Study of Aqueous Ecballium Elaterium as Fibrinolytic in The Rabbit Model of Intrapleural Empyema.

AIMS: We aimed to investigate of intrapleural use of ecballium elaterium (EE) in a rabbit model empyema. METHODS: An empyema was induced in 21 rabbits after inoculation of Staphylococcus aureus. Glucose levels, pH, lactate dehydrogenase levels, and amounts of pleural drainage were evaluated in addition to pleural and empyema scores. The rabbits were divided into three groups, each 7, the isotonic solution, the streptokinase, and the ecballium group. RESULTS: At autopsy, there was no difference in pH, glucose, and LDH levels in three groups. The mean pleural drainage was greater in the ecballium group. A significant difference was detected between groups in terms of drainage amounts and pleural and empyema scores (P < 0.05). A significant difference in pleural and empyema scores was detected in the ecballium and streptokinase groups (P < 0.05). EE group had significant differences in drainage amounts and plural and empyema scores regard to the control group (P < 0.05). No significance was found between streptokinase and EE groups. CONCLUSION: We conclude that intrapleural use of EE is at least as effective as streptokinase for the treatment of empyema.

Battery-induced Esophageal Foreign Body Injury, Complications and Treatment Outcome

ABSTRACT Objective: To assess the severity caused by button batteries in esophagus. Methods: A total of 32 patients admitted with ingesting button batteries were retrospectively evaluated. Chest X-ray was ordered for diagnosis. Hospital stays, interventions, complications and mortality of the patients were collected. The time between the patients ingested the buton battery and its removal was defined as its duration in esophagus. All the patients underwent rigid esophagoscopy under general anaesthesia. Buton batteries at the first narrowing were removed by magyl clamp. Results: Of 32 patients, 21 were females, with a mean age of 22 months. The mean duration of ingestion was 17 hours. The mean hospital stay was 10 days. Of the patients, 75% were admitted within 24 hours. Complication rate was 19% and mortality rate was 6%. There was a strong correlation among the number of the cases and the coming years (p < 0.001). The regression was between the number of cases per year (outcome variable) and the years of the study (explanatory variable), (p< 0.001, R = 0.644, Figure 3). There was a significant finding that more cases (90%) were admitted in the last 12 years compared with the number in first 12 years (p < 0.001). There were no complications in cases in which the button battery was impacted in esophagus for less than 24 hours; however, eight cases whose duration was more than 24 hours resulted in complications in six patients and fatality in two patients (p < 0.001). Conclusion: Batteries should be removed upon its diagnosis. Otherwise, the injury in the esophageal mucosa may be caused by delay and can cause an increase in morbidity and mortality.

Spectrum of gastric histopathologies in morbidly obese Turkish patients undergoing laparoscopic sleeve gastrectomy.

OBJECTIVE: In this study, we aimed to describe the findings associated with gastric pathology and to identify the prevalence of Helicobacter pylori (H. pylori) in patients undergoing laparoscopic sleeve gastrectomy (LSG). PATIENTS AND METHODS: Gastric specimens of a total of 291 patients (225 females, 66 males; mean age: 42 years; range: 18 to 60 years) who underwent LSG for the treatment of morbid obesity were analyzed. Histopathologic diagnoses and their relation with body mass index (BMI), age and gender were evaluated. RESULTS: In the histopathological examination of sleeve specimens, 58 patients (19.93%) had chronic gastritis, 102 patients (35.05%) had chronic active gastritis, 27 patients (9.27%) had follicular gastritis, 47 patients (16.15%) had active follicular gastritis, one patient (0.34%) had a glomus tumor, and one patient (0.34%) had a gastrointestinal stromal tumor. The gastric mucosa was normal in 55 patients (18.90%). Intestinal metaplasia was detected in eight patients (2.74%). The H. pylori test result was positive in 126 patients (43.29%). There was no statistically significant difference between the pathological diagnoses and age and sex of the patient. CONCLUSIONS: Our study results suggest that the prevalence of chronic active gastritis and H. pylori positivity is high in morbidly obese Turkish patient population. No significant difference was found between the pathological diagnosis in obese patients with LSG operation in terms of age and sex.

