Effect of fibrin glue or suture on leakage in patients undergoing laparoscopic sleeve gastrectomy.

INTRODUCTION: Sleeve gastrectomy represents one of the most common surgical procedures used in bariatric surgery. The most feared complication following laparoscopic sleeve gastrectomy (LSG) is the leak that occurs at the staple line. One method to reduce the risk of leak is the use of reinforcement material at the suture line. In this study, the efficacy of sutures and fibrin glue in the prevention of staple leak has been compared retrospectively. METHODS: A total of 250 patients undergoing LSG between October 2011 and August 2015 at the Medical Faculty of Firat University were retrospectively assessed using the hospital database system records. RESULTS: There were 77 males (31%) and 173 (69%) females, with a mean age of 34 years (range: 16-65 years) and mean body mass index of 45 kg/m2. Staple line was sutured in 54 patients (22%). Neither suture nor fibrin glue was used for reinforcement of the staple line in 61 (24%) patients. Only fibrin glue was used for the reinforcement of the staple line in 135 (54%) patients. Postoperative leak occurred in eight patients (3.2%). Neither suture nor fibrin glue was used for reinforcement in 6 (9.8%) of these patients. One of them was in sutured staple line group and the other was in fibrin glue group (0.7%). One patient died due to leak and the consequent development of sepsis (0.4%). CONCLUSION: Despite some controversies, strong evidence exists on the effectiveness of fibrin glue in the prevention of leaks in patients undergoing LSG from this study.

Surgical management of anorectal foreign bodies.

PURPOSE: Anorectal foreign bodies (AFBs) inserted into anus constitute one of the most important problems needing surgical emergency due to its complications. We describe our experience in the diagnosis and treatment of AFBs retained in the rectosigmoid colon. MATERIALS AND METHODS: Between the years 2006 and 2015, a total of 11 patients diagnosed with AFBs were admitted to an emergency room and general surgery clinics. They were diagnosed and treated in four different hospitals in four different cities in Turkey. Information on the AFBs, clinical presentation, treatment strategies, and outcomes were documented. We retrospectively reviewed the medical records of these unusual patients. RESULTS: Eleven patients were involved in this study. All patients were male with their mean age was 49.81 (range, 23-71) years. The time of the presentation to the removal of the foreign bodies ranged between 2 h and 96 h with a mean of 19.72 h. Ten patients inserted AFBs in the anus with the purpose of eroticism but one patient's reason to relieve constipation. The objects were one body spray can, two bottles, three dildos, two sticks, one water hose, one corncob, and one pointed squash. Three objects were removed transanally after anal dilatation under general anesthesia. Eight of the patients required laparotomy (milking, primary suture, and colostomy). Five of the patients had perforation of the rectosigmoid colon. Abdominal abscess complicated extraction in one patient after the postoperative period. The hospitalization time of the patients was 6.18 (1-16) days. None of the patients died. CONCLUSIONS: A careful assessment is a key point for the correct diagnosis and treatment of AFBs. Clinical conditions of patients and type of AFBs are important in the choice of treatment strategy. If the AFBs are large, proximally migrated or the patients with an AFB have acute abdomen due to perforation, pelvic abscess, obstruction, or bleeding, surgery is needed as soon as possible. There are different types of surgical approaches such as less invasive transanal extraction under anesthesia and more invasive abdominal routes such as laparotomy or laparoscopy. The stoma can be done if there is colonic perforation. In the management of AFBs, the priority must be less invasive methods as possible.

Laparoscopy in the management of lumboperitoneal shunt catheter in obese patients with pseudotumor cerebri.

Lumboperitoneal shunts are widely used for the treatment of patients diagnosed with pseudotumor cerebri (PTC). Obesity is a risk factor for PTC. In particular, catheter migration out of the abdominal cavity is more commonly observed in morbidly obese patients. The aim of this study was to discuss the underlying mechanisms of catheter migration and treatment modalities in morbidly obese patients with PTC. The present study included four morbidly obese patients. All cases had undergone the previous laparotomy for insertion of a distal catheter into the abdominal cavity. In three cases, migration of the distal catheter out of the abdominal cavity was observed. Migration of the proximal tip of the catheter out of the spinal canal was observed in the fourth case. In all cases, laparoscopic revision surgeries were performed. During revision surgery, a catheter tunnel was prepared immediately over the external oblique fascia to obtain the shortest and deepest tunnel, and a distal catheter was inserted by laparoscopic guidance posterolaterally, i.e., through the postaxillary line. None of the patients developed any complications during the follow-up period of 4 years. We recommend laparoscopic insertion of distal catheters through the postaxillary line into the abdominal cavity using as short a catheter route as possible. Thus, tension and traction on the catheter due to abdominal movements can be decreased in morbidly obese patients to prevent catheter migration.

Measurement of L(III) Subshell Absorption Jump Parameters of Hafnium.

