Internal herniation as a major cause of intestinal obstruction.

OBJECTIVES: To evaluate internal herniation as a rare cause of intestinal obstruction. MATERIALS AND METHODS: Files of 18 cases, operated due to internal herniation between 2000 and 2006 at Selcuk University, Meram School of Medicine, General Surgery Department, were reviewed retrospectively. Sixteen patients (88.8%) were male (mean age: 58.2 years; range: 42-67) and 2 were female (mean age: 56.5 years; range: 52-61).Cases were grouped according to the location of internal herniation, and the clinical findings and applied treatment strategies were evaluated. RESULTS: All patients were taken into surgical operation after preoperative preparations were completed. Findings were as follows: 6 cases of paraduodenal internal herniation, 4 of internal herniation through a defect in the terminal mesoileum, 2 of herniation through a defect in the falciform ligament, 2 of herniation through a defect in the omentum majus, 1 of herniation to the recessus over the bladder, 2 of herniation through a defect in the transverse mesocolon and 1 iatrogenically caused internal herniation through a defect in the mesojejunum. CONCLUSION: In an adult patient with findings of intestinal obstruction, diagnosis is difficult. Most cases presented to date are incidental findings during laparotomy, and surgical treatment is necessary.

Sex as a factor in conversion from laparoscopic cholecystectomy to open surgery.

OBJECTIVES: Although laparoscopic cholecystectomy has become the standard treatment for symptomatic gallbladder diseases, conversion to open surgery is required in a substantial proportion of patients. In this study, we attempted to clarify whether male sex carries an increased risk for conversion to open surgery during laparoscopic cholecystectomy. METHODS: This study comprised 80 patients (41 females, 39 males) with symptomatic gallbladder stones. Average age was 39.2 years, and all female patients were of reproductive age. Patients were excluded from the study if they had acute cholecystitis, previous abdominal surgery, systemic or connective tissue diseases, or were using tobacco, alcohol, or medications that affect wound healing or inflammation. Tissue samples were obtained from the same sites in each gallbladder wall and pericholecystic tissue for the measurement of tissue hydroxyproline (HP) and collagen. Samples were examined under light microscopy for histopathology. Findings in male and female patients were compared by using the Student t test. RESULTS: All patients except 3 males received laparoscopic cholecystectomy. Conversion to open cholecystectomy was necessary in those 3 because of intense pericholecystic fibrosis. In male patient samples, macrophages were twice as numerous as in female samples, whereas mast cells in the men were 4 times more numerous, and eosinophils were 6 times more numerous (P<0.01). In men, HP levels in the gallbladder wall and pericholecystic tissue were 23.4+/-14.9 microg/mg dry tissue and 25.2+/-13.1 microg/mg dry tissue, respectively. The corresponding values in women were 13.1+/-9.4 microg/mg dry tissue and 14.5+/-8.1 microg/mg dry tissue. This higher level of tissue HP in men was statistically significant (P<0.015). Tissue collagen levels both in the submucosal area of the gallbladder wall and in pericholecystic tissue were significantly higher in men than in women (P<0.05). CONCLUSION: Our data suggest that in the context of symptomatic gallbladder stones, inflammation and fibrosis are more extensive in men than in women. These findings may help explain why the rate of conversion to open surgery is higher in men than in women.

The effects of serum estrogen levels on hypoxemia and blood nitric oxide levels in experimental hepatopulmonary syndrome.