Comparison of anterior segment parameter values obtained with Scheimpflug-Placido topographer, optical low coherence reflectometry and noncontact specular microscopy in morbid obesity.

OBJECTIVE: To investigate the measurement of anterior segment parameters using Sirius Scheimpflug-Placido topographer, Lenstar optical low coherence reflectometry (OLCR), and noncontact specular microscopy (SM) in morbidly obese and nonobese subjects. PATIENTS AND METHODS: Twenty-eight morbidly obese subjects (BMI ≥ 40; Group 1) and 28 age- sex-matched healthy nonobese subjects (BMI 18.50-24.99; Group 2) were included in this study. Anterior segment parameters were measured by Scheimpflug-Placido topographer and OLCR. Corneal endothelial cell parameters were measured by non-contact SM. The group data were analyzed using the Mann-Whitney U test and Student's t-test. Bland-Altman plots were used to assess agreement among the instruments, and 95% limits of agreement (LoA) for each comparison were calculated. RESULTS: In group 1, the mean CCT by Scheimpflug-Placido topographer, OLCR, and noncontact SM were 549.44±30.10 µm, 544.15±31.48 µm, and 541.59±29.87 µm respectively. In group 2, the mean CCT by Scheimpflug-Placido topographer, OLCR, and noncontact SM were 531.0±22.09 µm, 523.15±21.39 µm, and 521.12±21.70 µm respectively. Mean CCT values obtained by the three methods were significantly higher in the morbidly obese than the nonobese subjects. In both groups, mean CCT was significantly higher when measured by Scheimpflug-Placido topographer than by OLCR and noncontact SM, and mean AD and ACD were significantly higher when measured by Scheimpflug-Placido topographer than OLCR. No significant differences were found between mean corneal curvature and corneal astigmatism when measured by Scheimpflug-Placido topographer and OLCR. CONCLUSIONS: The mean CCT of the morbidly obese subjects were significantly higher than the nonobese subjects when measured by all three methods. The CCT values obtained by Scheimpflug-Placido topographer were significantly higher than those by OLCR and SM.

Gangliocytoma Presenting With Tacrolimus Neurotoxicity in a Renal Transplant Recipient: Case Report.

Tacrolimus is a widely used macrolide immunosuppressant in transplant surgery, with mild and major neurologic side effects. A 21-year-old woman had undergone preemptive transplantation of a kidney from her mother. On the 1st postoperative day, the patient had headache, nausea, vomiting, and agitation. Magnetic resonance imaging (MRI) of the brain showed hyperintensity and a lesion in the right mesial temporal lobe. After we switched from tacrolimus to cyclosporine, the symptoms regressed. Persistence of the lesion, confirmed by repeated MRI, required that the patient be operated on. Pathologic examination showed the gangliocytoma, a rare brain tumor. Our case shows that preexisting brain lesions may cause tacrolimus-induced neurotoxicity in the early postoperative period.

The impact of laparoscopic sleeve gastrectomy on plasma obestatin and ghrelin levels.

OBJECTIVE: To investigate the effect of laparoscopic sleeve gastrectomy (LSG) on the levels of obestatin and ghrelin hormones and body mass index (BMI) in morbidly obese patients. PATIENTS AND METHODS: The study included 30 morbidly obese patients who had LSG. Five cc blood samples were taken from the patients preoperatively and at postoperative months 3 and 6. After serum extraction, the levels of obestatin and ghrelin hormones and the levels of fasting insulin and glucose were studied using the enzyme-linked immunosorbent assay (ELISA) method. The homeostatic model assessment of insulin resistance (HOMA-IR) score was calculated. Preoperative and postoperative 3- and 6-month BMI were calculated. Kruskal-Wallis Analysis of Variance, Bonferroni-Dunn Test, Spearman's correlation test, and Pearson's correlation test were used for statistical analysis. RESULTS: BMI of the patients were statistically significantly reduced at postoperative months 3 and 6 compared to preoperative values, and at postoperative month 3 compared to month 6 values (p < 0.001). Ghrelin values were higher at postoperative month 6 compared to the preoperative and postoperative month 3 values (p < 0.001). Obestatin values of the patients were lower at postoperative month 6 compared to the preoperative and postoperative month3 values (p < 0.001). Insulin and glucose values were statistically significantly lower at postoperative months 3 and 6 compared to preoperative values (p < 0.001), whereas there was no difference between months 3 and 6. HOMA-IR score was significantly lower at postoperative month 3 compared to preoperative values (p < 0.001). CONCLUSIONS: LSG enables effective weight loss and glucose regulation in obese patients. LSG has also effects on obestatin and ghrelin hormones, which are coded by the same gene and have opposing effects, and the associated mechanisms of which are still controversial. Obestatin produces a feeling of satiety, whereas ghrelin initiates eating by producing a feeling of hunger. The patients were observed to have increased ghrelin and reduced obestatin postoperatively due to a negative energy balance.

