Gallbladder carcinoma associated with gallstones.

The great majority of gallbladder carcinoma is associated with gallstones. This cancer is generally diagnosed in advanced stages, and the prognosis is very poor. In this study we analysed retrospectively 3119 patients with cholelithiasis alone, and 35 patients with gallbladder cancer. Thirty-three of 35 cancer cases (94%) were associated with gallstones. Cancer rate was 1% in patients with cholelithiasis. Mean age was significantly higher in patients with gallbladder cancer than in those with cholelithiasis alone, 66.5 and 53.3 respectively (p < 0.0001). Sixty four percent of cancer cases were between 61-70 years of age, and the rate of carcinoma was 2.8% in this group (p < 0.001). The cancer rate was found to be 0.29% inpatients under 60 years of age, and 2.56% in those over 60 years (p < 0.001). According to Nevin's classification, 88% of cancer cases were found in advanced stages. Seventeen (52%) cases were diagnosed preoperatively. Ninety four percent of patients with preoperative diagnosis were in advanced stages compared with 31% of patients with incidental diagnosis (p = 0.0002). Patients with early stages carcinoma were alive and free of disease 58 months after operation. Average survival was only 9.5 months in patients with advanced cancer. We conclude that the incidence of gallbladder carcinoma increases significantly in patients over 60 years of age. Today preoperative early diagnosis is almost impossible, and long-term survival is possible only for early cases incidentally discovered at postoperative pathological examination of removed gallbladders for gallstone disease. Radical surgery has not provided long-term survival. We recommend close follow-up of patients with cholelithiasis, and enlargement of indication for cholecystectomy in a selective manner, considering some criteria in patients older than 55 years of age who are known with long-standing cholelithiasis.

Effects of neurotensin on the healing of experimental anastomosis of the colon.

The leakage of colonic anastomoses increases perioperative morbidity significantly. The purpose of the study was to investigate the influence of neurotensin, an intestinal trophic peptide, on the healing of colonic anastomosis. Forty-two Wistar-albino rats were separated into three equal groups: Group 1 (control group)--segmental resection of the left colon and end-to-end anastomosis; Group 2 (dexamethasone group)--resection and anastomosis, plus 0.1 mg/kg/day of dexamethasone; Group 3 (neurotensin group)--same surgical procedure plus 300 micrograms/kg/day of neurotensin. Bursting pressure and tissue hydroxyproline content were determined as parameters of the anastomosis strength and healing on the 3rd and 7th days postoperatively. On the 3rd day, mean bursting pressures were 141.4, 146.7 and 73.1 (p = 0.0001) cm of water in the control group, dexamethasone and neurotensin groups respectively. On the 7th day, bursting pressures were measured as 237.4, 100.6 (p = 0.0001) and 72.7 (p = 10(-6)) cm of water, in the control group, dexamethasone and neurotensin groups respectively. Between the 3rd and 7th days, bursting pressures were increased significantly in the control group (p = 0.0001), decreased in the dexamethasone (p = 0.048), and maintained their lowest values in the neurotensin (p = 0.96) groups. On the 7th day, mean hydroxyproline levels were measured as 9.20, 3.30 (p = 0.007), 2.86 (p = 0.007) micrograms, in the control group, dexamethasone, and neurotensin groups respectively. Between the 3rd and 7th days, tissue hydroxyproline levels were increased significantly in the control group (p = 0.004), decreased in the dexamethasone (p = 0.03), and maintained their lowest values in the neurotensin (p = 0.87) groups. The anastomosis resistance to intraluminal pressure was weak, tissue collagen content was insufficient, and healing was inadequate in the dexamethasone and neurotensin groups in respect to the control group. We concluded that neurotensin impaired the healing, and affected the strength of the colonic anastomosis.

Perfusion and functional anatomy of the splenic remnant supplied by short gastric vessels.

