Retrospective analysis of risk factors affecting pacreatic fistula formation after the closure of the pancreatic stump with sutures in distal pancreatectomy.

BACKGROUND/AIMS: Development of pancreatic fistula after distal pancreatectomy is still a major problem. Various methods have been defined to prevent the development of the fistula. In this study, the results of suture closure of pancreatic duct and closure of pancreatic stump with "U" sutures passing through each other and the risk factors affecting the development of fistula are studied. METHODOLOGY: Fifty-one patients with prospectively collected data were included in the study. In all patients, pancreatic stump was closed with the same surgical technique. Risk factors that may affect fistula formation were studied between groups with and without fistula. Pancreatic fistula definition was made according to the International Study Group on Pancreatic Fistulas classification. RESULTS: Eight (15.7%) of the 51 patients had fistula. Clinically significant fistula ratio was 9.8% (according to ISGPF B and C). Additional organ resections were performed in 18 patients (35.3%). In multivariate analysis, the soft texture of pancreatic parenchyma (OR: 12.420, p = 0.048) and over 150 mL of blood loss (OR: 1.003, p = 0.043) were found as risk factors for the development of fistula. CONCLUSIONS: Closure of pancreatic stump after distal pancreatectomy with "U" shaped sutures passing through each other is a method that can be performed safely.

Fulminant hepatic failure and serum phosphorus levels in children from the western part of Turkey.

BACKGROUND/AIMS: Clinical and laboratory predictors of recovery in children with fulminant hepatic failure are limited. Recently, hypophosphatemia has been reported as a laboratory indicator of recovering liver function in children with fulminant hepatic failure . We aimed to determine the incidence of hypophosphatemia and its association with clinical outcome in children in our center with fulminant hepatic failure. METHODS: We analyzed 21 children who had been diagnosed with fulminant hepatic failure. Laboratory findings were recorded from admission date until the patient spontaneously recovered, underwent orthotopic liver transplantation or died. RESULTS: Eight patients (38%) died, 6 (28.6%) underwent orthotopic liver transplantation, and 7 (33.3%) recovered without orthotopic liver transplantation. We identified hypophosphatemia in 57.1% of children with fulminant hepatic failure. Serum phosphorus levels were significantly lower in patients who recovered than in the orthotopic liver transplantation+death group. The presence of encephalopathy was determined at a much lower rate in the recovery group than in the orthotopic liver transplantation+death group. Serum phosphorus concentration ≥2.9 mg/dl and presence of encephalopathy were identified as independent risk factors for mortality. CONCLUSIONS: Hypophosphatemia can be identified as a marker of recovery in children with fulminant hepatic failure. Presence of encephalopathy and a serum phosphorus level ≥2.9 mg/dl appear to indicate a poor prognosis in children with fulminant hepatic failure.

The comparative effects of total hepatic vascular isolation techniques performed at different durations in rat.

BACKGROUND: Total hepatic vascular exclusion (THVE) leads to massive venous congestion below the level of diaphragm and may promote undesirable hemodynamic disturbances in some patients. Supraceliac aortic clamping during THVE may achieve hemodynamic stability at the price of arterial ischemia. However, the parenchymal injury of venous congestion has been a greater concern than of arterial ischemia in various settings. We hypothesized that supraceliac aortic occlusion during THVE may attenuate the reperfusion injury and improve the outcome that would be acquired after THVE alone. MATERIAL AND METHODS: Rats were randomly assigned to (1) THVE alone, (2) THVE plus aortic occlusion, (3) THVE plus celio-mesenteric arterial occlusion or (4) sham during 30, 45, or 60 min followed by 180 min reperfusion period. Serum enzymes (alanine aminotransferase, lactate dehydrogenase) and creatinine as well as tissue "thiobarbituric acid reactive substances" (TBARS) and histopathology were evaluated. Seven animals per group were followed for survival up to 7 d. RESULTS: After 30 min, no difference was found in serum enzyme, creatinine and tissue TBARS measures among the isolation methods used. In these, all rats survived to 7 d. However, after 45 and 60 min isolation, aortic occlusion resulted in significant rise in serum enzyme and tissue TBARS measures as well as poor survival (14% and 0%, respectively). In contrast, all rats survived even after 60 min of THVE. CONCLUSIONS: THVE was tolerated up to 60 min with less reperfusion injury and better survival than celio-mesenteric arterial occlusion and supraceliac aortic occlusion in the rat, if needed, aortic clamping should not exceed 30 min. Beyond that, selective celio-mesenteric arterial occlusion may be considered.

