Effect of sildenafil citrate on the liver structure and function in obstructive jaundice: An experimental study.

OBJECTIVE: We aimed to investigate the effect of 10 mg/kg sildenafil on the structure and function of the liver in a rat model of obstructive jaundice. MATERIAL AND METHODS: Sixty-two male Wistar albino rats were distributed into six different groups. Obstructive jaundice was performed by legating the common bile duct. 10 mg/kg sildenafil citrate in drinking water was delivered orally after the operation before sacrificing them. Rats were sacrificed either after 10 or 28 days according to the study design. The blood and tissue samples from the liver were obtained to perform a biochemical and histopathological analysis to study functional and structural changes in the liver. RESULTS: At the 10th day, there was no difference between the sildenafil-treated and control groups with regard to the aspartate aminotransferase and alanine aminotransferase levels (p=0.423, p=0.661). The alkaline phosphatase total bilirubin levels among the groups were statistically different (p<0.001). At the 28th day, liver function tests except alanine aminotransferase showed significant differences among the groups (p<0.001). Liver function tests did not changed significantly between the 10th and 28th day in sildenafil-treated rats (p>0.05). Significant differences were observed among the groups with regard to cholestasis, fibrosis, inflammation, and necrosis (p<0.001). However, edema increased in the sildenafil-treated group (p<0.001). On the 28th day, the severity of structural changes in the liver after obstructive jaundice, except edema, reduced significantly (p<0.001). The sildenafil-treated groups at different time points didn't show any statistical difference in histopathological changes (p>0.05). CONCLUSION: Oral administration of 10 mg/kg sildenafil citrate dramatically reverses the biochemical and histopathological liver changes induced by obstructive jaundice in rats.

Laparoscopic pancreaticoduodenectomy in pancreatic cancer: Our initial experience.

Pancreas cancer is an important cause of mortality worldwide. It has no particular symptoms, and may cause different complaints according to tumor diameter and localization. Local invasion may develop in the short term and distant metastasis may occur in vascular structures in its neighborhood. That's why, resectability rates are low at the time of diagnosis with a negative effect on survival rates. Minimally invasive surgery is being increasingly implemented in pancreas lesions owing to the positive short-term oncologic results of the technique in many other procedures. Traditionally, conventional open surgery is performed in pancreatic head tumors. As laparoscopic resection of pancreatic head cancer has serious technical difficulties and requires advanced laparoscopic experience, minimal invasive attempts in this field have not yet reached sufficient acceptance worldwide. Besides the fact that laparoscopic pancreaticoduodenectomy may provide sufficient short-term oncologic results that are comparative with open surgery, it can be implemented in selected patients in centers with advanced laparoscopic resection capacity. In this case series, we aimed to present our experience of laparoscopic pancreaticoduodenectomy in pancreatic head cancer patients.

The Effect of Peritoneal Prednisolone Lavage in Bacterial Peritonitis: An Experimental Study.

OBJECTIVE: This study investigated and compared the effects of antibiotic and steroid lavage on survival and cytokine levels in an experimental abdominal sepsis model. BACKGROUND: In abdominal sepsis, abdominal lavage with saline or antibiotic solutions is a well-documented intervention known to have positive impact on survival; however, the effects of steroid lavage in abdominal sepsis have not yet been investigated. MATERIALS AND METHODS: Ninety-six Wistar rats were divided into 4 groups (n = 24). Abdominal sepsis was induced by cecal ligation and puncture. Six hours after laparotomy, the authors performed a relaparatomy followed by cecal resection and an abdominal lavage. Abdominal lavage was performed using saline in group 1, equal volumes of cefazolin sodium in group 2, low-dose methylprednisolone (1 mg/kg) in group 3, and high-dose methylprednisolone (2 mg/kg) in group 4. After division of 2 subgroups from each of the 4 groups, the first of the rats (n = 12) were euthanized 6 hours later for evaluation of cytokines (ie, interleukin [IL] 1ß, 2, 4, 10, and tumor necrosis factor alpha [TNF-α]), and the others were followed for 30 days for analysis of mortality rates. RESULTS: The mortality rate of the rats in group 2 was significantly higher than group 4, which had no mortality (P = 0.032). Although insignificant, the lowest mean value of IL-1ß, IL-2, and TNF-α were in group 1, and the highest was in group 2. The lowest IL-4 level was in group 3, and the highest level was in group 2 (P = 0.41). Interleukin-10 levels were significantly lower in group 4 and higher in group 2 (P = 0.014). CONCLUSION: The authors state that peritoneal lavage with prednisolone improved survival rates with increasing doses in abdominal sepsis.

