A randomized trial of the effects of platelet- rich plasma on postoperative complications after meningomyelocele sac repair.

OBJECTIVE: Meningomyelocele is a common congenital neural tube defect. To reduce complications, we need early surgery and a multidisciplinary approach. In this study, we administered platelet-rich plasma (PRP) to babies with meningomyelocele following corrective surgery to minimize cerebrospinal fluid (CSF) leakage and accelerate the healing of the immature pouch tissue. We compared these with a control group that did not receive PRP. PATIENTS AND METHODS: Of the 40 babies who had surgery with the diagnosis of meningomyelocele, 20 patients received PRP after surgical repair, and 20 were followed up without PRP. In the PRP group, 10 of the 20 patients underwent primary defect repair, the other 10 underwent flap repair. In the group that did not receive PRP, primary closure was performed in 14 patients and flap closure in six. RESULTS: In the PRP group, CSF leakage occurred in one (5%) patient, and none developed meningitis. Partial skin necrosis occurred in three (15%) patients and wound dehiscence in three (15%) patients. In the group that did not receive PRP, CSF leakage occurred in nine (45%) patients, meningitis in seven (35%), partial skin necrosis in 13 (65%), and wound dehiscence in seven (35%) patients. The rate of CSF leakage and skin necrosis in the PRP group was significantly (p<0.05) lower than that in the PRP group. Furthermore, wound closure and healing were also improved in the PRP group. CONCLUSIONS: We have shown that PRP treatment of postoperative meningomyelocele infants facilitates healing and lowers the risk of CSF leakage, meningitis, and skin necrosis.

Is there any correlation among adiponectin levels in serum, tumor tissue and normal tissue of the same patients wih breast cancer?

PURPOSE: Adiponectin is secreted from adipose tissue and is characterized by hyperinsulinemia which is related with obesity. Although serum adiponectin levels in patients with breast cancer have been studied previously, adiponectin levels in the serum, tumor and normal tissue of the same patients have not been simultaneously investigated. The aim of this study was thus to evaluate the relationship among serum, tumor and normal tissue adiponectin levels in patients with breast cancer. METHODS: Fifty-three patients with breast cancer who were operated at the Dr. Lutfi Kirdar Kartal Education and Research Hospital, Department of Surgery, between February 2008 and June 2008, were analyzed. Their serum adiponectin levels, tumor tissue and normal breast tissue adiponectin levels were compared. The correlation between postoperative histopathological parameters, insulin resistance parameters and adiponectin levels was also examined. RESULTS: The mean adiponectin levels in tumor tissue, normal breast tissue and serum were 56 ± 9.6 ng/ml, 56 ± 10 ng/ml and 43.5 ± 3.1 ng/ml, respectively. The serum adiponectin levels were inversely correlated with tumor tissue adiponectin levels (p=0.001, r=-0.43). When tumor tissue adiponectin levels were increased, serum adiponectin levels were decreased. O n the other hand, there was a positive correlation between normal breast tissue adiponectin levels and tumor tissue adiponectin levels (p=0.0001, r= 0.850). The tumor tissue adiponectin level was inversely correlated with tumor stage (p=0.037 , r= -0.29). Moreover, in early-stage and low grade tumors, both tumor tissue and normal tissue adiponectin levels were high compared with those of advanced stage or high grade tumors (p=0.027, r= -0.32 and p=0.004, r= -0.408, respectively). In the subgroup analyses, no significant relationship was found between insulin resistance parameters and adiponectin levels (p>0.05). CONCLUSION: Our results indicate that serum adiponectin levels were inversely correlated with tumor tissue adiponectin levels, but no relationship between normal breast tissue and tumor tissue adiponectin levels was demonstrated. Adiponectin levels in breast tumor tissue increase while serum adiponectin levels decrease. Adiponectin might play an important role in the prevention of tumor progression by decreasing tissue neovascularization.

Efficacy of low and high fixed dose radioactive iodine therapy in patients with toxic nodular goiter.