BACKGROUND: : Hepatopulmonary syndrome (HPS) is a well-defined cause of hypoxemia in patients who have liver disease due to abnormal intrapulmonary vascular dilatation. The pulmonary symptoms of HPS are the result of oxygenation defects that occur as a result of acquired dilatations of the pulmonary blood vessels. In this study, we investigated the effects of estrogen and nitric oxide (NO) in experimental HPS, especially in intrapulmonary vascular dilatation. METHODS: : Fifty female Sprague-Dawley rats were used in this study. The animals were divided into five groups of 10. Group l (the control group): the common bile duct (CBD) was dissected but not ligated. Group 2 (the cirrhosis group): the CBD was ligated. Group 3 (the cirrhosis+oophorectomized group): the CBD was ligated and a bilateral oophorectomy performed. Group 4 (the cirrhosis+estrogen group): the CBD was ligated and exogenous estrogen (5000U/kg) given. Group 5 (the control+estrogen group): the CBD was dissected, but not ligated and exogenous estrogen (5000U/kg) given. A 5-week waiting period was observed for the development of cirrhosis and the rats' lungs and liver were taken for histopathological examination. Pulmonary vessel diameters were measured. The total bilirubin, direct bilirubin, alkaline phosphatase (ALP), estrogen and serum nitric oxide (NO) levels were measured. RESULTS: : The mean perialveolar vessel diameters were significantly higher in the cirrhotic rats (Groups 2, 3, and 4) than the control and control+estrogen administered groups. Again, when we compared the cirrhosis+oophorectomized group and the cirrhosis+estrogen group, the mean perialveolar vessel diameter was significantly lower in the cirrhosis+oophorectomized group than the cirrhosis+estrogen administered group (p=0.001). The mean perialveolar vessel diameter in the cirrhosis+oophorectomized group was significantly lower than the cirrhosis group (p=0.01). When we compared the cirrhotic rats (Groups 2, 3, and 4) and the control group, the plasma NO levels were significantly higher in the cirrhotic rats than the control group (p<0.001). Among the cirrhotic rats, the plasma NO levels were 47.2+/-0.7 and 70.9+/-1.5mumol/l in the cirrhosis+oophorectomized group and the cirrhosis+estrogen administered group, respectively (p=0.004). CONCLUSIONS: : We consider that raised levels of estrogen have a potential role in intrapulmonary vascular dilatation and hypoxemia in HPS. Also, we consider that this effect of estrogen is due to increased levels of NO. Antiestrogenic surgical therapy may decrease the serum estrogen and NO levels, and may decrease the diameter of perialveolar vessels in order to relieve hypoxia in cirrhotic cases.

Long-term results utilizing the unroofing technique in treating hydatid cysts of the liver.

PURPOSE: The aim of this study was to present the long-term follow-up results of liver hydatid cysts treated with unroofing, together with a review of the related literature data. METHODS: Of 700 liver hydatid cyst patients examined and treated at Selcuk University Meram Medical Faculty, General Surgery Department, between 1985 and 2007, 650 had accessible data and the unroofing method had been applied in 189 of them. The clinical and laboratory findings, stages, operations, and complications of patients treated with unroofing were reviewed. In particular, the resolution of residual cyst cavities over time after the application of this method was evaluated using computed tomography. RESULTS: Four hundred and thirty-six (67.07%) of the cases were female [mean age: 35 (range: 10-73) years] and 214 (32.9%) were male [mean age: 46 (range: 12-76) years]. Of the 189 cases treated with unroofing and followed by tomography, the data of 144 were documented. Cavities were classified into five groups (A-E) according to their postoperative appearance. CONCLUSIONS: Unroofing is an easy approach and it does not require extensive experience. This technique is recommended for peripherally localized cysts but may also be applied to those more deeply situated. Unroofing should be applied as deeply as possible and the residual cavity should also be as shallow as possible.

Effects of platelet rich plasma on colonic anastomosis.

PURPOSE: To investigate the effect of platelet-rich plasma (PRP) on tissue maturation and wound healing in experimental colonic anastomosis. MATERIALS AND METHODS: Thirty Sprague Dawley rats were divided into three groups of 10 rats each. Group I (control group) was subjected to colon anastomosis only. Group II (PRP group) was subjected to colon anastomosis and topical PRP was applied. Group III (Bioglue group) was subjected to colon anastomosis and topical tissue sealant was applied (Bioglue; Cryolife, Kennesaw, GA). The rats were sacrificed on postoperative day 7, and the bursting pressure of the anastomosis and tissue hydroxyproline levels were measured; histopathological changes on the anastomosis line were also examined. RESULTS: The bursting pressure was statistically higher in the PRP group than in the control and Bioglue groups (P < 0.05). The hydroxyproline levels were also statistically higher in the PRP group than in the control and Bioglue groups (P < 0.05). Histopathologically, there was less inflammatory cell infiltration, intensive fibroblast development, and rich collagen production in the PRP group. CONCLUSION: PRP may be used in colon anastomosis, especially in patients with impaired wound healing, to obtain a better anastomotic strength.

Clinical and surgical profile and follow up of patients with liver hydatid cyst from an endemic region.