BACKGROUND: Surgeons have described many methods to preserve the injured spleen for the maintenance of host defence. The volume and the perfusion of remaining splenic tissue are important for better functional results. Imaging the functioning tissue with radionuclide provides information about the physiology of the concerning organ. METHODS: Thirty rats were separated into three groups: control, explorative laparotomy alone; partial splenectomy, upper part of the spleen supplied by short gastric vessels was preserved after partial resection; and devascularized spleen, the entire spleen was preserved after ligation of splenic artery. The size, functional anatomy, and perfusion status of splenic tissue were assessed by liver-spleen scintigraphy using radiolabeled heat denatured red blood cells. RESULTS: In the partial splenectomy group, splenic radioactivity count, spleen/liver ratio, and radionuclide uptake were mildly reduced, and found to be 87% (P = 0.012), 91% (P = 0.16), and 88% (P <0.001) of the normal spleen, respectively. The area of functional tissue in the upper splenic remnant was 51% (P <0.001) of the normal spleen. In the devascularized spleen group, the radioactivity count, the ratio, and the uptake were 38% (P <10(-6)), 36% (P <10(-6)), and 49% (P <10(-6)) of the normal spleen respectively. The area of functional tissue in the devascularized spleen was calculated as 47% (P <10(-6)) of the normal spleen. CONCLUSIONS: The collateral circulation is insufficient for proper function of the entire spleen after disconnection of the main arterial blood supply. The functional tissue is markedly impaired. On the other hand, the upper part of the spleen is remained well perfused via the short gastric vessels. The collateral circulation is satisfactory for this splenic tissue after reduction of its volume. That size splenic tissue seems to have satisfactory functional ability. Proper functional results mostly depend on the balance between the volume and blood supply of the remaining splenic tissue.

Protective procedures following splenic rupture.

The aim of the present study was to improve spleen-preserving procedures in patients undergoing laparotomy following abdominal trauma. Of a total 288 patients who underwent laparotomy for abdominal trauma in the Fourth General Surgical Department of Hardarpasa Teaching Hospital between 1989 and 1996, 94 patients with splenic injuries were retrospectively analyzed. The mean age of these 94 patients, 69% whom were male, was 28.9 +/- 3.5 years. Traffic accidents were found to be the major cause of splenic injuries (71.3%) and diagnostic peritoneal lavage was frequently used as a diagnostic tool (58.8%). Grades IV and V splenic injuries were seen in 71 patients (75.4%), all of whom required splenectomy. Omentoplasty with partial splenectomy or omentoplasty with splenorrhaphy successfully controlled hemorrhage from the spleen in 22 patients (23.4%). The complication rate was calculated at 18.06% in this study, but no deaths occurred as a direct result of splenic injury. In conclusion, omentoplasty, partial splenectomy, and splenorrhaphy are safe and successful methods of controlling bleeding from a damaged spleen of grade III in patients without multiple injuries.

Hypertonic saline prevents early bacterial translocation in hemorrhagic shock.

The most appropriate solution for volume replacement in hemorrhagic shock is controversial; however, hypertonic saline (HTS) solutions have recently gained widespread acceptance. In this study, various solutions were used to resuscitate rats in hemorrhagic shock, and their impact on the extent of bacterial translocation was investigated. Rats were bled to a mean arterial blood pressure of about 35 mmHg which was maintained for 30 min. They were then randomized into six groups. Blood pressure was found to be regulated by blood + lactated Ringer's solution (LR) and HTS + LR, but no significant improvement was observed in the control and LR groups. Groups II (7.5% HTS + 60 ml/kg LR) and IV (60 ml/kg LR + autologous blood) had a significantly better result than groups I (7.5% HTS), III (60 ml/kg LR), and IV (P < 0.05), among which no statistically different results were seen (P > 0.05). While no organisms were isolated from the mesenteric lymph nodes in the sham group, the rates of positive culture were 12.5%, 12.5%, 50%, 62.5%, and 62.5% in groups I, II, III, and the control group, respectively. Escherichia coli was the most commonly isolated organism. HTS + LR was demonstrated to be effective for decreasing the rate of early bacterial translocation to mesenteric lymph nodes and also for restoring the mean arterial pressure.

Does chemical composition have an influence on the fate of intraperitoneal gallstone in rat?