AIM: The efficacy of low and high fixed dose radioactive iodine (RAI) therapy in patients with toxic nodular goiter was investigated. METHODS: Ninety-three patients (25 males, 68 females) were included into the study (32 patients with toxic adenoma, 61 patients with toxic multinodular goiter). Patients were treated with a fixed dose of 370 MBq (10 mCi) or 740 MBq (20 mCi) RAI. The average follow-up period was 17±10 months. RESULTS: The overall cure rate (eutyhroidism and hypothyroidism) was 81% in patients treated with 740 MBq RAI and 51% in patients treated with 370 MBq RAI (p<0.05). RAI therapy with a dose of 370 MBq and 740 MBq provided the cure in 73% and 91% of the patients with toxic adenoma and 42% and 76% of the patients with toxic multinodular goiter, respectively. No significant difference for gender was observed. Hypothyroidism developed in 4 and 15 patients with a dose of 370 MBq and 740 MBq RAI, respectively. CONCLUSION: A dose of 740 MBq RAI was found to be more effective for the treatment of toxic nodular goiter as compared to a dose of 370 MBq RAI.

Bilateral asymptomatic giant renal artery aneurysm.

The incidence of renal artery aneurysm is very low. Approximately in 20% of these patients hypertension is observed. The diameter of aneurysm increases with accompanying complication rates. The most feared complication is rupture. The risk of rupture also increases with the diameter of aneurysm. We report an aneurysm with the biggest diameter reported in the literature. The patient had a 12 cm-diameter of aneurysm in one kidney and did not show any symptoms including hypertension until she was seventy years old.

Myocardial perfusion alterations observed months after radiotherapy are related to the cellular damage.

AIM: Myocardial perfusion scintigraphy (MPS) is one of the widely used tools to follow developing radiation-induced heart disease (RIHD). But the clinical significance of MPS defects has not been fully understood. We have investigated the biodistribution alterations related to perfusion defects following radiotherapy (RT) and showed coexisting morphologic changes. ANIMALS, METHODS: A total of 18 Wistar rats were divided into three groups (1 control and 2 irradiated groups). A single cardiac 20 Gy radiation dose was used to induce long term cardiac defects. Biodistribution studies with technetium (99mTc) sestamibi and histological evaluations were performed 4 and 6 months after irradiation. The percent radioactivity (%ID/g) was calculated for each heart. For determination of the myocardial damage, positive apoptotic cardiomyocytes, myocardial cell degeneration, myocardial fibrosis, vascular damage and ultrastructural structures were evaluated. RESULTS: Six months after treatment, a significant drop of myocardial uptake was observed (p < 0.05). Irradiation-induced apoptosis rose within the first 4 months after radiation treatment and were stayed elevated until the end of the observation period (p < 0.05). Also, the irradiation has induced myocardial degeneration, perivascular and interstitial fibrosis in the heart at the end of six and four months (p < 0.01). The severity and extent of myocardial injury has became more evident at the end of six month (p < 0.05). At ultrastructural level, prominent changes have been observed in the capillary endothelial and myocardial cells. CONCLUSION: Our findings suggest that the reduced rest myocardial perfusion, occurring months after the radiation, indicates a serious myocard tissue damage which is characterized by myocardial degeneration and fibrosis.

Deep venous thromboembolism and pulmonary embolization as a rare complication of diagnostic femoral catheterization and prevention of recurrence with inferior vena cava filter prior to cardiac surgery.

Deep venous thrombosis (DVT) and pulmonary embolism (PE) are rare complications after diagnostic femoral catheterization. A few clinical cases have been reported, especially in the setting of venous compression with an enlarging haematoma, mechanical groin compression or prolonged procedures. Similarly, clinically evident PE after cardiac surgery is also very rare, but may be catastrophic. In this article, we present a case of PE after silent (symptomless) DVT due to femoral catheterization. The patient had critical coronary artery disease and was a candidate of coronary artery bypass grafting. A inferior vena cava filter was implanted prior to cardiac surgery for prevention of a potential pulmonary embolus.