Effects of melatonin on cytokine release and healing of colonic anastomoses in an experimental sepsis model.

BACKGROUND: The present objective was to identify effects of early melatonin application on healing of anastomotic wound and inflammation in an experimental sepsis model. METHODS: A total of 60 Wistar albino rats were divided into 2 groups. Cecal ligation puncture (CLP) and colonic resection anastomosis were performed on both the control group and the melatonin treatment group. Both groups were divided into 3 subgroups consisting of 10 rats each. One subgroup from each group underwent re-laparotomy at the 16th hour, the next on the 3rd day, and the final subgroup on the 7th day. Presently evaluated were effects of melatonin treatment of early sepsis on interleukin-6 (IL-6), interleukin-10 (IL-10), interferon gamma (INF-γ), and C-reactive protein (CRP) levels, as well as burst pressures (BPs), collagen and hydroxyproline (OHP) content of the anastomotic segments, histopathologic healing, immunohistochemical expressions, CD34, and transforming growth factor beta (TGF-ß). RESULTS: IL-6 and INF-γ levels of the treatment group showed a significant decrease at the 16th hour and an increase on the 3rd and 7th postoperative days. IL-10 levels were significantly higher at the 16th hour and significantly lower on the 3rd and 7th postoperative days in the control group (p<0.001 for each). The treatment group also showed significantly higher capillary permeability, fibroblast proliferation, and collagen deposits (p<0.001 for each). CD34 expression was significantly increased in the treatment group on the 7th postoperative day (p=0.005). CONCLUSION: Application of melatonin in early sepsis significantly improved colonic anastomotic healing in a rat model.

The development of pneumobilia after blunt trauma.

Pneumobilia is the detection of gas within the biliary system. It usually develops after bilioenteric anastomosis, percutaneous or endoscopic biliary interventions, infections and abscesses. The treatment is surgical, especially in cases with no prior interventions to the biliary system. The development of pneumobilia is quite rare after blunt trauma. Therefore, both the diagnosis and management are challenging for surgeons. Herein, we present the diagnosis and conservative management of a patient with pneumobilia after blunt trauma.

Acute abdomen due to Meckel's enterolith: Case report and review of the literature.

Meckel's diverticulum is a rare condition with an incidence of 1-3% in general population. It is usually asymptomatic and is incidentally detected during laparotomy/laparoscopy. Enterolith formation within Meckel's diverticulum is even rarer. Herein, we present the diagnosis and management of a 50-year old patient with Meckel's diverticulum enterolith and discuss this rare condition based on the literature.

The effect of methylprednisolone and tenoxicam on the protection of damage of the nerve physiomorphology caused by prolene mesh.

