Comparison of Antisperm Antibody levels following totally extraperitoneal inguinal hernia repair and Lichtenstein hernia repair. A randomized controlled trial.

The study was supported by TUEK (Board of Education and Expertise in Medicine - grant number 2016-1201). Funding source had no involvement in conducting or reporting process of this study. Comparison of Antisperm Antibody level following extraperitoneal inguinal hernia repair and Lichenstein hernia >A randomzed rial PURPOSE: We compared laparoscopic totally extraperitoneal (TEP) hernia repair and open Lichtenstein hernia repair (LHR) in terms of Antisperm Antibody Levels (ASA), pain, operative times, return to work times, hernia recurrence, and postsurgery complications. METHODS: The patients were randomly divided into two groups as LHR and TEP. Blood samples were obtained for analysis of levels of ASA. Postoperative pain scores were assessed on the first day after repair using the Visual Analog Scale (VAS), and hernia recurrence, operation times, return to work times, and early and late postoperative complications were recorded. RESULTS: Sixty male patients enrolled in the study. All patients were negative for ASA presurgery. ASA were detected in two patients in the LHR group postsurgery. The VAS score of the patients in the TEP repair group was significantly lower than that in the LHR group (median: 4.0 vs. 6.0) (p <0.001). The mean operation time in the TEP hernia repair group (50 min) was significantly longer than that in the LHR group (40 min) (40.0) (p <0.011). The median return to work time in the TEP hernia repair group (7 d) was significantly shorter than that in the LHR group (15 d)(p <0.001). There was no statistically significant difference between the two methods in terms of ASA,recurrence, or postoperative complications (p> 0.05). DISCUSSION: Many studies have compared the superiority of different inguinal hernia repair methods. Which CONCLUSION: It is not possible to determine the superiority of concerning technics in reducing infertility after surgery. TEP inguinal hernia repair is superior to LHR in in terms of postoperative pain and return to work times. KEY WORDS: Lichtenstein, Antisperm antibody, Infertility, Inguinal hernia, Totally extra peritoneal repair.

Identification of the recurrent laryngeal nerve during thyroidectomy can affect the complication rate.

AIM: Identification of recurrent laryngeal nerve (RLN), performed via different techniques, decreases nerve injury during thyroidectomy. We aimed to evaluate the effect of different anatomic levels at which RLN was identified on postoperative complications. MATERIAL AND METHODS: The patients underwent total thyroidectomy or lobectomy without lymph node dissection were included. Two different surgical methods were performed: thyroidectomy identifying RLN at level of inferior thyroid artery (ITA) (Group 1); at level of Berry's ligament (Group 2). Patients were evaluated with indirect laryngoscopy on 3rd postoperative day, if nerve damage was determined, at each six months. Nerve damage and postop hypocalcemia were accepted transient up to 6th month, permanent after 6th month. Total serum calcium levels were postoperatively measured on 24th and 48th hours, and then monthly. RESULTS: Unilateral and bilateral RLN damage were detected as 4.4% and 2.2% in Group 1; and 8% and 2.67% in Group 2, respectively. The frequency of RLN damage was similar (p=0.62). Postoperative hypocalcemia was significantly higher in Group 1 (p=0.04); hypocalcemia was similar (p=0.149). One patient in Group 1, and 2 patients in Group 2 had f superior laryngeal nerve (SLN) injury. Three patients from each group showed permanent hypocalcemia. One patient in Group 1, and two in Group 2 developed permanent hoarseness. DISCUSSION: RLN injury was similar in both groups, however, temporary hypocalcemia was more frequent in patients undergone thyroidectomy with RLN identification at ITA level. CONCLUSIONS: Devascularization of parathyroid glands may be accused. Future studies are needed. KEY WORDS: Recurrent laryngeal nerve, Thyroidectomy.

An electron microscopy study of liver and kidney damage in an experimental model of obstructive jaundice.

