Prosthetic repair of incarcerated inguinal hernias: is it a reliable method?

BACKGROUND AND AIM: It is generally accepted that most inguinal hernias should be operated on electively using synthetic grafts. However, limited information is available on the usage of these materials in patient with incarcerated and strangulated hernias. The objective of this study is to compare the outcomes of incarcerated inguinal hernia repair with or without graft. MATERIALS AND METHODS: One hundred-thirteen patients with incarcerated inguinal hernia that underwent surgery were included in this study. Patients who underwent Lichtenstein repair were assigned to group I; those who underwent primary repair were assigned to group II. Demographics and characteristics of patients in each group were compared. Chi-square and Student's t-tests were used. RESULTS: No statistical difference was found between patients who did and did not receive anastomosis in both groups in terms of surgery duration, length of hospital stay, postoperative morbidity, and mortality. Recurrence was found in 4.0% and 20.8% patients in group I and group II, respectively (P = 0.036). CONCLUSIONS: Mesh repair can be preferred in incarcerated inguinal hernia patients because recurrence rate was significantly lower in patients who underwent Lichtenstein repair in this study.

Effect of sildenafil on wound healing: an experimental study.

PURPOSE: We aimed to investigate the effect of sildenafil on the healing process of abdominal wall wound in rats. MATERIALS AND METHODS: The study was performed with adult female Wistar-Albino rats. Control group (n = 50) were fed on standard laboratory diet until 12 h before surgery. Study group (n = 50) were applied orally with orogastric tube 10 mg/kg once a day for 10 days of sildenafil therapy. Each rat was anesthetized, and a 4-cm-long midline laparotomy was performed. Ten animals from each group were killed at postoperative days (PODs) 4, 7, 14, 21, and 35. Breaking strength analysis was measured, and the abdominal incision wounds were examined histologically. RESULTS: Breaking strength for the midline incision, acute inflammation score on POD 14, and neovascularization on PODs 7, 14, 21, and 35 were significantly higher in the study group. CONCLUSIONS: Sildenafil can be used as a supporting factor in wound healing.

Early diagnosis and prediction of severity in acute pancreatitis using the urine trypsinogen-2 dipstick test: a prospective study.

AIM: To evaluate the use of the trypsinogen-2 dipstick (Actim Pancreatitis) test for early diagnosis and prediction of severity in acute pancreatitis (AP). METHODS: Ninety-two patients with AP were included in this study. The control group was 25 patients who had acute abdominal pain from non-pancreatic causes. Urine trypsinogen-2 dipstick test (UTDT) and conventional diagnostic tests were performed in all patients. Patients were divided by the Atlanta classification into two groups as having mild or severe pancreatitis. RESULTS: UTDT was positive in 87 (94.6%) of the AP patients and in two (8%) controls (P < 0.05). Positive UTDT was found in 61 (92.4%) of 66 (71.7%) patients with mild pancreatitis and in all (100%) of the 26 (28.3%) with severe pancreatitis (P > 0.05). UTDT positivity lasted longer in severe pancreatitis compared with that in mild pancreatitis (6.2 +/- 2.5 d vs 2.0 +/- 1.43 d, P < 0.05). The sensitivity, specificity, positive predictive value, negative predictive value (NPV), positive likelihood ratio (PLR) and negative likelihood ratio (NLR) of UTDT were 91%, 72%, 96.6%, 70.4%, 3.4 and 0.1, respectively. CONCLUSION: UTDT is a simple, rapid and reliable method for use on admission. It has high specificity and low NLR for early diagnosis and prediction of severity in AP. However, its relatively low NPV does not allow trypsinogen-2 dipstick test to be a stand-alone tool for diagnosis of acute pancreatitis; the use of other conventional diagnostic tools remains a requirement.

Survival analysis after surgical treatment of gastric cancer: review of 121 cases.