The L(III) subshell absorption jump ratio and jump factor of hafnium have been measured using two different ways which are X-ray attenuation method and Energy Dispersive X-ray Fluorescence technique. The results obtained both ways have been compared with theoretical values. They are in good agreement with each other.

Mad honey intoxication: what is wrong with the blood glucose? a study on 46 patients.

OBJECTIVE: This study was designed to analyze the characteristics of adult patients with mad honey intoxication, with special emphasis on its effects on vital signs and blood glucose levels. METHODS: Patients admitted to the Emergency Department of urban hospital in the Black Sea region of Turkey over the 16-months study period due to mad honey intoxication were included. Patients' demographic and clinical characteristics, including age, sex, systolic and diastolic blood pressure, rhythm at ECG, heart rate, blood glucose levels and clinical outcomes were recorded and analyzed. RESULTS: Forty-six patients with a presumptive diagnosis of mad honey poisoning were recruited. Mean age was 52.2 (±17.2). Blood glucose level was normal in 28 cases (60.9%) and high in 18 (39.1%). Systolic blood pressure (SBP) was low in 40 patients (87%) and normal in six (13%). Diastolic blood pressure (DBP) was low in 42 cases (91.3%) and normal in four (8.7%). Mean glucose level in patients with low SBP was 116.1 (±52.9) mg/dL, vs. 120.7 (±23.0) mg/dL in those with normal or high SBP (p = 0.389). Mean glucose level in patients with low DBP was 118.7 (±51.4) mg/dL, compared to 96.0 (±22.8) mg/dL in those with normal or high DBP (p = 0.146). Heart rate was below or equal to 45 bpm in 28 patients (60.9%). Complete (third degree) heart block was diagnosed in one case. CONCLUSION: Mad honey was found not to cause significant decreases in blood glucose levels in humans. Hypotension, bradycardia and related clinical consequences are commonly encountered in patients diagnosed with mad honey or grayanotoxin poisoning.

Comparison of plasmapheresis and molecular adsorbent recirculating system efficacy in graft failure after living donor liver transplantation.

INTRODUCTION: Liver transplantation may result in graft failure, requiring time and supportive treatment for regeneration of the graft. The aim of this study was to compare the laboratory parameter changes after single-session molecular adsorbent recirculating system (MARS) and plasmapheresis procedures among living donor liver transplantation patients experiencing graft failure. PATIENTS AND METHOD: We analyzed retrospectively the results in 45 liver transplantation patients treated with plasmapheresis and/or MARS between June 2011 and July 2012: (plasmapheresis, n = 17; MARS, n = 15; MARS + plasmapheresis, n = 13). When cadaveric donor cases (n = 11) were excluded, the remaining 34 included patients, underwent. MARS (n = 18) or plasmapheresis (n = 16) at the first session. FINDINGS: Both groups were similar in age, sex, and body mass index features. The MARS group displayed significantly higher levels of international normalized ratio, blood urea nitrogen, and Model for End-stage Liver Disease score. The plasmapheresis cohort, displayed significantly higher levels of initial direct bilirubin and gamma glutamyl transferase (P < .05). The plasmapheresis group showed a significant decrease in GGT after treatment (P < .05). RESULTS: An initial MARS session provided significantly greater decrease in renal function associated with graft failure after living donor liver transplantation.

Living donor liver transplantation for hepatocellular carcinoma.

BACKGROUND: Liver transplantation is a widely accepted modality in the treatment of hepatocellular carcinoma (HCC). In our center, patients with HCC limited to the liver without macrovascular invasion are accepted as candidates for living donor liver transplantation (LDLT). The aim of this study was to describe the patient characteristics and outcomes at a single institution to analyze the impact of our criteria on the survival of HCC patients. PATIENTS AND METHODS: We reviewed the medical records of all HCC (n = 105) patients who underwent liver transplantation in our institution. We excluded deaths in the early postoperative period and deceased donor liver transplantation (DDLT) patients, leaving 74 subjects (65 males and 9 female). Their median age was 53 years (range, 19-69). Univariate Kaplan-Meier and multivariate Cox proportional hazards models were used to analyze overall and disease-free survivals. RESULTS: Thirty-two (43%) patients were within the Milan criteria, and 42 (57%) exceeded them. One- and 2-year overall survival rates for patients within versus exceeding the Milan criteria were 72% versus 68% and 61% versus 58%, respectively. One- and 2-year disease-free survival rates for patients within versus exceeding the Milan criteria were 72% versus 68% and 60% versus 55%, respectively (P > .05). Tumor recurrence rates for patients within versus exceeding the Milan criteria were 0% versus 36%, respectively (P = .0002). Alpha-fetoprotein level was the only predictor of overall survival; alpha-fetoprotein level and tumor differentiation were predictors of disease-free survival. CONCLUSION: Although higher recurrence rates have been observed among patients exceeding the Milan criteria, LDLT is the only treatment option for the patients in countries with limited sources of cadaveric organs. As a general principle, we believe that the use of cadaveric donor liver grafts is not suitable for patients who exceed these criteria.

