and facilitates an early grafting process.

Fascin expression in colorectal carcinomas.

PURPOSE: The purpose of this study was to investigate the significance of fascin expression in colorectal carcinoma. METHODS: This is a retrospective study of 167 consecutive, well-documented cases of primary colorectal adenocarcinoma for which archival material of surgical specimens from primary tumor resections were available. We chose a representative tissue sample block and examined fascin expression by immunohistochemistry using a primary antibody against "fascin". We calculated the "immunohistochemical score (IHS)" of fascin for each case, which was calculated from the multiplication of scores for the percentage of stained cells and the staining intensity. RESULTS: Fascin immunoreactivity was observed in 59 (35.3%) of all cases with strong reactivity in 24 (14.4%), moderate reactivity in 25 (14.9%) and weak reactivity in 10 (6.0%) cases. Strong/moderate immunoreactivities were mostly observed in invasive fronts of the tumors or in both invasive and other areas. Fascin immunoreactivity scores were significantly higher in tumors with lymph node metastasis (p:0.002) and advanced stage presentation (p:0.007). There was no relation between fascin expression and age, gender, depth of invasion, distant metastasis or histological grade (p>0.05). There was a higher and statistically significant correlation between fascin immunoreactivity in the invasive borders of tumors and lymph node metastasis (r:0.747, p:0.005). In stage III/IV tumors, two-year survival was 92.2% in tumors without fascin immunoreactivity, and only 60.0% in tumors with a fascin IHS>10 (p:0.003). CONCLUSION: These findings suggest that fascin is heterogeneously expressed in approximately one third of colorectal carcinomas with a significant association with lymph node metastasis, tumor stage and location. Moreover, these results indicate that fascin may have a role in the lymph node metastasis of colorectal carcinomas.

Fascin expression in colorectal carcinomas

PURPOSE: The purpose of this study was to investigate the significance of fascin expression in colorectal carcinoma. METHODS: This is a retrospective study of 167 consecutive, well-documented cases of primary colorectal adenocarcinoma for which archival material of surgical specimens from primary tumor resections were available. We chose a representative tissue sample block and examined fascin expression by immunohistochemistry using a primary antibody against "fascin". We calculated the "immunohistochemical score (IHS)" of fascin for each case, which was calculated from the multiplication of scores for the percentage of stained cells and the staining intensity. RESULTS: Fascin immunoreactivity was observed in 59 (35.3 percent) of all cases with strong reactivity in 24 (14.4 percent), moderate reactivity in 25 (14.9 percent) and weak reactivity in 10 (6.0 percent) cases. Strong/moderate immunoreactivities were mostly observed in invasive fronts of the tumors or in both invasive and other areas. Fascin immunoreactivity scores were significantly higher in tumors with lymph node metastasis (p:0.002) and advanced stage presentation (p:0.007). There was no relation between fascin expression and age, gender, depth of invasion, distant metastasis or histological grade (p>0.05). There was a higher and statistically significant correlation between fascin immunoreactivity in the invasive borders of tumors and lymph node metastasis (r:0.747, p:0.005). In stage III/IV tumors, two-year survival was 92.2 percent in tumors without fascin immunoreactivity, and only 60.0 percent in tumors with a fascin IHS>10 (p:0.003). CONCLUSION: These findings suggest that fascin is heterogeneously expressed in approximately one third of colorectal carcinomas with a significant association with lymph node metastasis, tumor stage and location. Moreover, these results indicate that fascin may have a role in the lymph node metastasis of colorectal carcinomas.

Comparison of the efficacy of melatonin and 1400W on renal ischemia/reperfusion injury: a role for inhibiting iNOS.