Bedside glue blepharorrhaphy for recalcitrant exposure keratopathy in immobilized patients.

PURPOSE: To report the practical use and the effectiveness of cyanoacrylate glue blepharorrhaphy in immobilized patients with recalcitrant exposure keratopathy. METHODS: Retrospective case series. Temporal two thirds of upper eyelid eyelashes were glued to lower eyelid skin with tissue adhesive n-butyl-2-cyanoacrylate (histoacryl blue) after application of a contact lens. The systemic condition for immobilization; duration of exposure signs in the ocular surface; location, depth, and dimensions of the corneal ulcer; duration of effective blepharorrhaphy; and the time to heal were recorded. RESULTS: Twelve eyes of nine patients were treated. The reasons for immobilization were coma due to malignancy (3 patients), ischemic encephalopathy (2 patients), subarachnoid hemorrhage (2 patients), head trauma (1 patient), coma and hypotony of unknown cause (1 patient). All of the corneal ulcers healed within 4 to 11 days (mean: 5.5 days). Blepharorrhaphy opened spontaneously in 4 to 21 days (mean: 8.6 days). CONCLUSIONS: Bedside glue blepharorrhaphy with tissue adhesive n-butyl-2-cyanoacrylate is a practical, economic, and effective procedure in the treatment of exposure keratopathy in immobilized patients.

Hemolysis after mitral valve repair: a report of five cases and literature review.

BACKGROUND AND AIM OF THE STUDY: Hemolytic anemia is known to be a rare complication after the prosthetic replacement of the mitral valve, especially in the presence of perivalvular leaks, and even more rarely after mitral valve repair. Following repair, certain distinct patterns of the regurgitant flow disturbances associated with high shear stress are responsible for the hemolysis. Early echocardiographic recognition of these flow patterns may be important to diagnose the condition and may lead to re-repair or replacement of the valve. METHODS: During the past eight years, mitral valve repair was performed by the present authors in 159 patients, with a prosthetic ring being placed in 130 cases. In five of the patients receiving rings (3.8%) however, intractable hemolytic anemia quickly developed, due to recurrent or residual mitral regurgitation, and this necessitated reoperation. RESULTS: The valve was replaced in all five patients. One patient died from respiratory and renal failure leading to multiorgan failure. The other four patients were followed up and are currently in good health, with no evidence of hemolysis. CONCLUSION: Hemolysis frequently occurs immediately or soon after mitral valve repair, and may even appear in mild regurgitation. Thus, following repair with a prosthetic ring it is essential to clearly visualize the dynamic flow patterns postoperatively with transesophageal echocardiography, focusing especially on probable fragmentation, collision and rapid acceleration jets. These findings may lead the surgeon to revise the repair, or to replace the valve.

Exophthalmometry values of Turkish adult population and the effect of age, sex, refractive status, and Hertel base values on Hertel readings.

PURPOSE: To establish normal exophthalmometry values in the adult Turkish population, and the impact of age, gender, interpupillary distance, Hertel base selection, and refractive status on globe position. METHODS: Exophthalmometry measurements and refractive status of 2477 subjects were conducted in one tertiary and five primary health care centers. Change of globe position by age, intersex differences in terms of globe position, correlations of Hertel base with exophthalmometry results, and interpupillary distance (IPD) were evaluated. Multiple linear regression analysis was performed to test determination effect of each variable on final Hertel reading. RESULTS: Median Hertel reading was 13 mm, and 95% of the population had an upper limit of 17 mm for both eyes. There was a negative correlation between spherical equivalent of refractive status and exophthalmometry results and a weak positive correlation between IPD and exophthalmometry result. Mean Hertel value was found to decrease significantly after the third decade. Hertel base value was found to have moderate linear correlation with Hertel results. A weak correlation was detected with Hertel base/IPD ratio with final Hertel results. Multiple linear regression analysis was performed and only 13% and 20% of change in Hertel values bilaterally were found to be determined by other variables (age, IPD, refractive status, and Hertel base value) for females and males. CONCLUSIONS: Normative dataset for exophthalmometry results of the Turkish population is established to be used in clinical practice and research. Only 13% to 20% of change in Hertel values was detected to be determined by age, IPD and Hertel base values.