INTRODUCTION: Aim was to investigate the effect of methylprednisolone and tenoxicam on the protection of damage of the nerve physiomorphology caused by prolene mesh used in hernia repair. METHODS: Fifty male Wistar-albino rats weighing 250-350 gr, were randomly divided into 5 groups. Sciatic nerve was dissected in all rats after performing EMG on basal neural transport. In group 1, only sciatic nerve manipulation was performed. Other groups received a monofilament polypropylene cuff around the sciatic nerve. No additional procedure was performed in group 2. In group 3, 2 mg/kg single dose methylprednisolone was injected around the nerve and mesh. In group 4 and 5, 0.5 mg/kg/day methylprednisolone and 1 mg/kg tenoxicam was injected around the nerve and mesh for 4 weeks, respectively. Neural transport was evaluated by electromyography 4 weeks later and compared with pre-procedural values. Then the rats were sacrificed and, sciatic nerves including 1 cm around the mesh were excised. Inflammation and fibrosis were scored histopathologically. RESULTS: While basal latency was similar, postoperative latency was significantly different among groups. Latency was significantly longer in group 2 than the group 1. It was significantly shorter in group 3 when compared to group 2 (p = 0.007). Preoperative and postoperative amplitudes were similar among groups. Denervation was significantly different among groups (p < 0.05). Denervation was higher in group 2 than group 1. It was similar to group 2 in study groups. Inflammation and fibrosis was significantly different among groups (p < 0.05). Inflammation and fibrosis scores were significantly higher in group 2 than group 1. The highest inflammation and fibrosis scores were detected in repetitive drug administrated groups. Although it wasn't statistically significant, inflammation was lower in single dose steroid administrated group than group 2. Similarly, the highest fibrosis scores were detected in repetitive drug administrated groups. Single dose steroid administration didn't increase fibrosis when compared to group 2. CONCLUSIONS: Prolene mesh used in hernia repair caused increased inflammation and fibrosis and effected latency and denervation negatively. Single dose methylprednisolone administration decreased nerve damage and inflammation. On the other hand, daily administration of methylprednisolone and tenoxicam for 4 weeks caused increased inflammation and fibrosis and wasn't affective on protection of nerve physiomorphology.

Effect of Weight Loss Induced by Intragastric Balloon Therapy on Cardiac Function in Morbidly Obese Individuals: A Pilot Study.

OBJECTIVE: The aim of the study was to investigate the effect of intragastric balloon therapy on left ventricular function and left ventricular mass in a cohort of morbidly obese patients. SUBJECTS AND METHODS: A prospective trial was performed in a cohort of 17 class II and class III morbidly obese individuals. The intragastric balloon was retained in the stomach for an average of 6 months. Conventional and tissue Doppler echocardiography were performed in all patients before and after the procedure. RESULTS: The mean age of the study participants was 36 ± 10 years (range: 18-55). The mean body mass index was significantly decreased following the intragastric balloon insertion procedure (44 ± 8 vs. 38 ± 5, p < 0.001). The left ventricular mass index and left atrial volume index were significantly decreased following the procedure (112 ± 21 vs. 93 ± 17, p = 0.001 and 20 ± 6 vs. 14 ± 5, p = 0.02, respectfully). In addition, the ratio of mitral peak early diastolic velocity to tissue Doppler-derived peak diastolic velocity and tissue Doppler echocardiography-derived left ventricular myocardial performance index were decreased significantly following the procedure (9.5 ± 1.9 vs. 7.7 ± 1.5, p = 0.002 and 0.57 ± 0.11 vs. 0.46 ± 0.06, p = 0.001, respectively). CONCLUSIONS: Intragastric balloon therapy resulted in significant weight reduction in morbidly obese patients. This weight reduction was associated with improved left ventricular function.

Same-day colonoscopy preparation with Senna alkaloids and bisacodyl tablets: a pilot study.

AIM: To evaluate the efficacy of same-day bowel preparation with Senna alkaloids combined with bisacodyl tablets in routine colonoscopy procedures. METHODS: Between March and June 2013, a same-day bowel preparation was implemented in our endoscopy unit. The preparation consisted of a semi-liquid, fiber-free diet one day prior to the procedure, with two bisacodyl tablets after lunch and dinner, and 250 mL of Senna alkaloid with 1.5 L of drinking water at 6 am the day of the procedure. The quality control parameters of colonoscopy were evaluated and implemented according to the guidelines of the American Society for Gastrointestinal Endoscopy. The pre-procedure, during-procedure and post-procedure patient data were collected and analyzed: (1) pre-procedure (age, gender, comorbid diseases, colonoscopy indications, complete lack of compliance with the bowel preparation protocol); (2) during-procedure (sedation dose, duration of colonoscopy, withdrawal time, cecal intubation rate, polyp detection rate, Boston Bowel Preparation Scores and presence of foam and clear liquid); and (3) post-procedure (visual analogue scale score, pain during the procedure, patient satisfaction and premature withdrawal due to the insufficient bowel preparation). RESULTS: A total of 75 patients were included in this study with a mean age of 54.64 ± 13.29 years; 53.3% (40/75) were female and 46.7% (35/75) were male. A complete lack of compliance with the bowel preparation protocol was seen in 6.7% of patients (5/75). The mean total duration of colonoscopy was 16.12 ± 6.51 min, and the mean withdrawal time was 8.89 ± 4.07 min. The cecal intubation rate was 93.8% (61/64) and the polyp detection rate was 40% (30/75). The mean Boston Bowel Preparation Score was 7.38 ± 1.81, with the following distribution: right colon, 2.34 ± 0.89; transverse colon, 2.52 ± 0.67; left colon, 2.52 ± 0.63. The mean visual analogue scale score was 4.59 ± 1.57. Due to insufficient bowel preparation, seven patients (7/75; 9.3%) were asked to repeat the procedure. Of these, five patients had poor or modest compliance with the protocol, and two patients reported constipation. Premature withdrawal due to insufficient bowel preparation was 2.7% (2/75). The overall satisfaction with the protocol was 86.7% (65/75), with patients reporting they would prefer the same protocol in a repeat procedure. CONCLUSION: The same-day administration of Senna alkaloids appears to be a safe and effective bowel cleansing protocol for colonoscopy procedures.