With this experimental study we investigated the consequences of ligation of the common bile duct (CBD) on hepatic cells and on the renal ultrastructure by electron microscopy and also determine the effects after liberation of the ductus joint in order to clarify the mechanisms of renal failure commonly observed in cholestatic liver disease. The study was conducted on 53 Wistar albino rats divided into 4 subgroups. In the comparison group (sham) we proceeded to the simple laparotomy. After preparation of the common bile duct of all the rats of the four groups, and ligation of the duct at the level of the distal third, eight rats in each group were sacrificed on the 3rd, 7th, 10th and 14th day after surgery, taking blood samples to measure the serum levels of ALP and bilirubin, and liver and renal tissue samples for histological evaluation. In four rats of each group the common bile duct was unligated at the same deadlines to obtain free drainage of the bile for a week. At the end of this week, the rats were sacrificed by collecting blood and liver and kidney tissue samples. RESULTS: after CBD ligation in both groups, the ALP value, total and direct bilurubin levels were proportionally increased. After duct release, bilurubin levels decreased significantly. In group II, while large lipid granules were observed to indicate oxidative damage, mitochondrial swelling and crystals were observed after duct liberation. Areas of glycogen and normal mitochondria were observed in group IV. After duct release in this group, increases in Ito granules, lipid granules and normal mitochondria were observed, which may reflect the evolution of hepatic regeneration. When renal tissue was examined in group II, fusion processes in the feet, thickening of the basement membrane and mesengium were observed, and mitochondrial crystals were observed in renal tissue as well as in the liver after duct release. Damage in group III and group IV was increased parallel to prolongation of jaundice and after loosening persistent damage with mitochondrial crystals. CONCLUSION: Ultrastructural changes in rat liver tissue in conditions of obstructive jaundice may be reversible after restoration of drainage. On the other hand, ultrastructural changes in renal tissue in cases of prolonged jaundice are irreversible even if the internal drainage is restored. KEY WORDS: Bile Duct, Liver, Kidney, Obstructive Jaundice.

Efficacy of Hyperbaric Oxygen Therapy in Diabetic Foot Ulcers Based on Wagner Classification.

Diabetic foot ulcer is a common chronic complication of diabetes mellitus. In addition to conventional primary therapy, there are adjuvant therapy methods such as hyperbaric oxygen therapy for the healing of diabetic foot ulcer wounds. The present study aimed to determine the efficacy of hyperbaric oxygen therapy in diabetic foot ulcers based on Wagner classification. It was performed retrospectively from prospectively collected data. One hundred thirty patients with diabetic foot ulcers were assessed in 2 groups: 1 group received hyperbaric oxygen therapy; the other group did not. Patients were examined according to age, sex, ulcer grade based on Wagner classification; ulcer healing status; whether hyperbaric oxygen therapy was received; duration of diabetes in years; HbA1C, sedimentation, C-reactive protein levels; and presence of accompanying diseases, including peripheral arterial disease, chronic obstructive pulmonary disease, hypertension, chronic kidney disease, neuropathy, and retinopathy. The mean follow-up period was 19.5 ±â€¯4.45 months (range 12 to 28 months). Seventy-one (54.6%) patients received hyperbaric oxygen therapy, and 59 (45.4%) patients did not. All patients in Wagner grade 2 healed in both groups. In the group that received hyperbaric oxygen therapy for grade 3 and 4 patients, 35 (87.5%) and 11 (84.6%) healed, respectively. In total, 60 (84.5%) patients in the group that received hyperbaric oxygen therapy healed. The subgroup comparison conducted according to Wagner classification revealed no differences between the 2 groups of grades 2 and 5 patients. It also revealed that treatment had higher levels of efficacy in the healing of ulcers in grade 3 and 4 patients.

Factors affecting mortality in elderly patients who underwent surgery for gastric cancer.