Renal failure in high altitude: renal functions, renal pathology and bone mineralization in rats with ablation nephropathy at 1200 m altitude.

The effect of altitude on renal failure and bone mineralization is not well known. This topic is studied in a 5/6 nephrectomy rat model. After hemoglobin, creatinine clearance and proteinuria were determined in 28 Wistar rats. Two 5/6 nephrectomy (Nx1-Nx2, n=7 each) and two sham (Sh1-Sh2, n=7 each) groups were formed. The Nx1-Sh1 and Nx2-Sh2 groups were kept at sea level and at 1200 m altitude, respectively. The same analyses were performed after 3 months just before sacrifices in order to harvest kidneys and femurs for histopathologic examination. Hemoglobin, creatinine clearance, and proteinuria were similar in all groups at the onset. Final hemoglobin was higher in Nx2-Sh2, but only Sh2 vs. Sh1 was significant (p=0.001). Creatinine clearance decreased (p=0.001 for Nx1) and proteinuria increased (p=0.002 for Nx1 and p=0.005 for Nx2) after 5/6 nephrectomy, but Nx1 vs. Nx2 was similar. Histopathological changes in the remnant kidneys were prominent, but Nx1 vs. Nx2 was not different. Although the relative osteoid volume increased in Nx groups, only Nx1 vs. Sh1 was different (p=0.006). In conclusion, exposure to 1200 m altitude, compared to the sea level, preserved the creatinine clearance better in 5/6 nephrectomized rats. No change was observed in proteinuria, renal histopathology, and bone mineralization.

A rare clinical entity misdiagnosed as a tumor: peliosis hepatis.

Peliosis hepatis (PH) is a rare condition characterized by the presence of cystic, blood filled cavities within the hepatic parenchyma. Regardless of the reason, surgery should be performed under meticulous control of hemorrhage, if it is thought to be unavoidable. In this case report, ominous results of clinically misdiagnosed PH have been presented. PH should be kept on mind in all patients with hepatic mass, especially presented by sudden onset distention of the abdomen. Every effort should be done for the differential diagnosis with other cystic conditions like hydatid cyst in endemic areas.

Efficiency of MR imaging in the detection of malignant liver lesions.

PURPOSE: To evaluate the efficacy of preoperative magnetic resonance (MR) imaging in the detection of malignant liver neoplasms. MATERIALS AND METHODS: MR images of 23 patients who had undergone hepatic resection or liver transplantation in the last two years were evaluated retrospectively. All MR imaging studies were performed with a 1.5 T magnet using a phased-array multi-coil. The MR imaging protocol was comprised of fat-suppressed T2-weighted TSE imaging, GRE with and without fat-suppressed T1-weighted imaging, and gadolinium-enhanced multiphasic dynamic GRE imaging. Images were reviewed on a PACS workstation by two independent abdominal radiologists. The image review was conducted on a lesion-by-lesion as well as segment-by-segment basis. MR imaging findings were compared with the results of pathology studies and intraoperative ultrasound examinations. Sensitivity, specificity, and positive predictive value (PPV) of MR imaging and interobserver variation were evaluated. RESULTS: A total of 59 malignant liver lesions in 23 patients were identified by pathology studies and intraoperative sonographic examinations. Sensitivity and PPV of MR imaging on a lesion-by-lesion analysis were 68-86% and 85-89%, respectively; kappa=0.175 and agreement was 65.8% in these analyses. Sensitivity of MR images for small ( < 1cm) lesions was 13-67% and for large ( > 3 cm) lesions it was 100%. In segment-by-segment analysis, sensitivity and specificity of MR images were 87-95% and 97-98%, respectively; kappa=0.207 and agreement was 76.1%. Sensitivity and PPV of MR imaging in the detection of hepatocellular carcinoma were 46-85% and 55-73%, respectively. CONCLUSION: Although MR imaging is generally a highly accurate method for the diagnosis of malignant liver tumors, it has some difficulty in detecting small lesions and hepatocellular carcinoma in cirrhotic livers.

Expression of transforming growth factor-beta-1 and p27Kip1 in pancreatic adenocarcinomas: relation with cell-cycle-associated proteins and clinicopathologic characteristics.