AIM: The aim of this study is to present the changes in the treatment of liver hydatid cyst during the last 20 years in our clinic according to literature data. MATERIAL AND METHODS: Clinical, laboratory and operational findings and pre- and postoperative complications of 650 from 700 patients with liver hydatid cysts, examined and treated at Selcuk University Meram Medicine Faculty, General Surgery Department, between 1985-2005, were evaluated in two groups: 1st period (1985-1995) and 2nd period (1995-2005). RESULTS: 436 of the cases were females (67.1%) and 214 (32.9%) males. The mean age of the females was 35 years (ranges 10-73) and of the males 46 years (ranges 12-76). Surgical treatment comprised radical and obliterative conservative techniques in the first period, while non-obliterative conservative techniques and percutaneous puncture and aspiration of the cyst, injection of scolex eliminating substance and reaspiration (PAIR) were preferred in the second period. During the follow-up (498 cases were followed for a mean period of 32 [12-72] months), recurrence occurred in 12 in the first period and in 9 in the second period, a total of 21 patients (4.21%). CONCLUSION: We consider that regardless of the surgical treatment used in liver hydatid cyst cases, combination with chemotherapy is the safest and most effective approach.

Electron-microscopic alterations of the peritoneum after both cold and heated carbon dioxide pneumoperitoneum.

BACKGROUND: Carbon-dioxide (CO(2)) is used universally as an insufflation agent to create a laparoscopic pneumoperitoneum. In this study, we aimed to examine the electron and light microscopic alterations of the peritoneum after both cold-dry and heated-humidified CO(2) pneumoperitoneum. MATERIALS AND METHODS: Thirty male Sprague-Dawley rats were used in this study. The rats were separated into three groups each comprising 10 rats. Group-I: (Control group): Gas insufflation was not applied to these animals. Group-II: These animals received standard cold-dry (21 degrees C, 2% relative humidity) CO(2). Group-III: These animals received heated-humidified (40 degrees C, 98% relative humidity) CO(2). In groups II and III, peritoneal gas was emptied 2 h after pneumoperitoneum application. All rats were killed after 12 h. Peritoneal samples were examined both by scanning electron and light microscopy by two different pathologists who were not aware of the groups. RESULTS: According to light microscopic examination; in group II and III, cellular response (increased lymphocyte) was significantly higher than the control group (P < 0.01). Similarly, in group II cellular response was significantly higher than group III. (P < 0.01). There was no difference in increased capillarity among all groups. (P > 0.05). According to scanning electron microscopic examination, in group I, normal peritoneum was covered by a sheet of flat mesothelial cells densely covered with microvilli. No intercellulary clefts and no free basal lamina were detected. In group II, drastic alterations of the surface layer were seen. The mesothelial cells had extreme desquamation, and the basal membrane was clearly visible. In group III, the mesothelial cells had bulged up to the surface layer and retracted. Intercellulary clefts become visible, but the basal lamina was not seen. CONCLUSIONS: Electron and light microscopic examination revealed that heated-humidified CO(2) results in less peritoneal alteration than cold-dry CO(2.) Accordingly, we believe that heated-humidified CO(2) is more suitable for pneumoperitoneum application in laparoscopic surgery especially in selected cases.

Analysis of experimental liver metastasis from tumors inoculated in the mouse stomach cavity.

PURPOSE: This study was conducted to develop a patient-like hematogenous metastatic model of gastric-cancer in order to gain an understanding of the tumor biology and to search for new methods of treatment. METHODS: We established a natural and easily reproducible liver metastasis model by orthotopic gastric inoculation in Balb/c mice, using the syngeneic tumor, colon 26. RESULTS: This model allowed us to evaluate the effect of partial gastric resection with excision of tumor nodules on the formation of experimental liver metastases from the stomach cavity. Mice given partial gastrectomy showed less metastatic ability than control mice. In these experimental groups, liver metastasis was observed in the only group of mice that died of local tumor regrowth due to incomplete resection of the primary tumor. It is suggested that a period of at least 10 days is required for the formation of liver metastases after tumor inoculation into the stomach cavity. There was no significant increase in the number of liver metastases following splenectomy, or after the administration of anti-asialo GM1 antibody or silica. CONCLUSION: This experimental model of liver metastases will provide a useful means of understanding tumor biology and the regulation of liver metastases by host immunocompetent cells, and for assessing new therapeutic agents.