AIM: The aim of this study was to determine factors affecting overall mortality in patients over 60 years of age who underwent surgery for gastric cancer in our clinic. MATERIAL AND METHODS: Data on histopathological diagnosis (tumor size, lymph node status, and number), pathological stage, serum albumin level, tumor markers, complete blood count, and demographic information of 109 patients over 60 years of age who had surgery for gastric cancer between January 2011 and July 2016 were obtained retrospectively from the patient files. In addition, the survival status of all patients were examined and recorded. Metastatic lymph node ratio (MLR), red cell distribution width platelet ratio (RPR), neutrophil-lymphocyte ratio (NLR), plateletlymphocyte ratio (PLR), and prognostic nutritional index (PNI) were calculated. RESULTS: On univariate analysis of independent parameters, pathological LN number (p = 0.001), MLR (p <0.001), T3 (p = 0.001) or T4 (p = 0,006) tumor stage according to TNM system, the presence of metastasis (p = 0.063), and male gender (p = 0.066) were found to affect overall mortality (OM). On multivariable Cox regression analysis of these results, MLR (p = 0.005) and T stage (p = 0.006) was determined to be a statistically significant and independent prognostic value. CONCLUSION: In patients over 60 years of age who underwent surgery for gastric cancer, the factors affecting mortality were determined to be the presence of metastases, number of pathological lymph nodes, and male gender. Metastatic lymph node ratio and T1&T2 stage were determined to be independent prognostic factors. KEY WORDS: Elderly, Gastric cancer, Mortality, Prognostic factor.

Evaluation and Comparison of Charcot's Triad and Tokyo Guidelines for the Diagnosis of Acute Cholangitis.

Reliability of Charcot's triad has long been questioned. Tokyo Guidelines committee published Tokyo Guidelines in 2007 and 2013. The aim of this study was to retrospectively examine the patients who had been treated with the diagnosis of acute cholangitis and evaluate 2007-2013 Tokyo criteria and Charcot's triad. The files of the patients with acute cholangitis in a referral center were examined retrospectively. All patients were classified and evaluated according to 2007 and 2013 Tokyo criteria and Charcot's triad; and results were compared. It was detected that 51.7 % of patients who did not meet Charcot's triad were in definitive diagnosis group of both Tokyo criteria. Kappa value was calculated as 0.404 in the analysis of consistency between two Tokyo criteria. Two patients who had features sufficient to objectively make the diagnosis of acute cholangitis failed to meet the Tokyo criteria 2007 or 2013. Charcot's triad is not sensitive and specific enough in the diagnosis of acute cholangitis. Revision of Tokyo 2007 criteria caused a change in the diagnostic status of 15 % of the patients. It is remarkable that kappa value can hardly be considered as a sign of moderate agreement between two Tokyo guidelines. Tokyo criteria should be supported and updated.

Questions from and answers to a patient with groin hernia.

Inguinal hernia surgical treatment are the most commonly performed operations in general surgery practice. There is a need for detailed anatomical knowledge and surgical skills to satisfactorily treat this disease. In this review, we aimed to present up-to-date information and approaches on basic diagnosis, treatment, complications and management of inguinal hernias in our institution. KEY WORDS: Chronic pain, Groin hernia, Inguinal hernia, Recurrence, Surgery.

The evaluation of the complications observed in patients with bilateral total and bilateral near total thyroidectomy.

AIM: The objective was to compare the recurrent laryngeal nerve (RLN) and superior laryngeal nerve (SLN) injuries in patients with bilateral total thyroidectomy (BTT) and bilateral near total thyroidectomy (BNTT) with the frequency of the hypocalcemic complications regarding the operation procedures. MATERIALS AND METHODS: Patients, who underwent BTT and BNTT in our clinic between January 1999 and January 2011, were included in this retrospective clinical study. Patients' files are evaluated. Demographic information, pre-operative complete blood cell count and biochemical analysis, thyroid function tests, ultrasonographic results, results of the fine needle aspiration biopsy, implemented operative procedures (BTT or BNTT), vocal cord investigation, post-operative calcium levels, postoperative complications were analyzed. RESULTS: In 328 of 408 (80.4%) patients BTT was the preferred method and 80 underwent BNTT (19.6 %). Postoperative hypocalcemia was observed in 59 patients in the BTT group (17.9 %) and in 11 patients in the BNTT group (13.7 %) . Hypocalcemia persisted in 8 patients in BTT group (2.4 %) and in 6 patients in BNTT group (7.5%). Unilateral RLN paralysis was observed in 22 patients in BTT group (6.7 %) and in 13 patients in the BNTT group (16.2 %). CONCLUSION: In this study, the likelihood of the temporary RLN paralysis and permanent hypoparathyroidism is found to be higher in the patients with BNTT compared to the patients with BTT. BNTT may be the preferred choice of treatment in suitable patients. KEY WORDS: Complication, Hypocalcemia, Nervus laryngealis recurrens, Nervus laryngealis superior, Thyroidectomy.