Extra-anatomic coronary artery bypass graftings in patients with porcelain aorta.

AIM: Severely atherosclerotic (porcelain) ascending aorta is associated with increased morbidity and mortality during coronary artery bypass grafting (CABG) due to the increased risk of perioperative atheroembolism. Three maneuvers during CABG can cause atheromatous embolism from the diseased ascending aorta: 1) cannulation of the ascending aorta; 2) cross- clamping; 3) partial clamping for the construction of the proximal anastomosis. METHODS: In our hospital, extra-anatomic CABG was performed in 8 patients with heavily calcified ascending aorta: 6 patients were men and 2 women. Operations were performed on the beating heart in 5 patients, 2 patients operated on beating heart and another patient on fibrillating heart with supportive cardiopulmonary bypass (CPB). Arterial cannulation was done through the right femoral artery on these patients. Apart from internal mammary artery (IMA) grafts, proximal anastomotic sites were the right axillary, right subclavian and innominate arteries. RESULTS: One patient who preoperatively had dialysis dependent chronic renal failure, died as a result of dialysis complication on the 5th day. The postoperative course was uneventful in the other patients and no patient experienced either any cerebrovascular or visceral organ injury as a result of atheroemboli. CONCLUSION: We think that extra-anatomic CABG procedures are safe and reliable in patients with severely atherosclerotic (porcelain) ascending aorta to minimize the prevalence of perioperative stroke and systemic embolization.

Atrial septal defect repair with minithoracotomy using two stage single venous cannula.

AIM: Repair of atrial septal defect (ASD) via minimal access has been the preferred method to improve cosmesis and fast rehabilitation. A 2-stage single venous cannula introduced via the femoral route allows better vision of the surgical field and improves surgical acts through a limited incision. METHODS: From February 1999 to December 2001 a minithoracotomy approach was used for closure of secundum type ASD by using single bicaval venous cannula in 17 adult patients. A 6 to 7 cm anterior minithoracotomy (submammary) approach with femoral arterial and 2-stage single venous cannula were utilized. Defects were closed primarily by running suture in 14 and with a patch in 3 patients. RESULTS: Calculated flow levels were maintained with a single venous cannula without assisted venous drainage in all patients. The postoperative course was uneventful in all patients except 1 who required revision for bleeding which was done through the same incision. Extension of the thoracotomy or shifting to the classic sternotomy was never required. CONCLUSION: Single venous bicaval cannula allows efficient drainage of both vena cavae and improves the surgical vision and manipulation through the right minithoracotomy. With this technique, repair of ASD can be done safely with good cosmesis.

The role of posterior pericardiotomy on the incidence of atrial fibrillation after coronary revascularization.

AIM: Pericardial effusion and atrial fibrillation (AF) are two common complications in coronary revascularization surgery. The aim of this study was to evaluate the efficiency of posterior pericardiotomy in pericardial effusion and AF. METHODS: This randomized prospective study includes 113 patients who underwent isolated CABG procedure between May 2000 and December 2000 in our hospital. Posterior pericardiotomy incision was done in Group I (n=54). Group II constituted the control group (n=59). Postoperative pericardial effusion was assessed by echocardiography and rhythm follow-up was done by the same cardiologist. RESULTS: There was no significant difference between study group and the control group considering the chest drainage (940.18+/-367.96 vs 894.92+/-360.65; p=0.507). The number of patients with remarkable intrapericardial effusion (>50 ml) was significantly lower in the posterior pericardiotomy group (25.93% vs 47.45%, p=0.020). The incidence of postoperative AF was no different between the posterior pericardiotomy group and the control group (12.96% vs 20.34%; p=0.32). In both groups, the incidence of AF was significantly higher in patients with mild or moderate pericardial effusion (29%), compared to patients with no or minimal pericardial effusion (10%), (p=0.017). CONCLUSION: Posterior pericardiotomy significantly reduces the pericardial effusion in coronary bypass procedure postoperatively. Patients with pericardial effusion were subjected to AF more frequently.