BACKGROUND/AIMS: This study was performed to evaluate major morbidity, early mortality and to analyze survival in our patients that underwent surgical treatment for gastric cancer. METHODOLOGY: Records of 121 patients with gastric adenocarcinoma that underwent surgery between 1997 and 2004 were reviewed retrospectively. Age, gender, tumor site, presence of local invasion, depth of tumor invasion, lymph node metastases, stage of the disease, distant metastases, histological differentiation, type of surgery, and blood transfusions were evaluated in relation to survival. Survival curves were estimated using the Kaplan-Meier method and the differences in survival were compared by the log-rank test. RESULTS: Forty-two cases (34.7%) underwent total gastrectomy, 34 (28.1%) had subtotal gastrectomy, and 45 (37.2%) received palliative surgery. The majority of the patients (61.2%) had stage IV gastric cancer. Total morbidity and mortality were 26.4% and 17.3%, respectively. The factors that influence survival were type of surgery, adjacent organ invasion, existence of metastases, lymph node status, blood transfusions, and stage of the disease in this study. Among the significant prognostic factors in the univariate analysis, only one factor, R0 resection proved to be independently significant in the multivariate analysis. CONCLUSIONS: R0 resection was found to have a significant favorable effect on survival in our study.

Palliative surgery for advanced stage (stage IV) gastric adenocarcinoma.

BACKGROUND/AIMS: The factors that effect resectability, major morbidity, early mortality, and survival in advanced stage gastric adenocarcinoma patients are evaluated. METHODOLOGY: Records of 74 patients that underwent surgery for stage IV gastric adenocarcinoma in the Third Surgical Clinic of Izmir Atatürk Training Hospital between January 1997 and January 2004 were reviewed retrospectively. Two groups (the patients with resectable disease and those with unresectable disease) were compared with regard to age, gender, primary complaint, symptoms, site of the tumor, involvement of adjacent organs, lymph node involvement, distant metastases, differentiation of tumor, surgical procedure, perioperative blood transfusions, and postoperative hospital stay. RESULTS: Mean age of the 74 patients was 58.4 years. Forty-five cases (60.8%) were considered as unresectable and 29 (39.2%) patients underwent a palliative resection. There was a significant relation between resectability and site of the tumor, and severity of invasion. As the number of perioperative blood transfusions increased, morbidity and mortality increased significantly. Although early mortality was high in the palliative resection group, survival (mean 10.4 months, longest 25 months) was better compared to that of the unresectable gastric cancer group (mean 3.5 months, longest eight months). CONCLUSIONS: A palliative gastric surgery may be applied to improve prognosis of advanced gastric cancer patients, even at the presence of peritoneal dissemination, hepatic metastases, N3 lymph node involvement, adjacent organ invasion, or poor differentiation of the tumor.

Band ligation of the perforated gall bladder during laparoscopic cholecystectomy.

Perforation of the gall bladder is a frequent complication during laparoscopic cholecystectomy. Grasping the perforated part of the gall bladder, clip application, or endoscopic loop application are possible solutions to prevent spillage. We propose laparoscopic rubber band application to close the perforated part of the gall bladder as an easy and safe method. We performed rubber band application after iatrogenic perforation of the gall bladder during laparoscopic cholecystectomy in 5 patients. Two-millimeter-wide multiple rubber rings, cut from a 14-Fr Foley catheter, are loaded on a grasper. When a perforation occurred during the dissection of the gall bladder, the hole is grasped with this instrument and 1 of the rings is placed on the gall bladder by the aid of a dissector. Thus, the grasper remained available for traction of the Hartmann's pouch during further dissection of the gall bladder. The rubber bands were placed successfully in all cases. Two perforations occurred in 1 case, and 2 bands were placed with ease. Bile leakage or gall stone spillage did not occur. Operation time was not prolonged. Rubber band ligation of perforation of the gall bladder is a simple, safe, inexpensive, and effective method to prevent spillage of the bile or gallstones in laparoscopic surgery.