Validation of COLA score for predicting wound infection in patients undergoing surgery for rectal cancer.

AIM: The purpose of our study was to estimate the incidence of SSI (Surgical site infection) and the effect of COLA (contamination, obesity, laparotomy and ASA grade) score on SSI in patients undergoing rectal surgical procedures for rectal cancer. MATERIAL OF STUDY: A total of 92 patients who underwent operation for rectum cancer were enrolled in this study. Wound surveillance was performed in all patients by a staff surgeon identified infected wounds during the hospital stay, and collected information for up to 30 days after operation. RESULTS: The overall rate of incisional SSI and organ/space SSI was 22.8% and 7.6% respectively. Surgical site infection rates were 14.2%, 20.58%, 40.7%, 57.1% for COLA 1,2,3 and 4 scores respectively. The area under the receiver/ operator characteristic curve for the score was 0,660. CONCLUSION: COLA scoring systems predict, with reasonable accuracy, the risk of SSI in rectal cancer patients undergoing elective rectal surgery. KEY WORDS: COLA score Rectal surgery, Surgical site infection, Risk prediction, Wound infection.

Factors Affecting Mortality After Major Nontraumatic Lower Extremity Amputation.

Our aim was to evaluate the factors affecting the mortality of patients who underwent nontraumatic major lower limb amputation due to ischemic and/or diabetic causes. A total of 100 patients were included in the study. Among these patients, 70 (70%) underwent below-knee amputation, whereas 30 (30%) underwent above-knee amputation. Eleven (15.7%) of the 70 patients who underwent below-knee amputation and 12 (40%) of the 30 patients who underwent above-knee amputation (P = .008) were deceased. After multivariable Poisson regression analysis, female gender (risk ratio [RR] = 2.00, 95% CI = 1.07-3.74) and a neutrophil lymphocyte ratio (NLR) less than 6.8 (RR = 5.12, 95% CI = 1.86-14.08) were found to be independent risk factors for mortality. The value of 6.8 was used as a cutoff point for the NLR (area under the curve = 0.73, 95% CI = 0.62-0.85), with a sensitivity, specificity, positive predictive value, and negative predictive value of 83%, 66%, 57%, and 92%, respectively. The NLR and female gender were found to be independent factors that are related to increased mortality in patients who underwent lower limb amputation due to diabetic and/or ischemic causes. The coexistence of congestive heart failure and the amputation level (above knee) were found to be predictors of mortality in univariable analysis, but significance could not be demonstrated in multivariable analysis.

Can outcome of pancreatic pseudocysts be predicted? Proposal for a new scoring system.

BACKGROUND: The spontaneous resolution rate of pancreatic pseudocysts (PPs) is 86%, and the serious complication rate is 3-9%. The aim of the present study was to develop a scoring system that would predict spontaneous resolution of PPs. METHODS: Medical records of 70 patients were retrospectively reviewed. Two patients were excluded. Demographic data and laboratory measurements were obtained from patient records. RESULTS: Mean age of the 68 patients included was 56.6 years. Female:male ratio was 1.34:1. Causes of pancreatitis were stones (48.5%), alcohol consumption (26.5%), and unknown etiology (25%). Mean size of PP was 71 mm. Pseudocysts disappeared in 32 patients (47.1%). With univariate analysis, serum direct bilirubin level (>0.95 mg/dL), cyst carcinoembryonic antigen (CEA) level (>1.5), and cyst diameter (>55 mm) were found to be significantly different between patients with and without spontaneous resolution. In multivariate analysis, these variables were statistically significant. Scores were calculated with points assigned to each variable. Final scores predicted spontaneous resolution in approximately 80% of patients. CONCLUSION: The scoring system developed to predict resolution of PPs is simple and useful, but requires validation.

Small Intestinal and Mesenteric Multiple Gastrointestinal Stromal Tumors Causing Occult Bleeding.

Gastrointestinal stromal tumors are the meseancymal neoplasms which may involve any part of gastrointestinal tract. C-Kit and platelet derived factor receptor alpha polypeptide are believed to be responsible for the genetic basis. This case presentation aimed to discuss the diagnostic and therapeutic modality of multiple small intestinal, omental, and mesenteric GISTs with different sizes which caused occult bleeding in a 43-year-old male patient.