A new technique for abdominal heart transplantation in rats.

Experimental studies in animals play a major role in the progress of medicine. Different surgical techniques have been described for heterotopic heart transplantation in rats. In this study we introduce a new technique for heart transplantation in the abdominal cavity of rats. Fifteen Sprague Dawley rats have been used as recipients and 15 others as donors. Following preparation of recipient abdominal aorta and left renal vein, the donor heart including proximal arcus aorta was harvested. Donor aorta was anastomosed to the recipient's aorta; donor pulmonary artery was anastomosed to the left renal vein of the recipient using continuous suture technique. Graft function was evaluated daily by palpation of the rat abdomen. The mean operating time was 38.46+/-2.66 min and the mean ischemia time was 23.93+/-2.11 min. One death was seen because of bleeding of the aorto-aortic anastomosis. In this study we evaluated advantages and disadvantages of our technique and compared it to other techniques. This modification provides a more anatomical position, reduces exploration time, has a low incidence of morbidity and mortality. We conclude that, this implantation technique is more suitable for heterotopic heart transplantation in rats.

Course of serum lipoprotein(a) and acute phase protein levels in patients undergoing open heart surgery.

BACKGROUND: Lipoprotein(a) [Lp(a)] is an important risk factor in the pathogenesis of coronary artery disease because of its thrombogenic and atherogenic properties. Lp(a) also displays another property by acting as an acute phase reactant. METHODS: In this work, the study group consisted of 20 male patients having coronary artery bypass under cardiopulmonary bypass (CPB). Preoperative and postoperative levels of plasma total cholesterol, triglyceride, apolipoprotein A1 (Apo A1), apolipoprotein B (Apo B), alpha-1 antitrypsin (a1-AT), alpha-2 macroglobulin (alpha 2-MG), alpha-1 acid glycoprotein (alpha 1-AG), Lp(a) were measured in all patients one day before and after the 1st, 2nd, 4th, and 10th days of CPB. RESULTS: It was observed that the levels of Lp(a) levels gradually reached the preoperative levels at the 10th postoperative day period. Observed change of the Lp(a) levels was similar to that of the other acute phase proteins which are synthesized and released from liver. In contrast, alpha 2-MG has shown different behaviour in terms of operative values. The changes observed for all these 3 parameters were found to be statistically significant (p<0.01). CONCLUSIONS: The data has indicated that Lp(a) levels show similar progress with alpha 2-MG levels. It can be concluded that serum levels of Lp(a) after coronary arterial bypass decrease depending upon several factors and reach basal levels at the end of a 10 day-period of postoperation. The main cause for this decrease might result from the contact of blood with foreign surfaces of the heart-lung machine.

[Hip fracture-dislocation (Pipkin type IV) associated with an apparent traumatic aortic valve rupture. Case history]. / Kalça kirikli-çikigi (Pipkin tip-IV) ile beraber görülen travmatik aort kapak rüptürü. "Olgu sunumu".

Traumatic aortic valve rupture with resultant aortic insufficiency is a rare complication of blunt trauma. Here reported is a case with a posterior fracture-dislocation of the hip (Pipkin type-IV) and an undisplaced sternum fracture who developed hemodynamic instability in the clinical follow-up and was diagnosed having a traumatic aortic valve rupture using echocardiography. He first was treated with a biological valve replacement. Two weeks later a total hip arthroplasty combined with the osteosynthesis of the posterior wall of the acetabulum was performed. Sternum fracture healed conservatively. In multiply injured patients especially with a blunt thorax trauma hemodynamic instability despite appropriate fluid replacement should rise the suspicion of cardiac injuries, especially traumatic aortic valve rupture. Echocardiography is a simple but reliable method for the diagnosis.

