Serum YKL-40 levels in acute appendicitis.

INTRODUCTION: Acute appendicitis is one of the most common abdominal emergencies. The clinical diagnosis is often difficult even for experienced surgeons, however, as evidenced by the high rate of negative explorations. A delay in diagnosis of acute appendicitis is associated with increased risk of perforation and further complications. The aim of the present study was to assess the preoperative YKL-40 levels on for a clinical suspicion of acute appendicitis. METHODS: Between August 2008 and December 2008, a total of 34 patients who underwent appendectomy with a clinical diagnosis of acute appendicitis were studied. Patients underwent appendectomy with the preoperative diagnosis of acute appendicitis. The appendix specimens were classified as normal appendix (group 1; 10 patients), acute appendicitis (group 2; 24 patients). Serum YKL-40 levels were determined by a commercial ELISA. RESULTS: The levels of serum YKL-40 were significantly higher in the group 2 compared with the group 1 (66.4 +/- 13.2 vs 41.6 +/- 11.6 ng/mL, p < 0.001). Receiver operating characteristic curves of YKL-40 levels counts was on a statistically significant level (area under the curve [AUC] = 0.926, p < 0.001). CONCLUSION: YKL-40 may be a useful marker for diagnosis of acute appendicitis but the number of subjects was limited in this study, future studies are required to confirm the results presented here (Fig. 1, Ref. 13).

Solid gastric emptying after highly selective vagotomy and pyloroplasty in patients with obstructing duodenal ulcer.

Before being superseded by medical management, highly selective vagotomy (HSV) without drainage was the procedure of choice for uncomplicated duodenal ulcer. It is also justified for complications, including perforation and bleeding in selected cases. This prospective study evaluated the effects of HSV plus drainage on solid gastric emptying in 20 patients with chronic duodenal ulcer and pyloric stenosis. Patients were treated with HSV plus pyloroplasty (Heineke-Mikulicz pyloroplasty in five patients, Finney pyloroplasty in six patients and Jaboulay gastroduodenostomy in nine patients) and underwent solid-phase gastric emptying scintigraphic studies pre-operatively and 2 months and 6 months post-operatively. Results were compared with those from 10 controls. No significant differences were observed between the different types of pyloroplasty, although emptying was slightly faster in the gastroduodenostomy group. Gastric emptying returned to normal by 6 months post-operatively. In conclusion, HSV plus pyloroplasty is effective and can be used for the relief of stenosis in selected cases of duodenal ulcer.

The evaluation of the peak flow velocity and cross-sectional area of the femoral artery and vein following totally extraperitoneal vs preperitoneal open repair of inguinal hernias.

BACKGROUND: Both totally extraperitoneal (TEP) and preperitoneal (PPOR) approaches involve the placement of prosthetic material preperitoneally. As the prosthetic material overlies the femoral artery and vein, we aimed to assess its effect on the velocity and the diameter of the artery and vein, using colour Doppler ultrasonography in both approaches. METHODS: Eighty patients with unilateral groin hernia were prospectively randomised to have either TEP repair (n = 40) or PPOR (n = 40). All patients underwent colour Doppler ultrasound study 6 months after the procedure, and all patients were followed up for 5 years to evaluate real recurrence rates. RESULTS: Our study revealed that neither mean diameter nor mean flow velocity is changed by the insertion of the mesh preperitoneally. Change was only observed in the peak systolic femoral arterial blood velocity, which was significantly decreased in the PPOR group. We also found that no patient in this study developed a clinically significant deep-vein thrombosis during 6 months of follow-up. CONCLUSIONS: It is concluded that the insertion of a prosthetic mesh during TEP or PPOR does not influence the mean peak flow velocity and the cross-sectional area of the vessels in the inguinal region and can be used safely for open and laparoscopic preperitoneal approaches.

Evaluation of risk factors for mortality in perforated peptic ulcer in Ankara Numune Teaching Hospital, Ankara, Turkey.

OBJECTIVE: To assess the risk factor that influence mortality from perforated peptic ulcer. DESIGN: Retrospective study. SETTING: Ankara Numune Teaching and Research Hospital, Ankara, Turkey. SUBJECTS: A total of 342 patients with perforated peptic ulcer disease were identified from April 1997 to January 2004. Data for the patients were extracted from the hospital records, operative notes and clinic charts. MAIN OUTCOME MEASURES: Age, sex, coexisting medical illness, use of non-steroidal anti-inflammatory drugs (NSAID) or steroids, preoperative shock, delay in treatment location of ulcer size, type of operation time, albumin concentration postoperative complications, postoperative hospitals stay and mortality results for all patients were obtained. RESULTS: Patients were aged from 17 to 80 years (mean 63 years, median 68 years) there were 210 males and 132 females. The mortality rate was 8.8% (30/342), and 62 patients had postoperative complications. Multivariate analysis showed that co-existing medical illness, preoperative shock, delay in treatment and low albumin concentrations were independent risk factors that significantly contributed to mortality. CONCLUSION: This study confirms co-existing medical illness, preoperative shock, delay in treatment and low albumin concentration as significant risk factors that increase mortality in patients with perforated peptic ulcers. These factors could serve as a guide to opine the risk and to improve the outcome in patients with perforated peptic ulcer. Mortality could be reduced by preventing delay in diagnosis and treatment for any co-existing medical illness and providing appropriate nutrition support.