Perforation and spillage of gallstones is a common occurrence in laparoscopic cholecystectomies. The long-term complications of these stones remains controversial. Experimental studies have been carried out to elucidate the outcome of intraperitoneal gallstones, but the chemical composition of these stones has not been considered in previous studies. In this study, we investigated the local effects of intraperitoneal gallstones in rats with respect to their chemical composition. Bile and gallstones were taken from human cholecystectomy specimens, and sent for bacteriologic and chemical analysis. Twenty cholesterol and 10 pigment stones were placed in the abdominal cavity of rats. Long-term local effects of gallstones were determined at the end of 3 months with macroscopic and microscopic examination. The fragments of two pigment stones were infected by Staphylococcus aureus. Five (17%) cholesterol stones were found free in the abdominal cavity, and 25 stones (83%) were wrapped with adjacent structures. Granuloma formation was found around 4 pigment stones (13% of all stones, 40% of pigment stones; p = 0.0077). We observed large granulomas and cutaneous fistula formation in two rats with infected pigment stones placed in the abdominal cavity. Histhopathologic examination also showed significantly severe inflammatory reactions secondary to pigment stones (p<0.001). In conclusion our findings revealed that chemical composition has a significant influence on the fate of intraabdominal gallstones, and infection may aggravate local reactions and complications. Based on our findings, laparoscopic retrieval of spilled stones whenever possible seems to be useful to prevent subsequent infectious complications and inflammatory reactions. Patients with retained intraperitoneal pigment stones after laparoscopic cholecystectomy must be followed up closely.

The inflammatory response to open tension-free inguinal hernioplasty versus conventional repairs.

BACKGROUND: The tension-free inguinal hernioplasty is now a popular method because of less postoperative disability and low recurrence rate. The laboratory evaluation of the inflammatory response to the injury is an objective approach to determine the stress status of a surgical procedure. The aim of this study is to evaluate and to compare inflammatory responses to open tension-free and conventional repairs of inguinal hernias. METHODS: Forty-eight male patients with primary indirect inguinal hernias were treated with elective operations, and separated into three groups according to surgical procedure: 12 pediatric patients treated with dissection of hernia sac in group 1, 16 adult patients with open tension-free hernioplasty in group 2, and 20 adult patients with conventional repairs in group 3. Ten healthy adult volunteers formed group 4 as control. The repair was performed with polypropylene mesh and suture as the Lichtenstein technique in group 2, and with polypropylene suture as one of Bassini, McVay, or Shouldice techniques in group 3. The inflammatory response was evaluated with serum interleukin-6 (IL-6) levels at 12 hours and serum C-reactive protein (CRP) levels at 48 hours postoperatively. Serum levels of IL-6 and CRP were measured in group 4 as control. Patient characteristics, operating time, and IL-6 and CRP levels were compared among the four groups. RESULTS: There were no significant differences in mean age and operating time between the two groups of adult patients with hernia repair. Mean serum IL-6 levels of 12.1 +/- 5.2 and 8.2 +/- 2.7 pg/mL, and CRP levels of 34.3 +/- 13.8 and 7.5 +/- 4 mg/L in pediatric and control groups, respectively, were significantly lower than in the other two hernia groups. Mean serum IL-6 levels were 58.9 +/- 25.4 pg/mL in group 2 (tension-free repair) and 44.3 +/- 18.1 pg/mL in group 3 (conventional repair) (P > 0.05). Mean serum CRP levels were 111.3 +/- 41.3 and 83 +/- 43.2 mg/L in groups 2 and 3, respectively (P > 0.05). The differences not being statistically significant, a similar and considerable inflammatory response was noted in patients with either prosthetic mesh repair or with conventional repairs of indirect inguinal hernias. CONCLUSIONS: The reinforcement of the posterior wall of the inguinal canal induces significant cytokine response regardless of tension-free or conventional repair. Open tension-free hernioplasty offered no advantages over conventional repairs from the standpoint of the inflammatory and acute phase response.

The effects of diltiazem on superior mesenteric artery ligation. An experimental study.

The effects of diltiazem on an experimental study of Superior Mesenteric Artery ligation were studied on three rat groups comprising controls (N = 5), SMA ligation (N = 8), and SMA ligation and diltizem (0.25 mg/kg injection), (N = 8). Creatine phosphokinase, lactic dehydrogenase, aspartate transaminase and alanine transaminase venous blood levels were significantly decreased after diltiazem injection compared with the SMA ligation group. Histopathologic examinations revealed that diltiazem partly protected the small intestine from ischemic changes.

Blockade of transdiaphragmatic lymphatic absorption reduced systemic inflammatory response syndrome during experimental peritonitis: evaluation with body oxygen kinetics in rats.