INTRODUCTION: We investigated the roles of melatonin (a powerful antioxidant, iNOS inhibitor, and a scavenger of peroxynitrite) and 1400W (a strong and selective inhibitor of inducible nitric oxide) on renal dysfunction and injury induced by ischemia/reperfusion (I/R) of rat kidney, since oxidative and nitrosative injury are believed to be the major causes. MATERIALS AND METHODS: Thirty-two male Sprague-Dawley rats were divided into four groups of sham-operated, I/R, I/R + Melatonin and I/R + 1400W. Rats were given either melatonin (10 mg/kg) or 1400W (10 mg/kg) in the I/R + Melatonin and I/R + 1400W groups respectively at 6 h prior to ischemia and at the beginning of reperfusion via intraperitoneal route. I/R injury was induced by 60 min of bilateral renal ischemia followed by 6 h of reperfusion. After reperfusion, kidneys and blood were obtained for histopathologic and biochemical evaluation. RESULTS: Melatonin and 1400W had an ameliorative effect on both oxidative and nitrosative stress in the kidneys against renal I/R injury in rats. In addition, melatonin significantly reduced elevated nitro-oxidative stress product, restored decreased antioxidant enzymes and attenuated histological alterations when compared with 1400W. CONCLUSIONS: Both Melatonin and 1400W were efficient in ameliorating experimental I/R injury of the kidneys. Moreover, melatonin was more effective than 1400W possibly through inhibiting iNOS as well as scavenging free oxygen radicals and peroxynitrite.

Management and mid- to long-term results of early referred bile duct injuries during laparoscopic cholecystectomy.

BACKGROUND/AIMS: Bile duct injuries (BDI) usually need operative repair and remain as a challenge even for surgeons who specialize in hepatobiliary surgery. The objective of this study was to define the presentation, in-hospital management, and mid- to long-term outcome of BDIs during laparoscopic cholecystectomy (LC) referred to a tertiary center in their early period. METHODOLOGY: From January 1996 to January 2006, 31 patients with BDI sustained during or after LC were treated at our institution. Patients were referred to our center from 18 community hospitals in their first 15 postoperative days. Patients' charts were retrospectively reviewed; presentation, management, and follow-up details recorded at the primary hospitals and at our institution were documented. RESULTS: There were 5 patients with type-A and one with type-C injury, according to Strasberg classification. The remainders had a major BDI. The mean time to referral was 3.45 (median 2) days. Treatment methods chosen after referral were as follows: drainage-observation in 2 patients (6.5%), nasobiliary drainage in 4 (12.9%), endoscopic sphincterotomy plus biliary stenting in 1 (3.2%), and surgical intervention (duct-to-duct anastomosis or biliary-enteric reconstruction) in 24 patients (77.4%). Although a success rate of 83.3% was achieved in the early period, 10 patients (32.3%) had late postoperative complications (stricture and cholangitis), and of these, 3 required endoscopic stent placement, and 7 patients underwent a biliary diversion with Roux-en-Y Hepaticojejunostomy. One out of 24 patients with long-term follow-up developed biliary cirrhosis, and one patient with malignancy expired. CONCLUSIONS: Minor BDIs can be satisfactorily treated with endoscopic interventions. Extended lateral injuries, complete CBD transsections, and long segment stenosis usually require surgical therapy. Duct-to-duct anastomosis may be an option as the first-line therapy in selected patients after early referral, though many patients eventually require a Roux-en-Y hepaticojejunostomy.

Invasive pulmonary aspergillosis after liver transplantation: rapid and complete response to combined and sequential antifungal therapy.

BACKGROUND: Invasive pulmonary aspergillosis is a rare, but severe and potentially fatal, complication after liver transplantation. There is no therapeutic regimen accepted worldwide for both initial and continuation therapy; nevertheless, several options have been proposed. METHODS: Case report and review of the pertinent English-language literature. RESULTS: In a patient with pulmonary aspergillosis after a liver transplant, combined and sequential therapy with caspofungin and voriconazole with termination of the immunosuppressive regimen and careful management were helpful to control the infection rapidly, possibly because of a positive drug interaction. CONCLUSION: In cases of invasive aspergillosis that are refractory to monotherapy, this regimen may be used in an attempt to overcome the infection.

Can SAPS II predict operative mortality more accurately than POSSUM and P-POSSUM in patients with colorectal carcinoma undergoing resection?