Effect of ß-glucan on drain fluid and amount of drainage following modified radical mastectomy.

INTRODUCTION: To reduce the seroma formation following mastectomy and axillary dissection, many different techniques and drugs have been investigated. The aim of this study is to evaluate the effects of oral ß-glucan on drain fluid and efficacy of daily drainage and drain removal day in mastectomy patients. METHODS: One hundred and thirty breast cancer patients of Ankara Oncology Training and Research Hospital were divided into 2 groups by consecutive randomization (n = 65 each). ß-glucan 10 mg capsules were administered to Group 1 twice a day for 10 days. Group 2 took placebos in the same manner. Age, menarche age, menopause, parity, history of oral contraceptives, comorbidities, postoperative daily drainage volumes and drain removal days were recorded and compared. Seroma samples during the first and second day of drainage were taken for analysis of Interleukin-6 (IL-6) and Tumor Necrosis Factor (TNF-α). RESULTS: There was no difference between groups in terms of age, menarche age, menopause period, parity, oral contraceptive use and comorbidities. Group 1 showed significantly lower daily drainage volumes between days 2 and 8. Mean drain removal day was 7.16 ± 1.72 in Group 1 and 8.59 ± 2.27 in Group 2. The difference was significant (p < 0.001). TNF-α and IL-6 levels on days 1 and 2 in Group 1 were significantly lower (p < 0.001). In addition, ß-glucan significantly shortened the number of days required for the drain removal in patients who have comorbidities (p = 0.018). The earliest removal was in patients without comorbidity and who received ß-glucan (p = 0.002). CONCLUSION: ß-glucan decreased drain discharges after mastectomy. The drains were removed earlier in ß-glucan administered patients.

Effect of antibiotic lavage in adhesion prevention in bacterial peritonitis.

BACKGROUND: Intra-abdominal adhesions remain a major clinical problem. Previously, rifamycin lavage was used to prevent adhesion formation in the septic abdomen. The aim of our study was to test the effectiveness of intraperitoneal application of alternate antibiotics in an abdominal sepsis model. METHODS: Sixty Wistar-albino rats were randomly divided into 6 equal groups. Bacterial peritonitis was induced using caecal ligation and puncture model in all groups. Group 1 was an untreated control. The peritoneum was lavaged with isotonic saline in Group 2, with imipenem in Group 3, with ceftriaxone in Group 4, with cefazolin in group 5 and with metronidazole in group 6. Four weeks after the surgery, intra-abdominal adhesions were graded, tensile strength of the adhesions was measured and histopathological examinations were performed. RESULTS: Imipenem, ceftriaxone and cefazolin significantly reduced adhesion formation (p<0.001) with significantly reduced fibrosis scores (p=0.013). Adhesion formation was greatest in the metronidazole treatment group. The breaking force of adhesions was significantly reduced in Groups 4 and 5 (p<0.001). Although, the inflammation scores were similar between groups (p=0.058), grade 3 inflammation scores were only seen in control, saline and metronidazole-treatment groups. CONCLUSION: According to these data, cephalosporins may be effective in preventing adhesion formation in septic abdomens. These antibiotics need to be evaluated in a clinical trial.

