Endoanal ultrasonographic evaluation of an unhealed anal fissure after the lateral internal sphincterotomy.

OBJECTIVES: The aim of this study was to evaluate the outcomes of the lateral internal sphincterotomy in patients who had unhealed anal fissures using the endoanal ultrasonography. BACKGROUND: Lateral internal sphincterotomy is an effective method in treatment of chronic anal fissures, but it is associated with 1 to 5 % unhealing and recurrence rates. Endoanal ultrasonography can be used to evaluate the sphincterotomy and the efficiency of the treatment. METHODS: Totally, 40 patients with unhealed anal fissures after the lateral internal sphincterotomy were enrolled consecutively. The fissures were diagnosed by proctologic examination in every patient. The results of sphincterotomy were evaluated by the endoanal ultrasonography. RESULTS: There were 23 men and 17 women with the median age 29.7 years (range, 20-44 years). Using the endoanal ultrasonography, an incomplete internal sphincterotomy was detected in 26 of patients. In 12 patients, while the internal sphincter was completely intact, a superficial (subcutaneous) external anal sphincterotomy was found. In two patients, although the internal sphincterotomy was observed to be sufficient, a localized abscess formation of less than 1 cm was detected at the anal crypts level. CONCLUSION: The use of endoanal ultrasonography in patients with unhealed or recurrent anal fissure is a beneficial diagnostic method in assessing the situations of sphincters after the lateral internal sphincterotomy. Although the lateral internal sphincterotomy is a successful surgical treatment and can be performed easily as an outpatient procedure, it should be performed with the correct and rigorously surgical technique (Tab. 2, Fig. 3, Ref. 31).

Spontaneous cholecystocutaneous fistula as a rare complication of gallstones.

Spontaneous perforation of gallbladder as a complication of biliary stones may lead to a cholecystocutaneous abscess or fistula. The pathophysiology of this condition has been associated with increased pressure in the gallbladder, secondary to biliary obstruction. Ultrasonography and Computed Tomography (CT) can be used for diagnosis of cholecystocutaneous abscess or fistula. The treatment of fistula requires adequate drainage, antibiotics, followed by elective cholecystectomy with excision of the fistula. We report a case of spontaneous cholecystocutaneous fistula in an 89-year-old female patient who presented with obstructive jaundice and subcutaneous abscess in the right subcostal area. Abdominal CT scan showed gallstones and communication between the abscess and the gallbladder. First abdominal wall abscess was drained externally then cholecystectomy and exploration of common bile duct was performed (Fig. 3, Ref. 8).

Prognostic value of oncoprotein expressions in thyroid papillary carcinoma.

The aim of this study was to evaluate the expressions of oncoproteins and to correlate the results with clinicopathologic parameters in papillary thyroid carcinoma (PTC). Papillary thyroid cancer (PTC) is the most common form and accounts for about 80% of all thyroid cancers. Although PTC generally has a good prognosis, some patients suffer from local recurrence and/or distant metastasis. Oncogenes have reported to be related not only in carcinogenesis but also in tumor prognosis, tumor type, differentiation and site of tumor in epithelial malignant tumors such as thyroid, breast, ovarian, and stomach cancer. This study was planned retrospectively and was performed in 87 patients (47 PTC, 40 benign lesions). The data of clinicopathologic parameters and tissue samples were collected from the archives. Sections stained with H&E were evaluated for each case and after confirming the diagnosis of PTC, oncoprotein expressions were determined by immunohistochemical analysis. The differences of oncoprotein expressions in PTC compared with control group were statistically significant. Cyclin D1 and p53 expressions were significantly increased in PTC. The expressions of bcl-2 and c-erbB-2 in PTC were found as increased, but the correlation between these proteins and poor prognostic parameters were not significant. We suggest that increased expressions of cyclin D1 and p53 could be used as prognostic factors in patients with PTC.

The survival effect of E-cadherin and catenins in colorectal carcinomas.