Diagnosis and treatment of gallbladder perforation.

AIM: To present our clinical experience with gallbladder perforation cases. METHODS: Records of 332 patients who received medical and/or surgical treatment with the diagnosis of acute cholecystitis in our clinic between 1997 and 2006 were reviewed retrospectively. Sixteen (4.8%) of those patients had gallbladder perforation. The parameters including age, gender, time from the onset of symptoms to the time of surgery, diagnostic procedures, surgical treatment, morbidity, and mortality were evaluated. RESULTS: Seven patients had type I gallbladder perforation, 7 type II gallbladder perforation, and 2 type III gallbladder perforation according to Niemeier's classification. The patients underwent surgery after administration of intravenous electrolyte solutions, and were treated with analgesics and antibiotics within the first 36 h (mean 9 h) after admission. Two patients died of sepsis and multiple organ failure in the early postoperative period. Subhepatic abscess, pelvic abscess, pneumonia, pancreatitis, and acute renal failure were found in 6 patients. CONCLUSION: Early diagnosis and emergency surgical treatment of gallbladder perforation are of crucial importance. Upper abdominal computerized tomography for acute cholecystitis patients may contribute to the preoperative diagnosis of gallbladder perforation.

Gastrointestinal stromal tumors (GISTs): analysis of 20 cases.

BACKGROUND/AIMS: Gastrointestinal stromal tumors (GISTs) are soft tissue sarcomas arising from the mesenchymal tissues in the gastrointestinal tract. Diagnosis, treatment and follow-up protocols of GISTs have not been exactly defined. In this study, twenty cases with GISTs treated in our clinic are examined retrospectively. METHODOLOGY: Twenty cases treated for GISTs in Izmir Atatürk Training and Research Hospital between the years 1999 and 2004 were reviewed retrospectively. Age, gender, clinical findings, diagnostic methods, intraoperative findings, type of surgery, histopathological findings and survival of the patients were evaluated. RESULTS: Fifteen of the cases were male (75%) and five were female (25%), with a median age of 55 years (35-80). The most frequent symptoms were abdominal pain and acute gastrointestinal bleeding. Tumors were gastric (40%), small intestinal (45%), colonic (10%) or rectal (5%). The median tumor size was 9.1 centimeters. Pathological evaluation showed that number of mitoses per 50 high-power field (hpf) was more than five in nine of 10 cases and CD-117 was positive in four of four cases. The mean follow-up period was 21 (1-72) months, and median survival was 21 (1-72) months. CONCLUSIONS: The prognosis of GIST is frequently related to the tumor size and rate of mitosis. Despite the recent demonstration of C-kit protooncogene and introduction of imatinib mesilate as a new chance in treatment, radical surgery remains to be the most effective treatment of GISTs.

Total gastrectomy for gastric carcinoma.