Relation between weight loss and age after laparoscopic sleeve gastrectomy.

OBJECTIVE: As a bariatric surgery; Laparoscopic Sleeve Gastrectomy (LSG) has gained popularity in recent years. In our study, we aimed to investigate the impact of age on postoperative weight loss at one year after laparoscopic sleeve gastrectomy. PATIENTS AND METHODS: In our clinic between May 2011 and July 2013, 55 patients who underwent LSG with the diagnosis of obesity were included in the study. Patients were divided into two groups below and over an age of 40. Preoperative and postoperative first year Body Mass Index (BMI), percent of Body Mass Index Lost (% BMIL) and Excess Body Mass Index Lost (% EBMIL) were recorded. RESULTS: A total of 55 patients with a mean age of 37.2 ± 8.6 years were included in the study. 37 were women. Patients divided into the age below 40 years old (group 1, n = 29) and over 40 years old (group 2, n = 26). The average age of the groups was 29.9 ± 4.63 and 45.3 ± 7.02, respectively. Characteristics of patients among groups were similar. The preoperative average BMI of groups were 49.34 ± 5.87 kg/m² and 49.73 ± 5.38 kg/m², postoperative first year mean BMI of groups were 30.05 ± 5.78 kg/m² and 36.15 ± 6.64 kg/m², respectively. Percentage loss in BMI was 19.29 ± 3.14% and 13.58 ± 2.96%, respectively; and % EBMIL was 82.95 ± 21.88% and 56.75 ± 15.90%, respectively. CONCLUSIONS: We suggest that age might be as a major determining factor for weight loss and patients over forty years old undergoing LSG for bariatric surgery should be informed about that they will have a lower weight lost.

Survival of renal transplant patients: data from a tertiary care center in Turkey.

OBJECTIVE: Data on transplantation survival is widely available for developed countries where cadaveric transplantation is the dominant transplantation type. We aimed to assess patient and graft survival and to determine the possible factors affecting graft survival in a developing country where kidney transplantations were mainly performed from living donors. METHODS: We retrospectively analyzed data from 427 adult kidney transplantations performed at our center from January 1990 to November 2010. We collected data from patient files, including characteristics of the recipients and donors, transplantation-related factors, post-transplantation features, causes of graft loss, and patient death. The Kaplan-Meier method was used to analyze survival, and Cox regression analysis was used to evaluate the effects of multiple factors on graft survival. RESULTS: Most of the recipients (82.6%) received their organs from living donors. One-year and 5-year graft survival rates were 87.5% and 78.3%, respectively, where the 5-year graft survival rates were 87.1% for living donors and 74.8% for cadaveric donors. The 1-year and 5-year patient survival rates were 90.9% and 88.9%, respectively. Univariate analysis showed that predictors for better graft survival were serum creatinine levels <1.5 mg/dL at 1 month after transplantation, proteinuria <500 mg/d at 1 year after transplantation, use of tacrolimus and mycophenolic acid derivative-based immunosuppression at baseline, living-donor transplantation, and transplantations performed in the years 2000-2010. CONCLUSIONS: We report data on kidney transplantation in an emerging country where living-donor transplantation constitutes a large proportion of kidney transplant activities. Modern immunosuppressive medications help to achieve a better survival. Our 5-year results are similar to those of developed countries.

Endocrowns: review.