AIM: The E-cadherin/catenin complex plays an important role in epithelial tissue architecture. Decreased expression of cell adhesion molecules (E-cadherin, α-, ß- and γ-catenin) have been reported to correlate with invasive behaviour. The aim of this study was to investigate the relation between the expression of adhesion molecules and clinicopathological characteristics and survival in colorectal carcinoma. METHOD: The expression of adhesion molecules were studied by immunohistochemistry in 138 colorectal carcinomas. RESULTS: The mean age of the patients was 65 years (range: 21-89 years). In primary carcinomas, a reduction in membranous expression of E-cadherin, α-catenin, ß-catenin, γ-catenin was demonstrated (70%, 68%, 73%, 77%, respectively). Nuclear expression of ß-catenin was found in eight (5%) patients. Decreased membranous ß- and γ-catenin expression significantly correlated with tumour differentiation (P = 0.013, P = 0.03, respectively). There was a significant association between advanced stage of the tumour and decreased membranous α-catenin expression (P = 0.012). Decreased E-cadherin and ß-catenin membranous expression correlated with short survival following curative resection of the primary tumour (P = 0.04, P = 0.03, respectively). CONCLUSION: The decreased membranous expression of E-cadherin and ß-catenin and increased cytoplasmic expression of ß-catenin might be used as a prognostic marker to monitor patients with colorectal cancer.

Necrotizing fasciitis: A life-threatening clinical disorder in uncontrolled type 2 diabetic patients.

We presented 23 patients with necrotizing fasciitis (NF), 15 of whom had uncontrolled diabetes mellitus (DM), for risk factors, clinical signs, laboratory findings and prognosis during the period 1998 and 2006 in Istanbul. A hospital incidence of NF was 14.2/100,000 admissions. Other risk factors were obesity in 9 and recent surgical trauma in 10 patients. The mean age of the patients with DM was higher than that of the patients with non-DM (58.6+/-12.8 vs 43.0+/-17.2 years, p=0.028). The most frequently isolated microorganisms from tissue cultures were Escherichia coli, Klebsiella pneumoniae and Group A streptococci. Of the 23 patients, 9 (39%), of whom 8 had DM, died between 2 and 29 days after admission. The mortality rate and length of hospitalization were longer in diabetic patients than in others (p=0.02 and p=0.286, respectively). The mean blood glucose levels and HbA1C were higher in non-survival group than in survival group (195.6+/-41.5 vs 133.7+/-22.1 and 10.6 vs 7.4) (p=0.04, r=0.39 and p=0.03, r=0.50, respectively). In the univariate analysis, the hospitalization time (r=0.72), white blood cell count (r=0.52) and surgical debridement count (r=0.47) were found to be prognostic risk factors. Our results showed that NF is a very serious life-threatening disorder in especially diabetic patients with bad metabolic control.

A possible role of Bacteroides fragilis enterotoxin in the aetiology of colorectal cancer.

The prevalence of enterotoxigenic Bacteroides fragilis (ETBF) was investigated in stool specimens from 73 patients with colorectal cancer and from 59 control patients. Stool specimens were cultured on Bacteroides Bile Esculin agar and B. fragilis was identified by conventional methods. After DNA extraction, the enterotoxin gene (bft) was detected by PCR in 38% of the isolates from colorectal cancer patients, compared with 12% of the isolates from the control group (p 0.009). This is the first study demonstrating an increased prevalence of ETBF in colorectal cancer patients.

D-dimer in the early diagnosis of acute mesenteric ischemia secondary to arterial occlusion in rats.

BACKGROUND: Early diagnosis of mesenteric ischemia can be life saving. The aim of this study is to investigate the time-dependent diagnostic value of plasma D-dimer and other ancillary laboratory evaluations such as creatine phosphokinase, lactic dehydrogenase, aspartate aminotransferase, alanine aminotransferase, amylase, and leukocyte count in an experimental superior mesenteric arterial occlusion (SMA-O) model in rats. METHODS: Forty male Wistar-Albino rats were separated into 4 groups: 2-, 4-, 6-, and 12-hour SMA-O groups. After laparotomy, the SMA was identified and ligated for 2, 4, 6 and 12 h in the 4 respective study groups. Blood samples were taken for laboratory tests 2 h after laparotomy in the control group and at the end of the ischemic period in the study groups. RESULTS: The longer the duration of mesenteric ischemia, the higher were the serum D-dimer levels in the study groups, and statistical significance was obtained at 2 h (p = 0.021). Sensitivity, positive predictive value, negative predictive value, and accuracy of the relation were 88.8, 88.8, 100 and 90%, respectively. Leukocyte count was significantly higher than controls after 12 h. No other laboratory parameter correlated positively with the duration of mesenteric ischemia. CONCLUSION: Serum D-dimer measurements may be a valuable diagnostic parameter in the early diagnosis of mesenteric ischemia.