Correlation of the gastroesophageal flap valve grade with the surgery rate in patients with gastroesophageal reflux disease.

BACKGROUND: The importance of endoscopic evaluation and grading of the gastroesophageal flap valve (GEFV) in patients with gastroesophageal reflux disease (GERD) was previously demonstrated with increased acid exposure and high grades of esophagitis in those with high-grade valves. On the other hand, no data exist on the relationship between GEFV appearance and surgical rate. METHODS: For 453 patients with symptoms suggestive of GERD, GEFV grading and 24-h ambulatory pH monitoring were performed. Surgery was performed for 82 of these patients who failed medical management or had disease complications. RESULTS: The GEFV grade 4 patients were younger than the patients with normal GEFV (grades 1 [p = 0.017] and 2 [p < 0.001]) and showed significant male predominance. The prevalence of hiatal hernia, the degree of esophageal acid exposure, and the prevalence and degree of erosive esophagitis significantly increased with GEFV grade (p < 0.001 for all). No GEFV grade 1 patients underwent surgery compared with 4.9 % of the grade 2 patients, 20.5 % of the grade 3 patients, and 63.6 % of the grade 4 patients who had surgery for various indications (p < 0.001). CONCLUSIONS: Esophagogastric opening estimated by endoscopic grading of the GEFV was strongly correlated with surgery rate in GERD patients. In particular, patients with grade 4 valves showed the highest rates of erosive esophagitis and axial hiatal hernia and frequently underwent surgery for either failed medical management or disease complications.

Comparison of cyanoacrylate-assisted arteriotomy closure with conventional closure technique.

BACKGROUND: We aimed to compare conventional suture closure of arteriotomy with N-butyl-cyanoacrylate-assisted suture closure. METHODS: Forty Wistar rats were randomly divided into two groups. Standard arteriotomy was performed to the abdominal aorta through a midline incision. In the first group, arteriotomy was closed by 3 stitches with 45 degrees between each and in the second by two stitches with 0.1 ml (12-12.5 mg) cyanoacrylate. Amount of blood loss, operation time and severity of myointimal hyperplasia by immunohistochemistry on aorta segments were measured on postoperative days 7 and 30. RESULTS: Mean anastomotic time was 13.5 +/- 1.64 in the first and 13.0 +/- 1.75 min in the second group (p = 0.356). Operation time was 23.45 +/- 3.63 in the control and 21.0 +/- 3.09 min in the second group (p = 0.027). Mean amount of bleeding was 473.75 +/- 260.5 in the first and 327.5 +/- 155.36 microl in the second group (p = 0.037). Intimal thickness on the 7th day was 80.62 +/- 7.92 in the first and 83.24 +/- 3.42 microm in the second group, and on the 30th day was 81.64 +/- 5.11 in the first and 88.77 +/- 11.03 microm in the second group. The early and late intimal thicknesses were similar (p = 0.35 and 0.87, respectively). CONCLUSION: Reconstruction of arteriotomies with fewer sutures in combination with cyanoacrylate is a safe method associated with less blood loss and shorter operation time. It also does not lead to increased myointimal hyperplasia.

Effect of n-butyl-2-cyanoacrylate on high-risk colonic anastomoses.

