Turkish Journal of Surgery - 2010; 26(2) - Current Issue

De�erli Meslekta�lar�m�z

�skender Sayek, Feza Remzi, Ertu�rul G�ksoy, Sad�k K�l��turgay — 2010-03-01

Science and economy: The place of Turkey in the world

2010-03-01

Aims: We aimed to provide information on world's economic and academic citation and to find the characteristics of overall, medical and particularly general surgical scientific paper production. Material and Method: Data form SCI were used in order to determine the progress of scientific production in the world. Fourty countries with the highest H-index rank that constituted 90% of the world's economic and scientific production were analyzed. An economic- scientific ranking (ESR) was developed in terms of average ranking of eleven criteria of these countries. Additionally, comparison of proportionate areas like USA versus eight European countries and Turkey vs Russia, Mexico, Egypt and Iran was done. Results: A tendency of decline in citations per paper was observed despite a constant increase in the number of articles. There was a considerably high correlation between ESR and H-index and total number of citations. While the proportion of USA in total world citations decreased, eight European countries filled this gap and became leader in medicine and overall in science. Turkey, which has a relatively high rank in the production of scientific articles, is inadequate in terms of the H-index, and new developments are needed. Although the number of publications from Turkey is considerably high, it is observed that H-index and the number of citations are inadequate. Conclusion: The H-index and total number of citations have been proved to be important in indicating social development, along with scientific productivity. It was concluded that the government and scientific institutions should aim to increase the number of publications that may provide high levels of citations in Turkey that needs innovation and patent formation, i.e. qualificational evolution.

Surgical treatment of Zenker's diverticulum

2010-03-01

Purpose: In this study, we aimed to evaluate surgical outcomes of patients who were operated for Zenker's diverticulum in our clinic. Patients and Methods: Between 2004 and 2009, 13 patients were operated on for Zenker's diverticulum in our clinic. We evaluated these patients with respect to the variables including age, gender, symptoms duration of symptoms, diagnostic modalities, upper gastrointestinal comorbidities concurrent with Zenker's diverticulum, Brombart stage, associated medical risk factors, ASA score, diverticular size operative technique, operating time, time to oral intake, postoperative complications, length of hospital stay and symptomatic relief. Results: Thirteen patients, 12 (72.2%) were male and one (27.8%) was female, and their median age was 56 years. Dysphagia odynophagia, weight loss and coughing were common symptoms. The median duration of symptoms was 27 months. According to Brombart classification, 5 patients were in stage III and 8 patients were in stage IV. The median diverticular size was 4.5 cm. Twelve patients (92.3%) underwent diverticulectomy with cricopharyngeal myotomy and one patient (7.7%) diverticulopexy with cricopharyngeal myotomy. One patient (7.7%) suffered from esophageal fistula postoperatively and treated conservatively. The median follow-up period was 47 months. Eleven patients (85%) were symptom-free. Conclusion: This study demonstrates that diverticulectomy or diverticulopexy with cricopharyngeal myotomy can be performed with acceptable morbidity in surgical treatment of Zenker's diverticulum.

Promoter polymorphisms of MMP 1 and 2 genes and risk for hepatocellular carcinoma: Case-control analysis in Turkish patients