BACKGROUND/AIMS: Gastric cancer is one of the most common organ cancers all around the world and surgical resection is essential for treatment. Total gastrectomy is the procedure of choice for treatment of proximal gastric cancer. Mortality and morbidity risks of this procedure are high, especially among the elderly. METHODOLOGY: Thirty-eight gastric cancer patients underwent total gastrectomy in the Third Surgical Clinic of Izmir Ataturk Training and Research Hospital between 1996 and 2001. Age, gender, location of the tumor, histopathological findings, TNM stage, type of anastomosis, operation time, blood transfusions, oral food intake, postoperative hospital stay, morbidity, mortality both early and late, and survival rate were evaluated. RESULTS: Mean age of the patients was 59.5 years (22-85 years). Sites of the tumors were: cardia 28.9%, cardia and corpus 15.8%, corpus 34.3%, corpus and antrum 18.4%, linitis plastica 2.6%. Histological types were adenocarcinoma (97.4%), and squamous cell carcinoma (2.6%). TNM stages were: stage la 2.6%, stage II 7.9%, stage IIIa 39.5%, stage IIIb 42.1%, and stage IV 7.9%. Esophagojejunostomies were performed manually (34.3%) or by circular staplers (65.7%). Operation time ranged between 3 and 6.5 hours. Gastric tubes were removed on the fourth postoperative day. Average postoperative hospital stay was 12.9 days. Postoperative morbidity was 21%. Wound infection occurred in three patients (7.9%), pulmonary infection occurred in two patients (5.2%) and anastomotic stricture developed in three patients (7.9%). Hospital mortality was 20%. Anastomotic leak occurred in five cases (13.2%) and all died on days 8, 13, 14, 26, and 30. Three patients (7.9%) died of cardiac complications on days 1, 5, and 29. Twelve patients survived for less than one year and eight patients survived for one to two years. Average survival was 10.5 months for 20 out of 30 patients (median 8 months). Ten patients are still alive after 14.3 months. Four patients have been living for less than one year, another four patients for one to two years, and two patients for more than two years. CONCLUSIONS: Total gastrectomy, either performed with a curative or palliative aim, is a safe procedure with acceptable mortality rates. 89.5% of our cases were stage III or IV resulting in a low survival rate. Longer survival rates can be achieved in patients with comparatively earlier stages.

A Retrospective Study of 39 Patients Treated With Anterior Approach of Thoracic and Lumbar Spondylodiscitis: Clinical Manifestations, Anterior Surgical Treatment, and Outcome.

The aim of this study is to report our 39 patients treated with anterior debridement and autologous iliac bone grafting with or without anterior instrumentation, which is the presumed treatment of choice for thoracic or lumbar spondylodiscitis.Our patients underwent surgical treatment of spondylodiscitis using anterior debridement and autologous iliac bone grafting with or without anterior instrumentation and were analyzed with a mean follow-up of 8 years (range, 2-11 years). Kaneda 2-rod system instrumentation was used in 12 patients, in total. Clinical outcomes were assessed by the Frankel grade. Radiographic fusion was characterized based on 3-dimensional computed tomography.Of the whole group, 20 patients suffered from tuberculous spondylodiscitis and 19 suffered from hematogenous spondylodiscitis. Pathogens responsible for pyogenic infection included Staphylococcus aureus (4 patients), Pseudomonas aeruginosa (3 patients), and Brucella melitensis (1 patient). Fifteen patients had thoracic involvement, 20 had lumbar involvement, and 4 had thoracolumbar junction involvement. Preoperative neurological deficits were noted in 13 of the 39 patients. In terms of Frankel grade, 8 patients have improved, 4 have remained the same, and 1 patient has worsened during the follow-up period. Imaging-documented fusion was achieved in 23 of 27 patients in the graft group (85% fusion rate) and 11 of 12 patients in the graft + Kaneda instrumentation group (91% fusion rate).There was no instrumentation failure, loosening, or graft-related complication such as slippage or fracture of the graft. This approach demonstrated a good recovery rate of neurological functions and a high fusion rate.

Primary tumors of the small bowel: diagnosis, treatment and prognostic factors.

BACKGROUND/AIMS: The neoplasms of the small intestine are rare and the preoperative diagnosis is difficult. The aim of this study is to review difficulties in diagnosis, treatment options and important prognostic factors. METHODOLOGY: Fifteen patients who underwent surgical resection for intestinal tumors from 1990 to 2000 in the Third Surgical Clinic of Izmir Atatürk Training and Research Hospital were reviewed retrospectively. Age, symptoms, diagnostic methods, operative procedures, and their effects on prognosis were evaluated. RESULTS: Seven patients were male and eight were female. The mean age was 52.3 years (27-77). Eight patients underwent urgent intervention and seven had elective surgery. Three cases were diagnosed as small bowel tumor preoperatively. The radical resection of the small bowel neoplasm was possible in 12 patients (80%), eight of whom being malignant and four of whom being leiomyoma. Three patients with leiomyoma are still alive for 3.5, 6 and 9 years but one patient died perioperatively because of respiratory distress syndrome. Two cases with lymphoma survived for 16 and 37 months while another two have been still alive for 7 and 8 years. The patients who had malignant epithelial tumor, leiomyosarcoma, and malignant mesenchymal tumor survived for 17, 54, and 20 months, respectively. The patient with malignant tumor of endocrine origin has still been living for 3 years. CONCLUSIONS: As a result we concluded that better evaluation of signs and symptoms may facilitate the diagnosis; and the most important prognostic factors are early diagnosis and radical surgery.