We investigated the effect of n-butyl-2-cyanoacrylate (BCA) on colonic anastomosis under clean contaminated procedure (CCP) and bacterial peritonitis (BP) conditions in rats. Male Wistar albino rats (n = 80) were divided into two groups: CCP and BP. In the CCP group, colonic resection and anastomosis were performed. BP was induced by cecal ligation and puncture. BCA was administered to the anastomosis in half of the rats in both groups. Anastomotic assessment was done on postoperative days 3 and 7 by evaluating the burst pressure, and gross anastomotic and histopathologic healing indices. The presence and severity of adhesion formation was also investigated. There were no differences in terms of gross healing parameters on days 3 and 7. Burst pressures were also similar on both days (p = 0.244 and p = 0.101, respectively). In the early phase (day 3), adhesion development (p < 0.001), granulocytic cell infiltration (p = 0.02), inflammation (p = 0.019) and necrosis (p = 0.019) were higher in the BCA groups. Mononuclear cell infiltration (p = 0.659), fibroblastic cell infiltration (p = 0.538) and capillary formation (p = 0.316) were similar. In the late phase (day 7), adhesion development (p < 0.001), necrosis (p = 0.001) and granulocytic cell infiltration (p = 0.034) were higher in the treatment groups. Fibroblastic cell infiltration (p = 0.017) and capillary formation (p = 0.016) were lower in BCA treated rats, particularly in the BP condition. Mononuclear cell infiltration did not differ (p = 0.176). The application of BCA did not provide any benefit under either CCP or BP conditions. Moreover, BCA caused increased inflammatory reactions, necrosis and adhesion formation. During the late phase of healing, the ongoing enhanced inflammation caused a reduction in capillary formation and fibroblastic infiltration, particularly under BP conditions.

Effect of cyanoacrylate on closure of gastric perforation: a comparative study in a rat model.

The aim of the study was to compare suture, clip and clip combined with topical N-butyl cyanoacrylate in an experimental model of gastric perforation. Sixty Wistar-Albino rats were divided into three groups. Midline laparotomy was performed and a 4 mm puncture was done on the anterior surface of the stomach. Closure was performed by sutures in the first group, clip in the second group, and clip with topical cyanoacrylate in the third group. Ten rats underwent a re-laparotomy on the 3(rd) and 7(th) days, respectively. Intraabdominal adhesions, burst pressures, procedural time, total operation time and histological evaluation were analyzed. In the early phase, clip with topical cyanoacrylate treatment significantly improved burst pressures (p=0.001). In the late phase, burst pressure levels were slightly higher in the third group. Procedural period and total operation times were significantly higher in the suture-treated group and lower in the clip group. Clip with topical cyanoacrylate treatment improved histological healing indices, with significant difference in granulation, chronic inflammation and collagenisation scores, but at the expense of a significantly increased adhesion formation (P=0.001). Our study shows that gastric perforations can be effectively treated by the combination of clip and cyanoacrylate with shorter time and acceptable side-effects in selected cases.

Effects of two different meshes used in hernia repair on nerve transport.

BACKGROUND: We aimed to investigate the effects of two different types of mesh used in hernia repair on nerve transport and neural injury. STUDY DESIGN: Forty-five Wistar-albino rats were randomly allocated to three groups. Basal neural transport on the index of the left sciatic nerve was performed in all groups before surgery. In the control group, only sciatic nerve manipulation was performed. Other groups received a cuff around the index sciatic nerve. The second group received a monofilament polypropylene and the third group received a polytetrafluoroethylene mesh. Effects of entrapment on neural transport were evaluated by electromyography on the 28th day. Tissue samples from sciatic nerves were taken for evaluation of nerve injury. RESULTS: There was no significant difference between basal latency and amplitudes (p=0.609 and p=0.152, respectively). But latency was significantly different 4 weeks after the operation (p < 0.0001). At post hoc evaluation, entrapment groups had longer latency times compared with those in the control group (p=0.006 and p < 0.0001, respectively). But the increase in latency between entrapment arms was similar on the 28th day (p=0.601). Both initial and late term amplitudes were similar (p=0.364 and 0.913, respectively). Histologic evaluation by Masson's trichrome staining revealed high fibrosis scores and increased collagen deposits, especially in the polypropylene group (p < 0.0001), and increased inflammation in the polytetrafluoroethylene group (p < 0.001). CONCLUSIONS: Our results showed that the two most commonly used meshes in tension-free hernia surgery have different effects on nerve physiology and morphology. We concluded that alterations in nerve physiomorphology are from the properties of the mesh and may be the source of postoperative pain in hernia surgery.

Comparison of different surgical options in the treatment of pilonidal disease: retrospective analysis of 175 patients.