A left pulmonary artery aneurysm secondary to pulmonary hypertension.

We report a case of pulmonary trunk aneurysm extending into the left pulmonary artery, due to pulmonary hypertension secondary to mitral valve disease. The mitral valve was replaced with a bileaflet mechanical prosthesis. A Dacron graft interposed between main trunk and left pulmonary artery branch, and right pulmonary branch attached to the graft in an end-to-side fashion. Early postoperative angiogram revealed a very successful treatment.

[Coronary bypass surgery in octogenarians]. / Dokuzuncu dekatta koroner bypass cerrahisi.

OBJECTIVE: The age of the patients referred for coronary bypass surgery is getting older progressively. Early and late postoperative outcome of octogenarians were evaluated and compared with younger age group in this study. METHODS: Records of 55 patients aged 80 years or older (mean age 82.7 +/- 2.8) among 3834 patients, who had coronary bypass graft procedure, operated between 1995 and 2001 were reviewed retrospectively. RESULTS: There were 39 men (70.9%) and 16 women (29.1%). Three patients had aortic valve replacement, 1 had left ventricular aneurysm repair, 1 had carotid endarterectomy additionally. Atrial fibrillation (21.8%), renal dysfunction (16.4%), and prolonged ventilation (10.9%) were the prominent complications. The hospital mortality rate was 7.27% (4 patients). Kaplan Meier Survival Analysis estimated that at the end of 5 years 83.1 + 5.2% of patients were still alive. CONCLUSION: Coronary bypass operations can be performed in octogenarians with slightly increased but acceptable hospital mortality and longer hospital stay. Early intervention and individual modifications in cardiopulmonary bypass techniques may improve the results in this patient population.

Acute aortic valve regurgitation secondary to blunt chest trauma.

Blunt injury to the cardiac valves leads to progressive acute ventricular failure, which often requires urgent surgical management. In this case report, we describe an acute aortic valve rupture caused by air-bag inflation during an automobile accident. Laceration of an aortic valve cusp was treated successfully with urgent aortic valve replacement. A concomitant orthopedic injury was treated electively 15 days after cardiac surgery Acute aortic valve rupture is a very rare complication of blunt chest trauma. We discuss how to diagnose and manage this potentially catastrophic event.

Coronary artery bypass grafting in the conscious patient without endotracheal general anesthesia.

BACKGROUND: Over the past several years, considerable experience has accumulated in performing coronary anastomoses on the beating heart, and various aspects of minimally invasive approaches have been simplified. In an attempt to further simplify and decrease the "invasiveness" of this procedure, performing this operation without endotracheal general anesthesia was deemed feasible in certain subsets of patients. METHODS: Between October 1998 and June 1999, 5 patients underwent coronary artery bypass grafting without endotracheal general anesthesia, using high thoracic epidural block to construct extension grafts with a short segment of radial artery, between the in situ left or right internal thoracic arteries and the left anterior descending (n = 4) or right coronary arteries (n = 1). There were 2 female and 3 male patients, with a mean age of 67.4 +/- 8.3 years. RESULTS: The perioperative course of the patients was uneventful. There was no perioperative morbidity or mortality. No patient was converted to general anesthesia or to conventional operation. Control angiograms revealed patent anastomoses in all patients. In 1 patient, spasm of the radial artery graft was observed that was relieved 3 weeks later spontaneously. Mean length of hospital stay was 2.2 +/- 0.4 days. All patients were symptom free and returned to normal daily life at the first postoperative month. CONCLUSIONS: Our initial experience confirms the feasibility of performing coronary bypass grafting in the conscious patient without endotracheal general anesthesia.