Gallbladder perforation: clinical presentation, predisposing factors, and surgical outcomes of 46 patients.

BACKGROUND/AIMS: We aimed to investigate the clinical features and the relation between patient characteristics and the different types of gallbladder perforation and to determine the predisposing factors. MATERIAL AND METHODS: The medical records of 478 patients who received urgent surgical treatment with the diagnosis of acute cholecystitis and underwent urgent surgery in our clinics between January 1997 and November 2008 were reviewed retrospectively. The demographic data of patients, time elapsed from the onset of the symptoms to the time of surgery, comorbidity status, American Society of Anesthesiologists classification, laboratory data, imaging results, surgical procedures, postoperative complications, and postoperative length of stay of the patients were analyzed. RESULTS: There were 46 (9.6%) patients with the diagnosis of gallbladder perforation. Morbidity and mortality occurred in 15 (32.6%) and 7 (15.2%) patients, respectively. Advanced age, male gender, fever >38°C, high white blood cell count, and presence of cardiovascular comorbidity were found to be significant risk factors for gallbladder perforation. CONCLUSIONS: While early diagnosis and early surgical intervention are the keys to managing gallbladder perforation, we suggest that patients having the above-mentioned clinical features should be carefully investigated.

Spontaneous healing of gallbladder perforation: report of a case.

Gallbladder perforation is a serious complication of acute cholecystitis. Spontaneous healing is very rare, and only three cases have been reported in the English literature. In this study, we present a 73-year-old female patient who underwent a laparoscopic cholecystectomy years after a gallbladder perforation and spontaneous healing.

Comparison of a modified anoscope and the purse-string anoscope in stapled haemorrhoidopexy.

AIM: To compare the results of the anoscope of the PPH kit and a modified anoscope during stapled haemorrhoidopexy. METHODS: The hospital records of 37 patients who underwent stapled haemorrhoidopexy between 2001 and 2006 were reviewed. The purse-string suture anoscope in the PPH kit was used on 15 patients (Group 1), and the modified anoscope was used on 22 patients (Group 2). Demographic characteristics of the patients, operation time, surgeon's performance, analgesic requirement, and complications were compared. RESULTS: Operation time was significantly longer in Group 1 (42.0 +/- 8.4 min vs 27.7 +/- 8.0 min, P = 0.039). The surgeons reported their operative performance as significantly better in Group 2 (the results of the assessments were poor in ten, medium in four and good in one in Group 1, while good in all patients in Group 2, P < 0.001). The need for haemostatic sutures was significantly higher in Group 1 (six cases) and was needed in two cases in Group 2 (P = 0.034). CONCLUSION: Operation time decreased and the surgeon's satisfaction increased with use of the modified anoscope, and fewer haemostatic sutures were required if the surgeon waited longer before and after firing the stapler.

Prognostic Factors of Patients With Transmural Advanced Gastric Carcinoma.