Pilonidal sinus disease is a benign disorder with an unidentified etiology and is observed mainly in young adults. It is an important health problem because it causes work loss. Although various nonsurgical treatment options have been tried up to date, there is a consensus on surgical intervention to treat the disease today. The optimal surgical method should be simple, associated with short hospital stay and low recurrence rates. In this study, patients who have undergone different surgical treatment methods due to pilonidal disease were retrospectively analyzed. The medical records of 175 patients who were operated on between 2002 and 2005 at the General Surgery Departments of Gaziosmanpasa University Medical School and Bartin State Hospital for pilonidal disease were reviewed for treatment option, postoperative complications, hospitalization time, work-off periods, and recurrence rates. The patients consisted of 150 (85.3%) males with a mean age of 26.47 +/- 7.78 years. Marsupialization was applied to 82 (46.9%), unroofing to 20 (14.7%), primary closure to 29 (16.6%), and Limberg flap to 44 (25.1%) patients. The longest hospitalization period of 3.61 +/- 1.08 days was observed in the Limberg flap group. The longest return to work period (20.12 +/- 5.1 days) was observed in the marsupialization group. Both differences were significant. The highest complication rate was observed among the primary closure group (31%) followed by the patients treated by Limberg flap technique (15.8%). In the primary closure group, infection was detected in five (17.2%) and wound dehiscence in four (13.8%) individuals. The highest complication rates (31.03%) and recurrences (13.8%) were observed in the primary closure group. Various operative methods utilized in the treatment of pilonidal disease are associated with a number of advantages and disadvantages. Postoperative complication rates of unroofing and marsupialization are low, but require long wound care. In our study, we did not observe any recurrence among the patients treated by unroofing, but experienced a high recurrence ratio among subjects treated by marsupialization. In addition, there were high complication rates in the primary closure and Limberg flap groups. So, the best option is to explain the advantages and disadvantages of the available surgical methods and respect the patient's decision.

Enucleation of centrally located giant hepatic hemangioma: report of two cases.

Two centrally located giant hepatic hemangiomas were referred with severe pain, one of which had a protruding abdominal mass was listed for transplantation at another center. Tumors were 35 and 30 cm at their longest diameter. One was centrally located involving the hilum and segments VI/VII and II/III were partially spared. Volumetric analysis and imaging suggested enucleation is feasible if the left lateral segment and the right posterior sector are left intact. Operation was straightforward except few breaks in enucleation technique in an effort to secure the venous drainage of the remnant liver. She had an uneventful recovery except a biliary fistula through the operatively severed left hepatic duct, which was repaired over a stent. This was managed by lateral segmentectomy and resection of the fistula after the enlargement of the right posterior sector was confirmed volumetrically. The other tumor-involved segments II, III, IV, V, and VIII and the hilum were totally hemangiomatic. Enucleation and postoperative recovery was uneventful. The era of liver transplantation enhanced our knowledge about complex liver surgery and these cases are good examples about the feasibility of enucleation even in extremely complicated liver hemangiomas saving both the patients and a donor liver.

Comparison of the plasma and hernia sac tissue copper levels in direct and indirect inguinal hernia patients.

Although the inguinal hernia is among the most commonly encountered and well-described health problems all over the world, the etiology is still controversial. The aim of this study was to compare the plasma and hernia sac tissue copper levels in direct and indirect inguinal hernia patients. Plasma and hernia sac tissue copper levels obtained from patients operated under spinal anesthesia with primary direct (group I, n = 55, 45 male, mean age = 45.68 yr) and indirect (group II, n = 55, 40 male, mean age = 38.57 yr) hernias were detected by atomic absorption spectrophotometer. Significantly lower plasma and hernia sac tissue copper levels were detected in group I in comparison to group II (p < 0.001). Both plasma and hernia sac tissue copper levels were significantly lower in males when we compare the patients according to their sex characteristics, including both direct and indirect hernia groups (p < 0.05 and p < 0.01, respectively). Age was not a significant factor. The plasma and hernia sac tissue copper levels were significantly lower in direct hernia patients in comparison to indirect hernia patients. Copper is a cofactor of lysyl oxidase, an important enzyme in collagen tissue metabolism, so there might be a defect in the collagen synthesis of direct hernia patients because of the decreased activity of the lysyl oxidase. Further investigations are necessary to clarify this concept.