A prospective randomized study of prophylactic antibiotics in elective laparoscopic cholecystectomy.

BACKGROUND: Elective laparoscopic cholecystectomy (LC) has a low risk for infective complications, but many surgeons still use prophylactic antibiotics. The use of prophylactic antibiotics for LC is inconsistent and varies widely among surgeons. METHODS: We performed a prospective double-blind randomized study of prophylactic antibiotics in elective LC. Antibiotics were was given first before the operation and then again 24 h afterward. Group A ( n = 49) received 2 g of cefotaxime; group B ( n = 43) received 10 ml of isotonic sodium chloride solution. A sample of bile was withdrawn by direct gallbladder puncture for anaerobic and aerobic cultures. Age, sex, weight, duration of surgery (DOS), presence of diabetes mellitus, American Society of Anesthesiologists (ASA) classification, gallbladder rupture, bile and/or stone spillage, gallbladder histological findings, findings from bile cultures positive for bacteria, episodes of colic within 30 days before surgery, length of stay (LOS), and number of septic complications were recorded for both groups. RESULTS: There was no differences between the two groups in terms of sex, weight, DOS, ASA score, gallbladder rupture, bile and/or stone spillage, gallbladder histological findings, findings from bile cultures positive for bacteria, or LOS. One infection occurred in the antibiotic prophylaxis group (2.04%); in the patients not receiving antibiotics, there was one other infection (2.32%). There was no statistical difference between the two groups in infective complications. CONCLUSION: In patients undergoing elective LC, antibiotic prophylaxis is justified only in high-risk patients. In all other patients, antibiotic prophylaxis does not seem to affect the incidence of postoperative infective complications. In low-risk patients, eliminating the unnecessary use of prophylactic antibiotics would result in a cost reduction; moreover, it would lower the risk of adverse reaction and reduce microbial resistance.

The effect of immunonutrition on bacterial translocation, and intestinal villus atrophy in experimental obstructive jaundice.

BACKGROUND & AIMS: Spontaneous bacterial infection and septicemia due to increased bacterial translocation (BT) in patients with obstructive jaundice result in significant morbidity and mortality. The present study evaluates the effects of enteral nutrition with immune enhancing feeds on BT and intestinal villus histopathology promoted by obstructive jaundice. METHODS: Fifty male Wistar-albino rats weighing 250-300g were assigned into five equal groups of 10. Animals in Groups I, II, and III were fed with standard chow, those in Group IV were given glutamine 1g/kg/day and the remaining 10 animals in Group V were fed with an arginine, omega-3 fatty acids, and RNA-supplemented enteral diet for (1g/kg/day amino acid and 230 kcal/kg) 7 days preoperatively. Group I underwent sham operation and the remaining animals in all other groups underwent common bile duct ligation. After operation, Group I had standard chow, Groups II and IV had glutamine, Groups III and V had an arginine omega-3 fatty acids, and RNA-supplemented enteral diet for 7 days. All animals were sacrificed on the 8th postoperative day and evaluated both biochemically and histopathologically. Samples from blood, liver, mesenteric lymph nodes and spleen were cultured under aerobic conditions. RESULTS: Significantly less BT was observed in groups fed with an arginine, omega-3 fatty acids, and RNA-supplemented enteral diet or glutamine in pre-and postoperative periods as compared to others (P<0.001). Histologic evaluation also showed significant reduction in villus atrophy in these groups. CONCLUSIONS: Enteral immunonutrition using glutamine or arginine, omega-3 fatty acids, and RNA-supplemented enteral diet during both pre-and postoperative periods seems to reduce BT and decrease atrophy of intestinal mucosal villi in rats with obstructive jaundice.

What happens to the lost gallstone during laparoscopic cholecystectomy?