Comparison of harmonic scalpel versus conventional knot tying for transection of short hepatic veins at liver transplantation: prospective randomized study.

The objective of this study was to compare harmonic scalpel for short hepatic vein transection with conventional ligation during recipient hepatectomy with caval preservation. Sixteen patients undergoing elective living donor liver transplantation were randomized into 2 groups. We recorded number, diameter, and location of each short hepatic vein, procedure time, central venous pressure, and degree of liver failure (Child-Pugh and Model for End stage Liver Disease scores). As an end point, we observed the intraoperative and postoperative bleeding rates of the transected veins. We transected 144 veins of mean diameter of 2.6 ± 1.8 mm (range, 1-12 mm). Mean number of short hepatic veins in each person was 9 (range, 5-16). Harmonic scalpel was safe for veins with a diameter ≤ 2 mm; these veins were more prone to bleeding with conventional ligation. Bleeding rate was higher after ligation of veins in the upper half than the lower half of the cava (37% vs 21%; P = .04). Both total and per vessel procedure time did not differ between the groups. No postoperative bleeding complications occurred. Transection of veins with a diameter ≤ 2 mm by harmonic scalpel was as safe as conventional ligation. Harmonic scalpel transection of small hepatic veins (≤ 2 mm) can be even safer than conventional control by knot tying, particularly in narrow areas.

Modified Limberg transposition flap in the treatment of pilonidal sinus disease.

BACKGROUND: Pilonidal sinus disease (PSD) is a common problem in surgical practice. Different non-surgical and surgical methods have been used for treating PSD. Flap techniques including the Limberg flap have become more popular in recent years. A modified Limberg flap was used to reduce the problems of skin maceration and recurrence associated with the conventional Limberg flap technique. The aim of this retrospective study was to assess the effectiveness of the modified Limberg flap technique for PSD. METHODS: Medical records of 94 patients with PSD who had been treated with a modified Limberg flap between December 2006 and 2009 were evaluated. The patients' age, sex, duration of preoperative symptoms, operative time, mean hospital stay, postoperative complications, wound infection rate, maceration rate and recurrence rate, time until return to work, time until sitting on the toilet without pain, hypoesthesia in the gluteal region, and satisfaction score were recorded during follow-up or at the last interview. Clinical data were obtained at the end of the 5th postoperative day and at 1, 3, 6, and 12 months following surgery. RESULTS: There were 83 male and 11 female patients. The mean operative time was 38.95 ± 6.77 min (range 30-67 min). All patients were followed up longer than 12 months, and the mean follow-up period was 30.97 ± 12.7 months (range 12-54 months). While wound dehiscence was observed in only one patient, we did not detect any case of flap necrosis. Two cases of seroma were observed. Wound infection was detected in 5 patients (5.3%). Surgical drainage was performed in 2 cases. Another 3 patients were treated with oral antibiotics. Maceration of the surgical incision site was detected in 8 patients (8.5%) who were all successfully treated with conservative measures. There were 4 patients (4.2%) with recurrence in this series. CONCLUSIONS: When compared with the available data on use of the conventional Limberg flap for PSD, our results suggest that use of the modified Limberg flap is associated with a lower maceration and recurrence rate, and greater patient satisfaction.

The effects of drainage on the rates of early wound complications and recurrences after Limberg flap reconstruction in patients with pilonidal disease.

BACKGROUND: Cavity drainage has been used routinely in Limberg flap repair for pilonidal disease but there have been few controlled studies on the rationale for routine usage of drains. The aim of this study was to determine whether routine cavity drainage affects the rates of early wound complications and recurrences after rhomboid excision with Limberg flap repair for pilonidal disease. METHODS: Sixty patients with pilonidal disease in the sacrococcygeal region were randomized sequentially into 2 groups as drained or non-drained. All of them underwent rhomboid excision and Limberg flap reconstruction. The patients were followed up by physical examination at 2 and 4 weeks after the operation and every 6 months thereafter. RESULTS: Two patients in the drained group and 3 patients in the non-drained group were excluded from the study because of non-attendance at the follow-up physical examinations. The average length of hospital stay was 3.1 ± 0.9 and 3.3 ± 0.8 days in the drained and non-drained groups, respectively. There were 5 seromas, 2 wound dehiscences and 1 hematoma in the non-drained group, while 3 seromas and 2 wound dehiscences developed in the drained group. The complication rates of groups were similar (29.6% in the non-drained group vs. 17.8% in the drained group). Pilonidal disease recurred in 2 patients in the drained group who had wound dehiscence and in 3 patients in the non-drained group who had wound dehiscence or seroma. CONCLUSIONS: Routine usage of drains for Limberg flap reconstruction in the sacrococcygeal region did not affect wound-related complications and recurrence rates.