BACKGROUND: This study assessed the APACHE II (Acute Physiology and Chronic Health Evaluation II), SAPS II (Simplified Acute Physiology Score-II), POSSUM (Physiologic and Operative Severity Score for Enumeration of Morbidity and Mortality), and P-POSSUM (Portsmouth-POSSUM) in patients with colorectal cancer undergoing curative or palliative resection. METHODS: Predicted mortality rates and the observed/expected mortality ratio were computed by means of each scoring system. The results were compared between survivors and nonsurvivors and between elective and emergency operations. Each model was assessed for its accuracy to predict the risk of death using receiver operator characteristic (ROC) curve analysis, and risk stratification was generated as well. RESULTS: Some 224 patients were enrolled in the study. The overall 30-day mortality rate was 3.6% (n = 8). Predicted mortality rates generated by APACHE II, SAPS II, POSSUM, and P-POSSUM were 9.1%, 3.7%, 13.4%, and 5.2%, respectively. All the scoring systems assigned higher scores to those patients who died than to those who survived. Areas under the curve calculated by ROC curve analysis for APACHE II, SAPS II, POSSUM, and P-POSSUM were 0.786, 0.854, 0.793, and 0.831, respectively. Best stratification was achieved by the SAPS II score. CONCLUSIONS: SAPS II and P-POSSUM were determined to be better predictors for patients with colorectal cancer undergoing resection. SAPS II also was found to have a higher degree of discriminatory power in colorectal resection for carcinoma. The predictive value of this useful severity score in several surgical subgroups must be examined to evaluate its routine use in risk-adjusted audit.

Accurate positioning of the 24-hour pH monitoring catheter: agreement between manometry and pH step-up method in two patient positions.

AIM: To investigate the agreement between esophageal manometry and pH step-up method in two different patient positions. METHODS: Eighteen subjects were included in the study. First, the distance from the nose to the proximal border of the lower esophageal sphincter (LES) was measured manometrically. Then a different investigator, who was blinded to the results of the first study, measured the same distance using the pH step-up method, with the patient in both upright and supine positions. An assessment of agreement between the two techniques was performed. RESULTS: In the supine position, the measurement of only one subject was outside the range accepted for correct positioning (< or = 3 cm distal or proximal to the LES). In the upright position, errors in measurement were recognized in five subjects. Bland-Altman plots revealed good agreement between measurements obtained manometrically and by the pH-step up method with the patient in the supine position. CONCLUSION: In the case of nonavailability of manometric detection device, the pH step-up method can facilitate the positioning of the 24 h pH monitoring catheter with the patient in the supine position. This should increase the use of pH-metry in clinical practice for subjects with suspected gastroesophageal reflux disease if our results are supported by further studies.

Detection of micrometastases and skip metastases with ex vivo sentinel node mapping in carcinoma of the colon and rectum.

BACKGROUND: The debate over sentinel lymph node mapping (SLNM) and focused pathologic examination to detect micrometastases in patients with colorectal cancer (CRC) continues. We present in this paper our experience with SLNM for CRCs to improve staging. In addition, we have detailed the mapping procedure on an anatomical basis to define skip metastasis. MATERIALS AND METHODS: Forty-seven patients underwent ex vivo SLNM. Immediately after resection, 1 ml of patent blue VF was injected submucosally around the tumor. Lymph nodes harvested from the first 15 patients were mapped in a standard fashion as the blue-stained nodes (SLNs), and the others (non-SLNs) were dissected away. In the remaining 32 patients, the lymph nodes were also mapped separately in relation to their anatomic location and described as epicolic-paracolic, intermediate, and principal. The blue-stained nodes (SLNs) and non-SLNs, negative by hematoxylin and eosin stain, were further stained with cytokeratin immunohistochemical analysis and carcinoembryonic antigen. RESULTS: A total of 873 histologically confirmed LNs were examined with a mean of 18.6+/-8.1 nodes per patient. In 46 of 47 patients (97.8%), SLNs were identified. Immunohistochemical staining revealed micrometastases in the lymph nodes of four patients, which were negative by conventional methods. Anatomical skip metastases were noted in 4 of 32 patients studied (12.5%). CONCLUSION: Ex vivo SLNM in CRCs is a feasible technique with a high SLN identification rate. Results of anatomical mapping of lymph nodes correlates with the limited literature, suggesting that occult skip metastases can occur in the apical lymph node group and may occur outside the resected area.

Preoperative and postoperative administration of hyperbaric oxygen improves biochemical and mechanical parameters on ischemic and normal colonic anastomoses.