OBJECTIVE: To assess the effect of blockade of transdiaphragmatic lymphatic absorption of infected peritoneal fluid on systemic inflammatory response syndrome during experimental peritonitis by evaluating body oxygen kinetics in rats. DESIGN: Randomised controlled experimental study. SETTING: Teaching hospital, Turkey. MATERIAL: 30 Wistar-albino rats, 10 in each group. INTERVENTIONS: Control group, sham laparotomy; peritonitis alone group, faecal peritonitis induced by caecal puncture; and lymphatic blockade and peritonitis group, transdiaphragmatic lymphatic absorption was blocked by fibrosis created by a sheet of braided polyester (Mersilene) mesh, and peritonitis induced with caecal puncture. MAIN OUTCOME MEASURES: Aerobic culture of peritoneal contents and blood. Arterial and mixed venous blood gas analysis, plasma lactate concentrations. Indicators of body oxygen kinetics were calculated from these variables. RESULTS: Bacterial peritonitis was detectable in all 20 animals in the experimental groups. Blood cultures grew pathogens in 9/10 animals in the peritonitis alone group and 4/10 in the lymphatic blockade group (p = 0.057). Among the measured blood gas variables there were significant differences in PvO2 (p = 0.006) and in PaCO2 (p = 0.02), and as indicators of tissue perfusion and acidosis there were significant differences in all calculated blood gas variables and in plasma lactate concentration (p = 0.0001) between the two experimental groups. Hypoxia as judged by the oxygen utilisation coefficient of over 0.5 and oxygen saturation of mixed venous blood of less than 50%, eight animals were hypoxic in the peritonitis alone group compared with one in the lymphatic blockade group (p = 0.006). CONCLUSION: Animals in which transdiaphragmatic drainage was obstructed had fewer positive blood cultures and better body oxygen balance during peritonitis, indicating that blockade of transdiaphragmatic lymphatic absorption of peritoneal contents reduced systemic inflammatory response syndrome.

Videolaparoscopic treatment of liver hydatid cysts with partial cystectomy and omentoplasty. A report of two cases.

Hydatid disease is one of the world's most important health problems. Although several conservative approaches have been used for the management of this condition, surgery remains the ideal choice in most of the cases. Videolaparoscopic approach can safely be applied for the management of liver hydatid cysts if several precautions are undertaken. In this study, we present two liver hydatid cyst cases successfully treated with partial cystectomy and omentoplasty using videolaparoscopic approach.

Accuracy of serum C-reactive protein measurements in diagnosis of acute appendicitis compared with surgeon's clinical impression.

UNLABELLED: Diagnosis of acute appendicitis is established generally by the surgeon's clinical impression. Today, negative laparotomy rate because of clinical diagnosis is still 15 to 25 percent. PURPOSE: This study was designed to determine the accuracy of C-reactive protein (CRP) measurements in the diagnosis of acute appendicitis and to compare it with the surgeon's clinical diagnosis. METHODS: One hundred eight consecutive patients were studied prospectively. Depending on results of the examination by a surgeon, patients underwent surgery for acute appendicitis. Serum CRP measurements were performed before the operations but were not taken into account for the decision of laparotomy to compare it with the surgeon's clinical diagnosis. RESULTS: Histopathologic findings confirmed acute appendicitis in 90 patients. Normal appendixes were removed in the remaining 18 patients. Mean serum CRP value was 5 (range, 0-12.6) mg/l in patients with normal appendix, 33.8 (range, 5-85.1) mg/l in patients with nonperforated appendicitis, and 128.5 (range, 79.2-230) mg/l in patients with perforated appendixes. These differences were highly significant (P < 10(-6)). Serum CRP levels were normal in three patients with acute appendicitis. Thus, the false-negative rate of CRP was 3 percent. Of 18 patients with normal appendectomy serum CRP levels were slightly elevated in two patients. We determined, therefore, a false-positive rate of CRP as 11 percent. CRP levels were false-negative in three patients and false-positive in two patients. Thus, CRP levels were true (positive or negative) in the remaining 103 patients. On the other hand, the diagnosis depending on surgeon's clinical impression was true in 90 patients and false in 18 patients. This difference was statistically significant (P = 0.0035). In the present study the sensitivity, specificity, and accuracy of serum CRP measurements were calculated as 93.5, 80, and 91 percent, respectively. CONCLUSION: We found that elevated serum CRP levels support surgeon's clinical diagnosis. We recommend CRP measurement as a routine laboratory test in patients with suspected diagnosis of acute appendicitis.