Effect of hyperbaric oxygen on anastomoses created under the influence of 5-FU.

AIM: This study investigates the effects of hyperbaric oxygen (HBO2) therapy on the healing capacity of colonic anastomoses under the influence of preoperative chemotherapy. MATERIAL AND METHOD: Forty male Wistar-Albino rats were divided into four groups of 10. Colonic resection and anastomosis were performed in each group. Group I (control) received no further treatment. In group II, 5-fluorouracil was administered intraperitoneally for five consecutive days preoperatively. Group III received HBO2 therapy for seven days after the anastomosis. Group IV received HBO2 therapy following the administration of preoperative 5-fluorouracil. On the seventh postoperative day, all the rats were examined to determine the bursting pressures of the anastomosis and to take tissue sample from the anastomotic line for hydroxyproline measurement. RESULTS: Bursting pressures of the anastomosis in group IV were increased significantly compared to group II. Hydroxyproline levels were significantly increased with the use of HBO2 in rats, independent of chemotherapy administration. CONCLUSION: HBO2 therapy strengthens anastomoses created under the influence of neoadjuvant chemotherapy. This technique might have a future role in the care of colon cancer patients undergoing new multimodality cancer treatments.

Hyperbaric oxygen improves healing in experimental rat colitis.

This study was designed to investigate therapeutic effects of hyperbaric oxygen on experimentally induced colitis in rats by assessing oxidative tissue damage, neutrophil accumulation and histological changes. Six groups of animals were used. No procedures were done in the sham group. In the vehicle group, 50% ethanol-induced colitis, and in four other groups, 2,4,6-trinitrobenzene sulphonic acid-induced colonic inflammation was achieved. In acute and chronic colitis non-treatment groups, no other procedure was done. In acute and chronic colitis hyperbaric oxygen treatment groups, rats underwent hyperbaric oxygen treatment for two or fourteen days. On the third and fifteenth days respectively tissue and blood samples were taken for microscopic and macroscopic damage assessment, myeloperoxidase activity and serum carbonyl content measurements. There was significant colonic tissue damage in non-treatment groups at 48 hours and 14 days. Hyperbaric oxygen treatment ameliorated the macroscopic damage significantly in chronic colitis. Amelioration of microscopic changes was not significant in each hyperbaric oxygen-treated group. Hyperbaric oxygen treatment significantly reduced tissue myeloperoxidase activity in acute colitis and decreased plasma carbonyl content in chronic colitis. In the present study, hyperbaric oxygen treatment significantly ameliorated trinitrobenzene sulphonic acid-induced chronic colitis in rats.

Hyperbaric oxygen prevents bacterial translocation in rats with obstructive jaundice.

This study was designed to demonstrate bacterial translocation following bile duct ligation and investigate preventive effects of hyperbaric oxygen on obstructive jaundice-related bacterial translocation in an animal model. Hyperbaric oxygen treatment significantly reduced the endogenous colony counts in distal ileum of normal rats both in the short (two days) and long (seven days) term. Endogenous bacteria in distal ileum significantly increased in bile duct ligated rats in the short and long term, and presence of bacterial translocation was proven by bacterial growth in mesenteric lymph nodes, liver, spleen, and blood. Short- and long-term hyperbaric oxygen treatments significantly reduced the intestinal colony counts and prevented the bacterial translocation almost completely in rats with bile duct ligation. It is concluded that obstructive jaundice causes bacterial overgrowth and translocation, and hyperbaric oxygen treatment can prevent both bacterial overgrowth and translocation effectively.

Is helium insufflation superior to carbon dioxide insufflation in bacteremia and bacterial translocation with peritonitis?