The ideal restoration of endodontically treated teeth (ETT) has been widely and controversially discussed in the literature. Prevention of healthy dental structure is essential to help mechanical stabilization of tooth-restoration integrity, increase the amount of suitable surfaces for adhesion and thus positively affect the long-term success. ETT are affected by a higher risk of biomechanical failure than vital teeth. With the development of adhesive systems, the need for post-core restorations is also reduced. Especially for restoration of excessively damaged ETT, endocrowns have been used as an alternative to the conventional post-core and fixed partial dentures. Compared to conventional methods, good aesthetics, better mechanical performance, and less cost and clinic time are the advantages of endocrowns.

Progression of metabolic syndrome in renal transplant recipients.

BACKGROUND: Metabolic syndrome, which is closely related to insulin resistance, is highly prevalent in renal transplant recipients. PURPOSE: We aimed to investigate prevalence, risk factors, and progression of metabolic syndrome in renal transplant recipients. METHODS: One hundred fifty-eight renal transplant recipients who had been on transplantation for more than 1 year and 79 age-sex matched healthy controls were included in the cross-sectional phase of the study. We measured baseline characteristics, blood pressure, fasting blood glucose, and lipid profiles and we defined metabolic syndrome using the National Cholesterol Education Program Adult Treatment Panel III criteria. One hundred twenty-four renal transplant recipients were eligible for the second evaluation after 22.9 ± 3.8 months. Metabolic syndrome prevalence and homeostasis model assessment insulin resistance levels were evaluated during the follow-up period. RESULTS: Overall, metabolic syndrome was present in 34.2% of the patients and 12.7% of the controls at the cross-sectional phase of the study (P = .000). Only the hypertension component of metabolic syndrome was significantly increased in patients compared to controls (P = .000). Pretransplantation weight and body mass index were significantly higher in patients who had metabolic syndrome (P = .000). During the follow-up period, prevalence of metabolic syndrome did not change (P = .510); however, body mass index and blood pressure increased and the high density lipoprotein cholesterol component of metabolic syndrome decreased (P = .001). We did not find any significant difference in glomerular filtration rate change among patients with and without metabolic syndrome (-2.2 ± 11.36 vs -6.14 ± 13.19; P = .091). Glucose metabolism parameters including hemoglobin A1c, insulin, and homeostasis model assessment insulin resistance were disturbed in patients with metabolic syndrome (P = .000, P = .001, P = .002, respectively). CONCLUSION: Metabolic syndrome is highly prevalent in renal transplant recipients and closely associated with insulin resistance. The prominent criterion of metabolic syndrome in patients seems to be hypertension, especially high systolic blood pressure. The identification of metabolic syndrome as a risk factor may yield new treatment modalities to prevent it.

Extraumbilical single-incision laparoscopic cholecystectomy with standard laparoscopic instruments.

BACKGROUND AND AIM: Single-incision laparoscopic surgery is a rapidly progressing field as it combines some advantages such as cosmesis and less incisional pain. However, it also has some disadvantages such as limitation of movement and clashing of the hand instruments, which increase the complexity and technical challenges of the operation. In this study, we describe a pilot trial of single-incision laparoscopic cholecystectomy through a paramedian access site. MATERIAL AND METHODS: A total of 25 patients underwent single-incision laparoscopic cholecystectomy with this method. Acute cases with empyema and patients with history of previous abdominal surgery were excluded. Single-incision is established on the right upper quadrant, right latero-superior of the umbilicus, so that trocar sites and projection of the gallbladder on the abdominal wall are on the same vertical line. Standard laparoscopic instruments were placed into the abdominal cavity providing triangulation. Once the laparoscope, grasper, and dissector are in place, the overall procedures are similar to the standard laparoscopic cholecystectomy. RESULTS: Single-incision laparoscopic cholecystectomy through an extraumbilical access site was successfully completed in all 25 patients without conversion to open surgery. Additional skin incisions and trocar access were required only in two patients. The mean operative time was 39.3 min (range: 20-75 min). The mean body mass index was 27.2. Postoperative course was uneventful in all patients. The mean postoperative hospital stay was shorter than 24 h, and all patients were discharged at first day postoperatively. No postoperative complications including seroma, wound infection, and trocar-site hernia were observed at 6-month follow-up. CONCLUSION: We described a new access site for single-incision laparoscopic cholecystectomy using standard laparoscopic instruments. We believe that this type of access site overcomes the technical difficulties of performing single-incision laparoscopic cholecystectomy, and it is a promising alternative method for the treatment of patients with symptomatic gallstone disease as a minimal invasive abdominal surgery.