Surgical Management of Liver Hydatid Cyst Related Non-traumatic Emergencies: Single Center Experience.

BACKGROUND: Vast majority of complaints and physical examination findings of hydatid disease are common in emergency room patients. Different emergency presentations of hydatid cyst disease and their treatment are evaluated. We studied preoperative laboratory findings of these patients to identify any parameters to predict hydatid cyst-biliary system communication. METHODS: We reviewed the files of patients who underwent emergency surgery due to liver hydatid cysts and related conditions between March 2010 and March 2014 in Ankara Numune Research and Training Hospital, Turkey, retrospectively. Patients were grouped, regarding to the presence of biliary system involvement. RESULTS: Twelve patients (9 males, 3 females) were included. We identified two groups. Biliary system involved group (n=9) had significantly higher pre-operative gamma glutamine transferase and alkaline phosphatase levels (P=0.036). No significant difference was noted regarding other pre-operative laboratory findings. Mortality rate was 17%. CONCLUSION: Medical literature lacks sufficient information about hydatid disease related non-traumatic emergency surgeries. Preoperative elevated gamma glutamyl transferase and alkaline phosphatase levels may be questioned as a warning about cyst-biliary communication in hydatid cyst patients with abdominal pain in the emergency room. Future studies with larger sample sizes are needed. In addition, prolongation of the time before diagnosis in these patients may result in life threatening complications.

Comparison of Coskun and Lichteinstein hernia repair methods for groin hernia.

PURPOSE: Coskun hernia repair technique has been reported to be an effective new fascia transversalis repair with its short-term follow-up results. Our aim is to determine the results of Coskun hernia repair technique and to compare it with Lichtenstein technique. METHODS: At this comparative retrospective study a total of 493 patients, who had groin hernia repair procedure using Coskun or Lichtenstein technique, between January 1999 and March 2010 were enrolled into the study. Patients were reached by telephone and invited to get a physical examination. RESULTS: Out of 493 groin hernia repairs, 436 (88.5%) were carried out by residents and 57 (11.5%) by attending surgeons. Lichtenstein technique was the choice in 241 patients and 252 patients underwent Coskun hernia repair technique. Groin hernia recurrence was detected in 8 patients (3.1%) in Coskun hernia repair group and 7 patients (2.9%) in Lichtenstein group. Comparison of early complication rates in Coskun group (3.9%) and Lichtenstein group (4.5%) showed no significant difference. Late complication rates were significantly higher in Lichtenstein group (1.2% vs. 4.9%). The operation time was shorter in Coskun group (44 minutes) than in Lichtenstein group (60 minutes). Subgroup of patients, whose hernia repair operations were carried out by attending surgeons, had a recurrence rate of 0% and 3.8%, in Coskun group and Lichtenstein group, respectively. CONCLUSION: This study showed that Coskun hernia repair technique has a similar efficacy with Lichtenstein repair, on follow-up.

Late Onset Traumatic Diaphragmatic Herniation Leading to Intestinal Obstruction and Pancreatitis: Two Separate Cases.

Although diaphragmatic injuries caused by blunt or penetrating trauma are rare entities, they are the most commonly misdiagnosed injuries in trauma patients and occur in approximately 3-7% of all abdominal or thoracic traumas. Acute pancreatitis secondary to late presenting diaphragmatic hernia is very rare. Here we present two separate cases: one with acute bowel obstruction and the other with acute pancreatitis secondary to late onset traumatic diaphragmatic hernia (three and twenty-eight years after chest trauma, resp.).

Postoperative fluid management.

Postoperative care units are run by an anesthesiologist or a surgeon, or a team formed of both. Management of postoperative fluid therapy should be done considering both patients' status and intraoperative events. Types of the fluids, amount of the fluid given and timing of the administration are the main topics that determine the fluid management strategy. The main goal of fluid resuscitation is to provide adequate tissue perfusion without harming the patient. The endothelial glycocalyx dysfunction and fluid shift to extracellular compartment should be considered wisely. Fluid management must be done based on patient's body fluid status. Patients who are responsive to fluids can benefit from fluid resuscitation, whereas patients who are not fluid responsive are more likely to suffer complications of over-hydration. Therefore, common use of central venous pressure measurement, which is proved to be inefficient to predict fluid responsiveness, should be avoided. Goal directed strategy is the most rational approach to assess the patient and maintain optimum fluid balance. However, accessible and applicable monitoring tools for determining patient's actual fluid need should be further studied and universalized. The debate around colloids and crystalloids should also be considered with goal directed therapies. Advantages and disadvantages of each solution must be evaluated with the patient's specific condition.