Mircelal Kazimi, Sinem Melek Nalbanto�lu, Murat K�l��, Afig Berdeli — 2010-03-01

Purpose: Matrix metalloproteinases are established as strong prognostic markers for hepatocellular carcinoma which is one of the most progressive and aggressive cancer types worldwide. Hepatocellular carcinoma is very common in various populations, but the pathogenetic link between MMPs is limited so far. Due to asociation with invasion in cancer metastasis, the matrix metalloproteinases MMP-1 and MMP-2 are candidate genes for predisposition to hepatocellular carcinoma. Patients and Methods: A total of 73 patients who were diagnosed as having hepatocellular carcinoma and had undergone liver transplantation were enrolled in the study. Following DNA extraction polymerase chain reaction-restriction fragment lenght polymorphism molecular genetic analyses were performed. By case-control and genotype-phenotype correlation analysis, we investigated the risk of association of MMP-1 and MMP-2 promoter polymorphisms in 73 Turkish hepatocellular carcinoma patients compared to healthy controls. Results: Genotypic distributions of the MMP2 -735 C/T and MMP1 -1607 1G/2G polymorphisms were in Hardy-Weinberg equilibrium in patient and control groups (p>0.05). In case-control analyses, the distribution of the genotypes and allele frequencies in the cases did not differ from those in the control group (p>0.05). In genotype-phenotype correlation analysis; for MMP1 -1607 1G/2G polymorphism 2G/2G genotype was associated with portal vein invasion (p<0.02). With regard to the post-transplantation results of the present study the 4-year survival rate in the patients was 77,3% and the recurrencefree survival rate in the post-transplant phase was 96,2%. Conclusion: No significant association was determined between Turkish hepatocellular carcinoma prognosis and post-transplantation metastasis and invasion with MMP2 -735 C/T and MMP1 -1607 1G/2G polymorphisms as risk predictors.

Surgical treatment of complications of radiotherapy: Essentials in surgery

2010-03-01

Purpose: Radiotherapy is frequently used following abdominopelvic surgical operations for malignancies. In this current study we tried to report our experience and methods for surgical repair of radiotherapy complications with review of literature. Materials and Methods: Patients who have complications due to postoperative radiotherapy for abdominopelvic cancer (n=119) were retrospectively compared with 207 cases, who did not receive radiotherapy between 2005-2008. Patients were retrospectively evaluated according to the age, gender, primary disease, time of the occurrence of complications following the radiotherapy, accompanied disease, BMI, applied surgical methods, mortality and morbidity. Peritoneal carcinomatosis and complications related to other causes than radiation were excluded from the study. Results : Fifty eight (48,7%) of patients who received radiotherapy did not require surgical repair, but 15 (12,6%) received surgical procedure. 5 (4.2%) of these patients died. In patients who did not received radiotherapy, number of complications which required surgical approach was only 3 (1.4%). There was a statistical significance between irradiated group and control group, according to gastrointestinal hemorrhage, ileus, fistula, proctitis, cystitis, enteritis and reoperation requirement (p<0,05; for fistula, proctitis, cystitis and p<0,001 for all other parameters ). Conclusion: Number of complications are increasing in patients receiving radiotherapy following the surgery for abdominopelvic malignancies. Preoperative nutrition is very important in patients who require surgery for these complications. Preferred surgical method and technique is crucial in these cases. Diversion and bypass procedures should be considered.

The role of ischemia modified albumin in the evaluation of hemodynamic changes in the splanchnic area during laparoscopic cholecystectomy

Hande K�ksal, Sevil Kurban, Mustafa �ahin — 2010-03-01

Purpose: Elevation of intraabdominal pressure by means of gas insufflation produces hemodynamic disturbances in the peritoneal viscera, leading to splanchnic ischemia. Recently, ischemia modified albumin (IMA) has been used to investigate conditions such as myocardial and skeletal muscle ischemia. The purpose of this clinical investigation is to determine the role of IMA in the evaluation of alterations in blood flow of the splanchnic area and abdominal viscera during laparoscopic cholecystectomy. Patients and Methods: Twenty two patients (F/M: 21/1) undergoing laparoscopic cholecystectomy (Group I) and 10 patients (F/M: 7/3) undergoing various surgical procedures under general anestheasia (Group II) were studied. No patient had any cardiovascular disease. Blood samples for IMA were collected at preoperative and intraoperative periods. A rapid, colorimetric assay was used to measure serum IMA levels. Results: In Group I, the preoperative and intraoperative IMA levels were 0.59�0.16 absorbance units (ABSU) and 0.74�0.17 ABSU respectively. The intraoperative IMA levels were higher than the preoperative levels (p=0.025). In Group II, the preoperative and intraoperative IMA levels were 0.43�0.12 ABSU and 0.52�0.15 ABSU respectively. The difference was not statistically significant (p=0.22). The intraoperative IMA levels in Group I were higher than Group II (p=0.003). Conclusion: IMA, a new sensitive marker for ischemia, can be helpful for determining alterations in blood flow of the splanchnic area and abdominal viscera during laparoscopic cholecystectomy.