Iatrogenic gallbladder perforation with resultant spillage of bile and gallstones is common during laparoscopic cholecystectomy. Although it's assumed to be harmless, several complications may occur as a result of spillage. We present a 57-year-old woman with localized abdominal pain in the upper abdomen, jaundice, and itching because of retained stones in both common bile duct (CBD) and the abdominal cavity, who had undergone laparscopic cholecystectomy three years previously. After reoperation, stones in the CBD were removed after CBD exploration and a T-tube was inserted. A mass (8 x 5 cm) located in the gastrocolic omentum, which was not reported on imaging studies, was found coincidentally and was totally excised. Investigation of the mass resulted in the discovery of eight gallstones located in the abcess-like central cavity, which was surrounded by fibrous tissue. The patient had an uneventful recovery. Despite the unaffected long-term sequelae, any patients with gallbladder perforations and spillage should not be considered for extension of antibiotic prophylaxis to avoid early complications. Whenever gallstones are lost in the abdominal cavity, every effort should be made to find and remove them to prevent late complications.

Factors influencing mortality in spontaneous gastric tumour perforations.

Spontaneous perforation of gastric cancer is a serious complication with a very high incidence of mortality. In order to evaluate the prognostic factors influencing mortality in patients with gastric tumour perforations and to clarify the optimal surgical treatment, the records of patients at one centre during a 5-year period were evaluated retrospectively. Between 1995 and 2000, 14 patients with perforated gastric cancer were operated on in the Emergency Surgical Unit of a Turkish Hospital. This figure represents 3% of all the patients with gastric cancer who were treated during the same period. The hospital mortality was 36% in patients with perforations. The duration of symptoms suggesting perforation and the presence of pre-operative shock were predictive factors of mortality. It was concluded that those patients with pre-operative shock and delayed diagnosis should be treated with extra caution to decrease mortality. Perforation and peritonitis must be treated initially and elective radical surgery delayed.

Major surgery with Guillain-Barré syndrome: a case report.

Guillain-Barré syndrome (GBS) is an acute demyelinating polyneuropathy characterized by progressive muscle weakness and areflexia. The pathogenesis of GBS is unknown, but it is generally believed to result from aberrant humoral and cellular immune responses against components of the peripheral nervous system. The overall prognosis of GBS is quite good with approximately 85% of survivors making a good functional recovery. When a diagnosis of GBS has been made, appropriate treatment should be started as early as possible. This may include supportive care in intensive care units, ventilatory assistance, monitoring of blood pressure, fluid status, cardiac rhythm, nutritional supports and medical therapy. Our patient reached maximum deficiency 3 weeks after the onset of GBS. Full recovery took 8 months. The occurrence of GBS after major surgery is rare. We believe that major surgical stress may be the potential triggering factor for the occurrence of GBS in this case report.

Intestinal ischemia and reperfusion impairs vasomotor functions of pulmonary vascular bed.

OBJECTIVE: To investigate the effects of intestinal ischemia and reperfusion (I/R) on the pulmonary vascular endothelium and smooth muscle. SUMMARY BACKGROUND DATA: Respiratory failure is an important cause of death and complications after intestinal I/R. Although the mechanism of respiratory failure in this setting is complex and poorly understood, recent studies of lung injury suggest that endothelial dysfunction may play a significant role. METHODS: A rat model of acute lung injury was studied after 60 minutes of superior mesenteric arterial occlusion followed by either 120 or 240 minutes of reperfusion. The pulmonary vasomotor function was examined in isolated lungs perfused at a constant flow rate. RESULTS: Sixty minutes of intestinal ischemia followed by 120 or 240 minutes of reperfusion led to a significant reduction in the ability of the pulmonary vasculature to respond to angiotensin II, acetylcholine, and calcium ionophore but not to nitroglycerin. The vasoconstriction response to N(G)-nitro-L-arginine methyl ester, which is a measure of basal nitric oxide release, was diminished in the 240-minute reperfusion group. Intestinal I/R was also associated with pulmonary leukosequestration and increased pulmonary microvascular leakage. CONCLUSIONS: Basal and agonist-stimulated release of nitric oxide from the pulmonary vascular endothelium and the ability of pulmonary smooth muscle to contract in response to angiotensin II were impaired by intestinal I/R. Such functional impairment in both pulmonary vascular endothelium and smooth muscle may contribute to the alveolocapillary dysfunction and pulmonary hypertension found in acute lung injury after intestinal I/R.

Laparoscopic versus open appendectomy: prospective randomized trial.

Although classic open surgery is simple, expeditious, and effective, it has some drawbacks, including wound sepsis, delayed recovery, operative difficulties, and possibility of unnecessary appendectomies for false appendicitis. The aim of this study was to assess the applicability and safety of laparoscopic appendectomy (LA) in a prospectively randomized trial. Seventy nonselective patients with suspected appendicitis were randomized to laparoscopic (n = 35, 17 male) or open appendectomy (n = 35, 15 male) and operated on an emergency basis. Operative findings, operating time, postoperative complications, and length of hospital stay were compared. We found that LA is associated with a shorter hospital stay, fewer postoperative complications, and better diagnostic accuracy, and it is recommended as the procedure of choice for the diagnosis and management of acute appendicitis.