PURPOSE: To evaluate the effects of CO2 or helium insufflation on bacteremia and bacterial translocation in rats with peritonitis. MATERIALS AND METHODS: Forty male Wistar-Albino rats were divided into four groups, each containing 10 rats. The rats in the first group were injected only with E. coli into their peritoneal cavities with no further manipulation. The second group, following E. coli injection, underwent midline laparotomy without manipulation of the viscera for 1 hour. After the injection of E. coli in the third and fourth groups, CO2 and helium pneumoperitoneum, respectively, were maintained for 1 hour under 14 mm Hg pressure. At the end of the sixth hour, tissue samples were taken from the liver, spleen, lung, and mesenteric lymph nodes in order to evaluate bacterial translocation. During the study, blood samples were taken from each rat at 0, 1, 2, 4, and 6 hours to demonstrate bacteremia. RESULTS: There was a significant increase in bacteremia in the CO2 pneumoperitoneum group compared with the laparotomy-only and helium groups at 1 and 2 hours. Although all the blood samples at the fourth hour were positive for E. coli in every rat of all groups, helium was associated with a lower incidence of bacteremia at the sixth hour compared with other groups (P < 0.05). The CO2 pneumoperitoneum caused bacterial translocation to all organs from which tissue samples were taken. Although there was an insignificant decrease in translocation to the liver, spleen, and lung with helium compared with CO2 insufflation, helium did not increase bacterial translocation to the spleen compared with laparotomy alone, as did CO2 (P < 0.05). CONCLUSION: Helium might be an alternative to CO2 insufflation in patients with peritonitis if these results are confirmed by further experimental and clinical trials.

Angiogenesis predicts poor prognosis in gastric carcinoma.

BACKGROUND/AIMS: New prognostic factors in gastric carcinoma to determine the prognosis of the disease or to identify patients who will benefit from adjuvant therapy are being researched. The aim of this study is to investigate the correlation between microvessel count (MVC) and various clinicopathologic features in gastric carcinoma in order to evaluate the role of angiogenesis on the prognosis of gastric cancer. METHODS: Fifty-seven patients who underwent surgical intervention for gastric carcinoma between 1993 and 1997 were reviewed retrospectively. The relationship between MVC and various clinicopathological features was assessed. The effect of angiogenesis on overall survival and the role of MVC and other prognostic factors on distant metastases were assessed by multivariate analysis. Microvessels were outlined by anti-factor VIII, which is a specific monoclonal antibody to factor VIII in vessel endothelial cells, using the streptavidin-biotin method and counted under light microscopy x200 magnification. RESULTS: There was no correlation between MVC and age or sex of the patient, duration of symptoms or tumor size. Proximally located, undifferentiated, diffuse type, serosal invasion positive, lymph node invasion positive, advanced stage, or distantly metastasized tumors had higher MVCs. Higher MVCs affected the overall survival adversely. Lymph node metastasis, serosal invasion and MVC were found as independent prognostic factors affecting distant metastases. MVC was the sole factor affecting recurrent liver metastasis. CONCLUSION: It is concluded that MVC in gastric carcinoma may be a valuable prognostic factor to predict patients at high-risk for possible recurrences and to decide on postoperative adjuvant therapy.

Surgical management of hydatid disease of the liver: a military experience.

Hydatid disease of the liver is highly prevalent in oriental countries including Turkey, in which their population live mostly in rural areas. The outcome of surgical methods used in the management of a cystic cavity in patients with hepatic hydatid disease was evaluated. Three hundred and forty consecutive patients who presented to Department of General Surgery between 1988 and 1996 with hepatic hydatid disease were reviewed retrospectively. In the first group surgical methods without drainage such as cystectomy (n = 11), capitonnage (n = 55), omentoplasty (n = 91) and capitonnage + omentoplasty (n = 53), in the second group surgery with drainage such as external drainage (n = 74), internal drainage (n = 7), and combined methods (n = 21) were applied. Symptoms, physical findings, types of surgical management, complication rate, hospitalisation period, mortality and recurrence rates were evaluated. Complication rate, average hospitalisation period, recurrence and mortality rates were 12.5%, 9.5 days, 9.9% and 0% respectively in patients without drainage and 63.7%, 26.5 days, 12.7% and 0.9% respectively in patients with drainage. It is concluded that surgical treatment of hydatid disease of the liver without drainage decreases postoperative complication rate and average hospitalisation period, and drainage or nondrainage of cystic cavity has no effect on recurrence.

Prevalence of inguinal hernia in otherwise healthy males of 20 to 22 years of age.

Twenty-seven thousand four hundred and eight adult males between 20 and 22 years of age who were otherwise healthy were examined to detect inguinal hernias. Eight hundred and eighty-five (3.2%) inguinal hernia cases were detected. These were 479 (54.1%) right inguinal hernias, 351 (39.7%) left inguinal hernias and 55 (6.2%) bilateral inguinal hernias. One hundred and eighty-five (20.9%) subjects reported first degree relatives and 147 (16.6%) subjects reported second degree relatives with inguinal hernias. It is concluded that these results may be a useful guide for future studies about the prevalence of inguinal hernias in the populations as a whole and suggest a familial predisposition.