Pilonidal sinus in the army: Its incidence and risk factors

�mit Sekmen, V. Melih Kara, Fatih Alt�ntoprak, Zafer �enol — 2010-03-01

Purpose: We aimed to determine the incidence of and risk factors for pilonidal sinus, especially in young adults. So we try providing protective methods to prevent this disease. Materials and Methods: A total of 1,000 soldiers in the Turkish army were examined regarding their age, height, weight, body mass index educational status, income, birth and living place, frequency of bathing family history for pilonidal sinus, presence of intergluteal symptoms and the amount of sitting time during working. Their physical examinations were done by the same surgeon, and existence of pilonidal sinus, hirsutism grade and type of body hair were also recorded. Results: The incidence of pilonidal sinus in this population was 6.1%. Pilonidal sinus in the family history, to be born or living in the Marmara region, high grade gluteal hirsutism were determined to be risk factors for the disease. The statistical power of the relationship between pilonidal sinus incidence and body-mass index, educational status, income, type of body hair, lumbar hirsutism, frequency of bathing or daily sitting time is not sufficient to assume any of them as risk factors. Conclusion: Follow-up and regional epilation may be suggested to people with high risk factors. Family history of pilonidal sinus and high grade of gluteal hirsutism should be accepted as risk factors.

Diaphragmatic injuries due to stab wounds: analysis of 18 patients

2010-03-01

Purpose: Although all diaphragmatic injuries caused by stab wounds need to be repaired, preoperative diagnosis is often difficult. The purpose of the present study is to share our experience regarding diaphragmatic wounds. Patients and Methods: Eighteen patients with stab wounds causing diaphragmatic injuries treated at General Surgery Clinic of �n�n� University Faculty of Medicine between March 2000 and June 2009 were evaluated retrospectively. Results: There were 15 male and 3 female patients with mean age of 33 (20-69) years. Most common complaints were difficulty in breathing, and abdominal and chest pain. Localization of the injury was on the left side of the diaphragm in 11 (61%) patients and on the right side in 6 (33%) patients, and one (6%) patient had injuries on both sides. Surgery was performed in 17 patients with midline abdominal incision within the first 24 hours after the injury and with lateral thoracotomy in a patient 10 days after injury. Mortality occurred in 3 (17%) patients; in 2 patients due to bleeding from accompanying injuries and in one patient due to postoperative sepsis. Conclusion: Preoperative diagnosis of diaphragmatic injury due to a stab wound is difficult. These patients highly probably have visceral organ injuries in addition to diaphragmatic injuries. Diaphragmatic injuries should be kept in mind in patients with abdominal penetrating stab injuries which are located between umbilicus and xiphoid. Both hemidiaphragms should be explored carefully during abdominal surgery of these patients.

Transaxillary robotic thyroidectomy: The surgical technique and report of first two cases

Mete D�ren, Serdar Giray — 2010-03-01

With the introduction of robotic surgery into endocrine surgery it has become possible to perform thyroidectomy via axillary approach without an incision and scar in the neck. The first two patients who underwent unilateral total thyroidectomy using da Vinci^� surgical system are presented in this study. With appropriate case selection, robotic axillary thyroidectomy is an alternative to endoscopic thyroidectomy.