Colonic anastomotic leaks are a major postoperative complication, causing increased mortality and morbidity. Tissue ischemia is one of the most important factors that disrupt anastomotic healing. It is possible to reverse inadequate tissue oxygenation by using increased atmospheric pressure and hyperoxia, which are obtained from hyperbaric oxygen treatment (HBO). Our aim was to investigate the effects of preoperative and postoperative HBO treatment on normal and ischemic colonic anastomoses in rats. Eighty male Wistar Albino rats, weighing between 180 and 240 g, were divided into 8 equal groups. A 1-cm segment of left colon was resected 3 cm proximal to the peritoneal reflection in all groups and colonic anastomosis was performed. In groups 2, 4, 6 and 8, colonic ischemia was established by ligating 2 cm of mesocolon on either side of the anastomosis. Control groups (1 and 2) received no HBO. HBO treatment was given preoperatively in groups 3 and 4, postoperatively in groups 5 and 6, and both preoperatively and postoperatively in groups 7 and 8. HBO treatment was applied for 2 days in the preoperative period and 4 days in the postoperative period. Relaparotomy was performed on postoperative day 5 and a perianastomotic colon segment 2 cm in length was excised for detection of biochemical and mechanical parameters of anastomotic healing and histopathological evaluation. HBO treatment increased tissue hydroxyproline levels in all groups, and this difference was significant in normal anastomosis groups receiving preoperative HBO compared to controls (p = .013 for group 1 vs. group 3; p = .023 for group 1 vs. group 5). This improvement was more evident in ischemic and normal groups treated by administration of combined pre- and postoperative HBO (p = .021 and p = .013). HBO treatment also increased the mean bursting pressure values in all groups, and again, a statistically significant increase was noted in the ischemic groups compared to controls (p = .002 for group 2 vs. group 6; p = .001 for group 2 vs. group 8). Histopathological evaluation of anastomotic line fibrosis was not found to show significant differences between the groups. Adequate tissue oxygenation is the main factor in wound and anastomosis healing. HBO treatment has a positive effect on biochemical and mechanical parameters of ischemic and normal colon anastomoses in rats. It is possible to see this effect more clearly with combined HBO treatment applied before and after ischemic anastomosis.

Outpatient prescription of oral antibiotics in a training hospital in Turkey: trends in the last decade.

AIM: The aim was to evaluate the changing trends in outpatient prescription of oral antibiotic forms at a Training Hospital in the last decade. MATERIAL AND METHOD: All the outpatient prescriptions during April and May 2004 were evaluated. The diagnosis, the department of the prescriber, the count and generic name of each prescribed antibiotic were all noted. RESULTS: Of the 33,491 outpatient prescripitions, 14.9% included antibiotic (n=5004). The pediatric clinics (26.4%), Ear, Nose and Throat department (13.7%), and the department of Gyneacology and Obstetrics (10.8%) were the leading departments in antibiotic prescriptions. Upper respiratory tract infections (45.4%), urinary tract infection (11.4%) and lower respiratory tract infections (4.2%) shared the first lines of diagnosis stated. Of the antibiotic prescriptions, 96.3% included oral forms. Co-amoxiclav (26.4%), quinolones (11.7%) and cephalosporins (16.5%) were the most frequently prescribed antibiotics. Percent of antibiotic prescriptions based on microbial sensitivity test results was 7.1%. CONCLUSION: Compared with the results of the study carried out 11 years ago; though co-amoxiclav is still the most frequently prescribed antibiotic, many other changes have been observed in antibiotic prescription attitudes.

An unusual complication of the use of stapler after Hartmann's procedure.

BACKGROUND: Circular anastomotic staplers have been used in colorectal surgery for several years with low complication rates. We report here an extremely rare case of direct colovaginal anastomosis and rectovaginal fistula occurred by using a 31 end-to-end anastomosis stapler after reversal of Hartmann's Procedure. STUDY DESIGN: A 33-year-old woman with complaint of rectal bleeding had undergone low anterior resection and end colostomy for rectal adenocarcinoma in 1995. In spite of making recommendation for colostomy closure, she had postponed the operation until 2003 due to afraid of incontinence. After reversal of Hartmann's procedure achieved by using circular stapler and diverting ileostomy, she developed complaints of vaginal gas and minimal vaginal fecal discharge. RESULT: Endoscopic examination and imaging methods revealed a rectovaginal fistula with a blind Hartmann's pouch. After a certain verification of complexity of the case, a reoperation which comprises true intestinal anastomosis and repair of fistula was performed. Postoperative period was uneventful except an incisional infection, and ileostomy was closed subsequently. CONCLUSION: A rectovaginal fistula, though encountered rarely, must be taken into account in cases with suspicious complaints after using circular stapler for pelvic intestinal anastomosis. Careful placement of stapler in accurate direction has a great importance to avoid stapling related complications.