BACKGROUND: The purpose of our study was to investigate the immunohistochemical expression of TGF-beta1 and p27 in pancreatic adenocarcinomas and to compare the findings with the clinicopathological features and survival. We also aimed to evaluate the expression of TGF-beta1 and p27 in the context of other cell cycle and proliferation markers such as cyclin D1 and Ki-67. METHODS: We examined TGF-beta1 and p27 expression immunohistochemically in 63 cases of invasive ductal adenocarcinoma of the pancreas. Standard streptavidin-biotin immunperoxidase method was used for immunostaining and the stained slides were examined microscopically using semiquantitative criteria. RESULTS: TGF-beta1 stained the cytoplasms of the tumor cells in 43 cases [68.3%]. There was a statistically significant difference among TGF-beta1 staining scores in terms of clinicopathologic factors such as blood vessel invasion, stage and distant metastasis [p < 0.05]. Of the 63 tumors evaluated 23 [36.5%] were positive for p27 within the nucleus. An inverse correlation was found between p27 immunoreactivity and grade [p < 0.05]. But no significant correlation was found between p27 and other parameters. Among the patients with survival data 27 patients had RO resections and these cases were considered in survival analysis. In the univariate analysis, neither TGF-beta1 nor p27 expression was related with patient survival. CONCLUSION: Our findings suggest that in pancreatic carcinoma, TGF-beta1 expression is related to tumor growth and metastasis. But it is not associated with cell cycle proteins. p27 expression is reduced in pancreatic adenocarcinomas and decreased protein levels of p27 may play a role in the differentiation of pancreatic cancer.

[Rectal foreign bodies: a report of four cases]. / Rektumda yabanci cisim: Dört olgu sunumu.

Foreign bodies were detected in the rectum in four male patients with ages ranging from 36 to 64 years. The materials were an iron rod, a specially shaped wooden device, and in two cases, deodorant caps. They were extracted with the patients in lithotomy position after anal dilatation, under general anesthesia in three cases, and spinal anesthesia in one case. No procedure-related complications occurred and the patients were discharged 24 hours after the operation.

[The beneficial effect of L-carnitine in rat renal ischemia-reperfusion injury]. / Siçandaki renal iskemi-reperfüzyon hasarinda L-karnitinin koruyucu etkisi.

BACKGROUND: We examined the effect of L-carnitine on experimental renal ischemia-reperfusion (I-R) injury. METHODS: Seventy-two Wistar albino rats were divided into five groups, four of which underwent right nephrectomy and left renal I-R for 60 min (groups 2 and 4) and 90 min (groups 3 and 5). The sham operated group (n=8) was left as controls. Intraperitoneal carnitine (200 mg/kg) was given to groups 4 and 5 three hours before operation. For histopathologic studies, half of the rats in the study groups (n=8) and the remaining rats were sacrificed 15 min and seven days after reperfusion, respectively. Blood urea nitrogen (BUN) and serum creatinine levels were also measured at 15 min and on Day 3 and Day 7. RESULTS: Concerning the 90 min I-R groups, survival was improved in carnitine-treated rats (7/8 vs 5/8). Of untreated groups, the 90 min I-R group exhibited significantly higher BUN (p=0.0023) and serum creatinine (p=0.0086) levels on Day 3. Although BUN and serum creatinine levels did not show significant differences between carnitine-treated and untreated rats in the two 60 min I-R groups throughout the study period, carnitine-treated rats in the 90 min I-R group exhibited significantly improved BUN (p=0.0063) and serum creatinine (p=0.0013) levels on Day 3. The severity of histopathologic changes was lower in all carnitine-treated rats 15 min after reperfusion. On Day 7, the mean histopathologic score was significantly lower in carnitine-treated rats in the 90 min I-R group than that of untreated rats exposed to I-R injury of same duration (p=0.0078). CONCLUSION: Our results suggest that L-carnitine has beneficial effects on renal function, histopathologic changes, and survival in renal ischemia-reperfusion injury.

The importance of cyclin D1 and Ki67 expression on the biological behavior of pancreatic adenocarcinomas.

The aim of this study was to evaluate the role of cyclin D1 and Ki67 proteins involved in cell-cycle control as a prognostic factor in pancreatic carcinomas. We examined formalin-fixed, paraffin-embedded material from 59 pancreatic adenocarcinomas, for which appropriate clinical and prognostic data were available. The standard streptavidin biotin immunoperoxidase method was used for immunostaining with cyclin D1 and Ki67. The extent of positive nuclear and cytoplasmic cyclin D1 staining was graded semiquantitatively. Ki67 reactivity was quantified and expressed as the percentage of stained nuclei. Staining with cyclin D1 and Ki67 was compared with histopathological prognostic features, and their relation with survival was also tested statistically. Patients whose tumors were cyclin D1-positive showed perineural invasion significantly more frequently than did patients with cyclin D1-negative tumors at the immunohistochemical level. In addition, tumors with lymphatic vessel invasion and without showed a significant difference in terms of cytoplasmic cyclin D1 staining. Ki67 indices were statistically different in stage groups. There was a significant and direct correlation between Ki67 index and nuclear cyclin D1 staining scores. No relation with survival was found. Our results suggest that cell-cycle proteins do not directly affect the prognosis of patients with pancreatic adenocarcinoma. Conversely, cyclin D1-positive tumors tend to have perineural invasion more frequently. In addition, lymph vessel invasion is another factor related to cyclin D1 reactivity of the cells. Ki67 indices differ statistically in stage groups.