Randomized Controlled Trial Comparing the Effects of Vessel Sealing Device and Milligan Morgan Technique on Postoperative Pain Perception after Hemorrhoidectomy.

BACKGROUND: The aim of this study was to compare postoperative pain perception after Milligan Morgan and Ligasure™ techniques in hemorrhoidectomy. METHODS: Fifty-four patients diagnosed with Grade 3-4 hemorrhoids requiring surgery between May 2013 and September 2013 were enrolled in the study. Patients were randomized into either the Ligasure™ hemorrhoidectomy group (Group 1, n = 26) or the Milligan Morgan hemorrhoidectomy group (Group 2, n = 28). RESULTS: The difference between visual analogue scale scores on postoperative day 1 was not statistically significant but on the third postoperative day, the Ligasure™ group had higher visual analogue scale scores (4 ± 2.61) when compared to the Milligan Morgan hemorrhoidectomy group (2.43 ± 1.20). This difference on the third postoperative day visual analogue scale scores was statistically significant (p < 0.025). CONCLUSIONS: Ligasure™ does not seem to have an advantage in postoperative pain when compared to Milligan Morgan hemorrhoidectomy.

Spontaneous Rectus Sheath Hematoma: an Overview of 4-Year Single Center Experience.

Rectus sheath hematoma is a clinical entity characterized by the presence of blood within rectus abdominis muscle sheath. The aim of this study was to analyze clinical characteristics, diagnostic approach, treatment strategy, and outcomes of patients with rectus sheath hematoma. Patients diagnosed and treated for spontaneous rectus sheath hematoma between March 2010 and March 2014 were included in the study. A total of 10 patients were diagnosed as spontaneous rectus sheath hematoma. The mean age was 66.5 ± 16.9 years, and the mean hospital stay was 4.4 ± 1.8 days. There was no mortality. Six patients were using anticoagulant or antiplatelet agents. Eight patients recovered after conservative treatment. Two patients underwent surgery. Spontaneous rectus sheath hematoma is associated with anticoagulant therapy. Cases with abdominal pain and a non-pulsatile abdominal mass particularly in elderly women should be kept in mind. Treatment is mostly based on supportive care to preserve hemodynamic stability.

Fournier's Gangrene as a Postoperative Complication of Inguinal Hernia Repair.

Fournier's gangrene is the necrotizing fasciitis of perianal, genitourinary, and perineal regions. Herein, we present a case of scrotal Fournier's gangrene as a postoperative complication of inguinal hernia repair. A 51-year-old male with giant indirect hernia is presented. Patient underwent inguinal hernia repair, and after an unproblematic recovery period, he was discharged. He applied to our outpatient clinic on the fifth day with swollen and painful scrotum and it turned out to be Fournier's gangrene. Polypropylene mesh was not infected. Patient recovered and was discharged after repeated debridements. Basic principles in treatment of Fournier's gangrene are comprised of initial resuscitation, broad-spectrum antibiotics therapy, and early aggressive debridement. In the management of presented case, aggressive debridement was made right after diagnosis and broad-spectrum antibiotics were given to the hemodynamically stable patient. In these circumstances, the important question is whether we could prevent occurrence of Fournier's gangrene.

Prognostic value of preoperative inflammation-based prognostic scores on hospital mortality after gastric cancer surgery.

Gastric cancer is the fourth most common malignancy worldwide. Poor prognosis in gastric cancer is linked with hypoalbuminemia. Previous studies demonstrated relationships between gastric cancer and chronic inflammation. The aim of this study was to assess the prognostic value of preoperative inflammation-based prognostic scores regarding hospital mortality after gastrectomy. Unlike other recent articles on the same topic; we could only verify prognostic value of prognostic nutritional index for in hospital mortality after surgery.