Transumbilical multiple-port laparoscopic cholecystectomy using standard laparoscopic instruments.

INTRODUCTION: As a complement to standard laparoscopy, single incision laparoscopic cholecystectomy (SILS) is gaining popularity. We report our technique and our initial experience with transumbilical multi-port laparoscopic cholecystectomy (TUMP-LC) without an access device, with standard laparoscopic instruments, and report the clinical outcomes. MATERIAL AND METHODS: Twenty-five (23 F: 2 M) consecutive patients with symptomatic cholelithiasis were included. The surgical outcomes such as length of stay, complications and perioperative morbidity were analyzed. For evaluation of surgical stress preoperative and postoperative C-reactive protein (CRP) values at 6 h and 24 h were measured. Postoperative pain was evaluated using a standard 10-point visual analogue scale (VAS). RESULTS: The mean duration of the surgery was 44.56 minutes (range, 18-110). Additional trocars were needed in two (8%) cases. Mean pain scores post-operatively at 4 h, 12 h and 24 h were 4 ± 1.19, 3.64 ± 1.03 and 2.24 ± 0.96, respectively (p < 0.0001). Plasma CRP values increased at 6 h and started to decrease at 24 h (p < 0.0001). None of the cases were converted to open surgery and no major complications occurred. DISCUSSION: TUMP-LC using standard laparoscopic instrumentation without an access device is an effective alternative to standard four-incision laparoscopic cholecystectomy. Our technique maintains the principles of the conventional procedure and the instrumentation, but also improves the access.

A new technique for inducing and releasing obstructive jaundice in rats.

AIM: It was the aim of this study to develop a simple, effective and reversible model of obstructive jaundice in rats. MATERIAL AND METHOD: Totally, 24 rats were divided into 3 groups: the sham group including sham-operated control rats who underwent laparotomy only (n = 8), the common bile duct standard ligation technique (CBD-SL) group including rats with CBD ligation using silk (n = 8), and the CBD new ligation technique (CBD-NL) group consisting of rats with CBD ligation by a new technique (n = 8). After release of the ligations, the CBD-SL group continued as the CBD-SL releasing group, and the CBD-NL group as the CBD-NL releasing group. RESULTS: It was observed that all the CBD ligated rats were both clinically and biochemically jaundiced but they were relieved after reversing the procedure. CONCLUSION: We present a simple, effective and reliable rat model which is suitable for studies which require a reversal of obstructive jaundice in rats.

Effect of erythropoietin on oxidative stress and liver injury in experimental obstructive jaundice.

BACKGROUND: To evaluate the time-dependent effects and pathophysiological mechanism of erythropoietin (Epo) on oxidative stress and liver injury resulting from obstructive jaundice in common bile duct-ligated rats. METHODS: Wistar Albino rats were divided into 5 groups, each including 8 rats. The sham group underwent laparotomy only, while the Non-Epo-3 and Non-Epo-7 groups underwent common bile duct ligation and were sacrificed 3 and 7 days, respectively, after the operation. The Epo-3 and Epo-7 groups underwent common bile duct ligation and Epo treatment and were sacrificed 3 and 7 days, respectively, after the operation. Blood and tissue samples were collected from all groups for the determination of oxidative injury and hepatocellular damage. Serum total and direct bilirubin levels, alkaline phosphatase, reduced glutathione (GSH), nitric oxide (NO), malondialdehyde (MDA) and white blood cell counts were measured. RESULTS: Significantly higher NO and MDA levels were found in Non-Epo groups than Epo groups. Significantly lower GSH levels were found in the Non-Epo-7 group than the Epo-7 and sham groups. Hepatocellular damage was also found to be reduced in Epo groups. CONCLUSIONS: In the present model, while common bile duct ligation increased oxidative injury and hepatocellular damage, treatment with Epo attenuated oxidative injury and hepatocellular damage by decreasing NO and increasing GSH.

Outcomes of emergency surgical treatment in malignant bowel obstructions.