The effects of vascular bed expansion in steatotic rat liver graft viability.

Disturbed microcirculation caused by fat accumulation in hepatocytes has been implicated in poor graft preservation and reperfusion. The aim of this study was to investigate the effect of vascular bed expansion (VBE) during cold preservation in graft survival Moderate liver steatosis in male Wistar rats (240-280 g) was induced by choline-deficient diet. Normal, steatotic or VBE-pretreated steatotic grafts were transplanted after 1 h or 9 h of cold preservation. Graft viability was determined by 7-day survival, serum liver enzymes, plasma tumour necrosis factor (TNF)-alpha, interleukin (IL)-6, and malondialdehyde (MDA) levels. Post-reperfusion bile flow and liver histology were also examined. After 9 h of preservation, VBE-pretreated steatotic liver grafts were associated with significantly reduced serum liver enzyme, plasma TNF-alpha, IL-6, and MDA levels, as well as increased bile flow and higher survival rates compared with untreated ones. The present study shows that VBE protects fatty liver grafts from subsequent long-term cold preservation and reperfusion injury in a rat liver transplantation model.

Serum tumor necrosis factor-alpha, glutamate and lactate changes in two different stages of mechanical intestinal obstruction.

BACKGROUND/AIMS: Mechanical intestinal obstruction is a difficult-to-diagnose surgical emergency, especially in the early stage. Clinical and radiological evaluation are the main methods for the diagnosis. Metabolic, inflammatory and ischemic changes occur during intestinal obstruction. No specific biochemical parameters related to diagnosis and severity of intestinal obstruction have been found. In this experimental study, we investigated serum tumor necrosis factor a L-glutamate and L-lactate levels as biochemical markers which reflect physiopathological processes in two different stages of intestinal obstruction. METHODS: Mechanical obstruction was created in Wistar rats with distal ileal ligation. Animals were divided into five groups (Control, Sham-12, Sham-24, Intestinal obstruction 12 and intestinal obstruction-24) and each group consisted of 10 rats. Blood samples were taken 12 and 24 hours after Sham and intestinal obstruction operations. Tumor necrosis factor a levels were measured by ELISA. Serum L-glutamate and L-lactate levels were measured by colorimetric method. RESULTS: Glutamate levels were significantly high especially in the early stage, whereas tumor necrosis factor a increase was significant only in late stage of intestinal obstruction. Serum lactate levels were similar among the groups. CONCLUSION: Serum glutamate levels may have a potential role as a biochemical parameter contributing to diagnosis, especially in the early stages of intestinal obstruction.

Prognostic significance of mean nuclear volume in pancreatic adenocarcinoma.

OBJECTIVE: To evaluate the correlation of stereologically estimated mean nuclear volume of tumor cells with other clinicopathologic prognostic features and survival in pancreatic ductal adenocarcinoma. STUDY DESIGN: The study included 27 patients with primary pancreatic ductal adenocarcinoma. A stereologic method proposed by Gundersen et al was used for the estimation of mean nuclear volume in hematoxylin and eosin-stained histologic sections of each case. Mean nuclear volume values were compared statistically with histopathologic prognostic feature groups and survival. RESULTS: The mean nuclear volume values of tumor cells ranged from 296.83 to 982.79 microns 3 (mean, 633.906 +/- 212.310). Higher values of mean nuclear volume were significantly related to advanced tumor stage and the presence of distant metastasis (Kruskal-Wallis, P = .036; Mann-Whitney U, P = .020). In contrast, nodal stage, tumor grade, perineural invasion, lymphatic and blood vessel invasion, and size of tumor showed no statistical relation to mean nuclear volume of tumor cells. Mean nuclear volume was found to be a significant predictor of survival in univariate analysis (P = .016). CONCLUSION: Estimation of mean nuclear volume may help in predicting the extent of disease and clinical behavior in pancreatic adenocarcinoma.

Primary hyperoxaluria: simultaneous combined liver and kidney transplantation from a living related donor.