Stromal tumor originating from sigmoid mesocolon: A case report

Rojbin Karakoyun, Oktay Banl�, Hasan Altun — 2010-03-01

Gastrointestinal stromal tumors arise from mesenchymal cells of gastrointestinal tract and are seen rarely. In fewer than 5% of cases they arise from outside of gastrointestinal tract, they originate primarily from mesentery, omentum and peritoneum. These are called extragastrointestinal tumors and they share the histological features with their gastrointestinal counterparts. A 57-year-old male patient was admitted to our hospital with complaint of abdominal pain. In his physical examination, an abdominal mass was detected in his left lower quadrant. Radiological examinations revealed an abdominal mass measuring 13x9 cm in diameter, adjacent to the bladder. Laparotomy demonstrated a lobulating mass of about 13x10 cm in diameter, originating from mesenterium of the sigmoid colon. En-bloc resection of the tumor with sigmoidectomy and end-to-end anastomosis was performed. Histopathology of the specimen showed that the tumor demonstrating high cellularity composed of spindle-shaped tumor cells. There was no continuity of tumor within the sigmoid colon and the margins of specimen were tumor-negative. Immunohistochemically, the tumor was positive for c-kit (CD 117). The tumor was diagnosed as a gastrointestinal stromal tumor originating from mesenterium of the sigmoid colon. A gastrointestinal stromal tumor of the sigmoid mesenterium is a rare entity. Surgical resection is the treatment of choice for these tumors, which usually have a poor prognosis.

Desmoid tumor at the anterior abdominal wall: A case report

Turgay Karata�, Mustafa Ak�n — 2010-03-01

Purpose: Desmoid tumors are seen rarely in the anterior abdominal wall. We want to present a female patient with a desmoid tumor in the anterior abdominal wall (in the rectus muscle) we treated and followed up. Material and Methods: We assessed the etiological factors, diagnosis and treatment, pathologic findings, follow-up and results after treatment in the patient with a desmoid tumor. Results: Initially, an abdominal ultrasonography was performed. A solid mass in the rectus muscle with a 24-12 mm diameter was observed. The patient is operated. The tumor is removed widely, together with the adjacent uninvolved tissues about 2 cm. Abdominal wall layers were closed conveniently. In the pathological evaluation, it was observed that the fibroblasts had destructed and atrophied the muscle fibrillae. Any postoperative complication or local recurrence was not seen in the long-term follow-up (108 months). Conclusion: The first line therapy is radical surgical resection in desmoid tumors which are seen rarely, particularly in childbearing women and have local invasive characteristics. Local recurrence does not usually occur in tumors which are resected with sufficient surgical margins.

Intestinal ischaemia associated with carcinoid tumor: A case report with review of the pathogenesis

Oktay Yener, G�khan Demiral, Fikret Aksoy, Canan Ereng�l, Niyazi �lgen — 2010-03-01

Background: Carcinoid tumors are rare, slow-growing neuroendocrine neoplasms that often are indolent and may not become clinically apparent until there has been metastatic spread or evidence of carcinoid syndrome. Case report: A 44-year old man who presented to our clinic with chronic crampy left lower quadrant pain, mass and severe anemia had a history of previous cancer operation from the left colon. The MR scan demonstrated a calcified mesenteric mass sized 12*8*10 cm, with surrounding left colon mesenteric infiltration. The liver was normal. A case of ischaemic ileal necrosis associated with elastic vascular sclerosing substances secreted by mesenteric metastases of an ileal carcinoid tumor is presented here. Conclusion: It is postulated that intestinal ischaemia may be of more importance in the development of abdominal pain in carcinoid tumors than that has generally been accepted, and that it is a result of the functional and structural changes in the mesenteric blood vessels, caused by substances secreted by the carcinoid tumor.

Chest tube insertion

Makbule Ergin, Ali Ye�insu, K�r�at G�rlek — 2010-03-01

Closed chest drainage has been performed since 1800s and has arrived to date by keeping its importance, without too much change in its principals. Chest drainage systems provide one way evacuation of free air and/or fluid accumulated in the pleural cavity due to various aetiologies. Tube thoracostomy is simple but life saving procedure in states of emergency. In the proper indication, it provides a dramatical attenuation in the acute symptoms of illness. Tube thoracostomy provides a safe and effective drainage when performed according to the proper surgical principals. On the other hand, lethal complications may occur during and after tube thoracostomy. Therefore, a thorough knowledge regarding the indications, technical principals, and management of tube thoracostomy would be helpful for understanding the basic applications that prevent complications a priori.

Colon carcinoma metastasis mimicking the simple cyst of the liver

Burhan �zdil, Can Ke�e, M�ge Ustao�lu — 2010-03-01