BACKGROUND: The purpose of this study is to evaluate perioperative morbidity, mortality and the prognostic factors that influence survival of the patients with transmural advanced gastric carcinoma after curative surgical therapy. METHODS: Fifty patients with transmural advanced gastric adenocarcinoma underwent curative resection in our clinic. The records of the patients were reviewed and the prognostic factors such as age, gender, location and size of the tumor, type of surgery, blood transfusion, depth of tumor invasion, lymph node metastases, stage of the disease, grading, vascular invasion, lymph vessel invasion, characteristics of the tumor according to Lauren's classification, and lymph node ratio were evaluated by using statistical methods. RESULTS: In a total of 12 patients (24%) major morbidities developed, and five patients (10%) died. The overall survival rate was 48% at 1 year, 31% at 3 years, and 19% at 5 years. Lymph node metastases (P = 0.03), lymph vessel invasion (P = 0.001), blood transfusion (P = 0.021), and lymph node ratio (P = 0.006) were the prognostic features identified by univariate analysis. Among the multiple significant prognostic factors in the univariate analysis only one factor, lymph node ratio, proved to be independently significant in the multivariate analysis (RR: 4.47). CONCLUSIONS: Our data showed that we can expect a good survival for patients with a lymph node ratio less than 0.2.

Special anoscope for easy purse-string suture application in stapled hemorrhoidopexy.

BACKGROUND: Internal hemorrhoids and loose rectal mucosa may block exposure during the purse-string suturing in stapled hemorrhoidopexy, and this may lead to complications. MATERIALS AND METHODS: To retract the prolapsing rectal mucosa, we modified the purse-string anoscope of the PPH01 kit (Ethicon-Endosurgery, Cincinnati, OH, USA) and produced a special anoscope. The open part of the purse-string suture anoscope is covered by transparent acrylic (Orthoacryl, Dentaurum, Pforzheim, Germany). The covering had completely cylindrical outer and inner surfaces and was thin enough to let the anoscope easily rotate in the anal dilator and to let the 26 mm curved, round-bodied needle of the 2/0 polypropylene suture move in the anoscope. A window, 3 cm long and 3-4 mm wide, was opened at the angled part of the anoscope 2 cm to the tip. This special anoscope was used for the purse-string suture during the stapled hemorrhoidopexy procedure in five patients. RESULTS AND CONCLUSIONS: No postoperative complications, early or late, were encountered, and we propose that stapled hemorrhoidopexy procedure can be applied more easily by using this special anoscope.

Acute intraperitoneal rupture of hydatid cysts.

BACKGROUND: Rupture into the abdominal cavity is a rare but serious complication of hydatid disease. The cysts may be ruptured after a trauma, or spontaneously as a result of increased intracystic pressure. Rupture of the hydatid cyst requires emergency surgical intervention. METHODS: Seventeen patients received surgical treatment for intraperitoneal rupture of the cysts over a period of 18 years. Age, gender, time to surgery from the onset of the symptoms, laboratory findings, diagnostic procedures, surgical treatment modalities, in-hospital stay, morbidity, mortality and recurrence were evaluated retrospectively. RESULTS: Five cases (29.4%) had a history of blunt abdominal trauma. Ultrasonography scans revealed intra-abdominal fluid in all cases. Intraperitoneal multiple cysts with heterogeneous cavity or cystic structures in the liver were shown in 14 cases. Computed tomography and magnetic resonance imaging showed multiple cystic lesions in the liver and peritoneum with intra-abdominal free fluid. Procedures to fill the cystic cavities were applied after removal of the intraperitoneal fluid. Four patients (23.5%) died in the early postoperative period. A total of nine morbidities developed in six patients (35.3%). Median hospital stay was 18 days and median follow-up was 78 months. Intra-abdominal recurrence occurred in one case (7.7%). CONCLUSIONS: Rupture of hydatid cysts into the peritoneal cavity, although rare, presents a challenge for surgeons. This pathology should be included in the differential diagnosis of acute abdomen in endemic areas. Computed tomography scan, in addition to clinical presentation, is essential for diagnosis. Emergency surgery is the main treatment for acute ruptured hydatid cysts. The morbidity and mortality rates of surgical interventions for ruptured hydatid cysts are higher than the rates for elective uncomplicated cases.