Primary hyperoxaluria type 1 (PH1) is a rare inherited metabolic disorder in which deficiency of the liver enzyme AGT leads to renal failure and systemic oxalosis. Timely, combined cadaveric liver-kidney transplantation (LKT) is recommended for end-stage renal failure (ESRF) caused by PH1; however, the shortage of cadaveric organs has generated enthusiasm for living-related transplantation in years. Recently, successful sequential LKT from the same living donor has been reported in a child with PH1. We present a sister-to-brother simultaneous LKT in a pediatric patient who suffered from PH1 with ESRF. Twelve months after transplantation, his daily urine oxalate excretion was decreased from 160 mg to 19.5 mg with normal liver and renal allograft functions. In addition to the well-known advantages of living organ transplantation, simultaneous LKT may facilitate early postoperative hemodynamic stability and may induce immunotolerance and allow for low-dose immunosuppression.

Effect of ursodeoxycholic acid on hepatic steatosis in rats.

Ursodeoxycholic acid (UDCA) has been shown to have hepatoprotective effects in various liver diseases. This drug has also been found to be effective in patients with nonalcoholic steatohepatitis, improving hepatic steatosis (HS) significantly. The aim of this study was to evaluate whether UDCA has an effect on both preventing and regressing HS in rats. To induce fatty liver, a choline-deficient diet (CDD) was used. For the rats assigned to receive UDCA, a 1.5% UDCA solution was administered at a dose of 25 mg/kg/day using an oral feeding tube. Assessment of HS was based on the quantification of percentage of hepatocytes containing lipid vacuoles. Forty-three male Wistar rats were randomly divided into two protocols. In protocol I, 7 rats were fed a standard diet (SD) plus UDCA for 30 days (control group). In protocol II, 19 rats were fed CDD and 17 rats were fed CDD plus UDCA for 30 days. At the end of this period, after performing liver biopsies, either SD or SD plus UDCA was started in both CDD-fed rats and CDD plus UDCA-fed rats for 30 days in a random order without the knowledge of the degrees of steatosis developed. At the end of this period, liver biopsies were repeated in order to evaluate whether UDCA has an effect on the regression of HS. In protocol I, there were no specific findings on the histological examination of the livers at 30 days. In protocol II, the percentage of HS in CDD plus UDCA-fed rats was significantly lower than CDD-fed rats at the end of the same period (percentage of steatosis, mean +/- SD: 12.2 +/- 29.6 to 23.2 +/- 34.1 respectively, P = 0.0201); after starting either SD or SD plus UDCA, steatosis was almost completely regressed at 30 days in all rats that developed that steatogenic changes. UDCA seems to prevent HS in rats; addition of UDCA to SD does not cause a further contribution in regressing HS.

Immunohistochemical detection of pS2 protein and heat shock protein-70 in pancreatic adenocarcinomas. Relationship with disease extent and patient survival.

We investigated pS2 and HSP-70 protein expression in 36 pancreatic adenocarcinomas for their effect on disease extent and patient outcome. The cases were reviewed, histologically diagnosed, typed, graded, and staged. Lymphatic vessel, blood vessel and perineural invasion as well as lymph node, resection margin and adjacent organ involvements were re-evaluated. The standard streptavidin biotin immunperoxidase method was used for immunostaining with pS2 and HSP-70 antibodies. Cytoplasmic staining with both antibodies was scored semiquantitatively. The scores were compared with histopathological prognostic parameters using statistical methods. Standard prognostic parameters and staining scores were tested by survival analysis in terms of their effect on survival. All the tumors showed a positive cytoplasmic reaction with HSP-70 antibody. Seventy-seven percent of the tumors showed positive cytoplasmic staining with pS2 antibody (22.2% +, 13.9% ++ and 41.7% +++). There was a statistically significant difference between HSP-70 staining scores with N status and final stages of the tumors (Chi-square, p = 0.03 and p = 0.026, respectively), while neither direct nor inverse correlation was detected for both parameters. PS2 staining scores showed no statistically significant relationship with tumor grade T, M status, perineural invasion, lymph and blood vessel invasion. In tumors with extensive staining with pS2, tumor stage tended to be low (Chi square, p = 0.024, Kendall Tau-b, r: -0.336, p = 0.036). There was a statistically significant difference and inverse correlation between tumors with extensive pS2 staining and tumors with less intense staining in terms of lymph node metastasis (Chi-square, p = 0.041, Kendall Tau: p = 0.024, r = -0,373). In the R0 resection group, in univariate analysis, we found that with higher scores of HSP-70 staining, the prognosis of the patient tended to improve. (Cox regression, p = 0.013). In multivariate analysis, HSP-70 expression was found to be an independent prognostic factor. We found no relationship between pS2 staining and patient survival.