BACKGROUND/AIMS: Malignant bowel obstructions are still a challenging problem for surgeons and carry high morbidity and mortality risk. The aim of this study was to review the presentation and outcomes of malignant bowel obstructions and to identify the risk factors related with poor prognosis. METHODOLOGY: One hundred and twenty-five patients underwent emergency surgical treatment for malignant obstructions between January 1997 and January 2002. Data included age, sex, past medical history, presenting symptoms; physical findings on admission, American Society of Anesthesiologists (ASA) class, operative details, postoperative complications, length of hospitalization and hospital mortality were reviewed retrospectively. RESULTS: Seventy-three (58%) of the patients have poor performance status on admission. Potentially curative resection was performed in 74 (60%) patients. Surgical treatment was palliative in 43 (34%) patients. Extended bowel resections were utilized in 20 (16%) patients. Our hospital mortality rate was 21%, and postoperative morbidity rate was 31%. Coexisting cardiopulmonary diseases, presence of generalized perforation, poor general condition and extended bowel resections appeared to be related with unfavorable outcomes. CONCLUSIONS: Emergency surgical treatment for malignant obstruction may be curative in selected patients with good performance status.

Does serum hexosaminidase activity play a role in the diagnosis of strangulated bowel obstruction? An experimental study.

Strangulation is associated with an increased risk of mortality and morbidity in patients with mechanical bowel obstruction. The accurate and early recognition of the presence of strangulation is important to allow safe nonoperative treatment. A number of studies have shown that there was no single and reliable test to detect or exclude the presence of strangulation. The aim of this study was to evaluate the role of serum hexosaminidase (Hex) levels in recognition of strangulation in an experimental model of closed loop small bowel obstruction. Forty-two Wistar albino rats were divided into four groups: I, control (n = 5); II, sham laparotomy (n = 5); III, simple obstruction (n = 16); and IV, strangulation groups (n = 16). Activity levels of total Hex and its fractions (Hex A and B) were assayed in serum samples obtained from rats after 3 and 8 hr. Samples of small bowel were also evaluated histologically. Histological evaluation of bowel sections obtained from the strangulation group after 8 hr, revealed transmural hemorrhagic infarction in all animals with a mean +/- SD total Hex activity of 978.25 +/- 150 nmol/hr/ml, which was significantly higher than that in the other groups (P < 0.001). Although sections of bowel from the strangulation group after 3 hr showed severe ischemic injury, the activities of total Hex, Hex A, and Hex B were not different from those of the control, sham, and simple obstruction groups. Histological examination of these groups did not show any sign of ischemia. Total Hex, Hex A, and Hex B activities in the strangulation group were all significantly greater than the activities seen in the simple obstruction group (P < 0.001, for all). In conclusion, increased serum hex levels indicate irreversible transmural infarction only in the late period of strangulation in the closed loop small bowel obstruction model. It seems unuseful for detecting reversible and/or irreversible ischemia in the early period of strangulation.

The value of 5-hydroxy indole acetic acid measurement in spot urine in diagnosis of acute appendicitis.

OBJECTIVE: To assess the role of 5-Hydroxy Indole Acetic Acid (5-HIAA) levels in spot urine in diagnosis of acute appendicitis. DESIGN: A prospective, controlled study. SETTING: Ankara Numune Teaching and Research Hospital, Ankara, Turkey. SUBJECT: Twenty six patients with histologically proven acute appendicitis following appendectomy were included in the study. Control group with consisted of patients prepared for hernia repair in the same duration. In the preoperative period, urine samples were collected from every patient for measurement of 5-HIAA. RESULTS: The study group comprised 26 patients; 15 of those had high urine 5-HIAA levels, whereas 11 patients had values within normal range. None of ten control patients displayed positive test result. The test had 58% sensitivity and 48% specificity. In histopathological examination only two of ten patients with gangrenous appendicitis showed positive test result, whereas 13 of 16 patients with no histopathological gangrenous changes had high values. CONCLUSION: Urine 5-HIAA measurement has low sensitivity and specificity. The value of the test is even clearly lower in gangrenous appendicitis. This may be misleading in management of patients in late phase of appendicitis and in cases with perforation which is mainly responsible for morbidity.