Turkish Journal of Surgery - 2005; 21(2)

ED�T�RLER KURULUNDAN...

2005-11-01

Synthetic mesh grafts and their specifications in hernia repair

Erc�ment Kuterdem — 2005-11-01

Effect of selective gut decontamination on peritoneal fibrinolytic activity in rats

�zer �lkg�l, Yama� Erhan, Hasan Aydede, Ahmet Var, Ece Onur — 2005-11-01

Purpose: Our goal with this experiment was to determine the influence of selective decontamination of the digestive tract (SDD) on peritoneal fibrinolytic activity in rats. Materials and Methods: Animals were divided into five groups. Group 1 was subjected to SDDtreated peritoneal adhesion. Group 2 was subjected only to perioneal adhesion. Group 3 was SDD-treated, whereas Group 4 was labeled as the control group. Group 5 was subjected to simple laparotomy. The rats in Group 1 and Group 3 were given SDD (tobramycin 20 mg/l and polymyxin E 25 mg/l) by gavage twice daily for 3 days preceding surgical operation. Control groups were fed orally with standard chow. After a 72-hour waiting period following the operation, biopsies of undamaged parietal peritoneum were obtained from the fibrinolytic parameters in order to measure tissue-type plasminogen activator (tPA) and plasminogen activator inhibitor type-1 (PAI-1). Results: Average tPA levels were low in both the sdd-treated group and the sdd+adhesion model group, however no statistical significance was elicited. PAI-1 levels were higher in sddtreated groups than in other groups, but no significantly meaningful difference was obtained. Conclusion: These results suggest that pretreatment with sdd reduces the peritoneal fibrinolytic activity and might also enhance the peritoneal adhesion formation in rats.

The effect of the PAF receptor antagonist gingko biloba EGB 761 on local ischemia reperfusion injury of healing colonic anastomoses

2005-11-01

Purpose: To show the negative effects of intestinal ischemia and reperfusion over anastomic healing and to prevent the harmful effect of pathological mechanisms, caused by mediators, through treatment with Gingko Biloba EGB 761, a platelet activating factor (PAF) antagonist. Material and Methods: 39 Wistar-Albino rats were divided into three groups of 13; sham, control (ischemia and reperfusion) and study (ischemia-reperfusion+EGB 761) groups. The rats in the sham group were subjected to descending colon transection and end-to-end anastomosis after a midline laparotomy. In the contol group rats (ischemia and reperfusion), an ischemia was created by clipping SMA with atraumatic clips, following midline laparotomy. Subsequently, anastomosis was done by descending colon transection, and reperfusion was restored at 30 minutes by removal of the clips. The rats in the study group received two equal parts of 60 mg/kg/day Gingko Biloba EGB 761 per oral b.i.d. starting three days before the operation, and ending on the 7th postoperative day. All rats were sacrificed on the 7th postoperative day and the colonic segments including the anastomotic area were resected and samplificated for measurements of bursting pressure and hydroxyproline levels. Results: Anastomosis bursting pressures and hydroxyproline levels were found to be significantly lower in the control group (ischemia-reperfusion) compared to sham and study groups (ischemia-reperfusion+ Gingko Biloba EGB 761). No statistically significant difference was determined between sham and study groups in terms of these parameters. Conclusion: The bursting pressure and hydroxyproline values in sham group are significantly decreased by ischemia-reperfusion and this decrement can be prevented by EGB 761.

Comparison of routine laparotomy and selective management in the treatment of stab wounds penetrating the peritoneum

2005-11-01

Purpose: Generally, laparotomy has been the routine practice to diagnose and treat patients with stab wounds that penetrate the peritoneum. Due to high rate of negative laparotomies however, the last two decades gave rise to the selective management of the abdominal trauma among clinicians who work in trauma centers. Although less intrusive than laparotomy, selective management is still a controversial method, because when and under what circumstances operation shall be required are not yet settled questions. With this retrospective study, we aimed to compare the two methods and find out whether unnecessary laparotomies can be prevented with the selective management of abdominal trauma. We also investigated the emergency laparotomy indications in this group. Materials and Methods: Patients admitted to the emergency department and had undergone routine laparotomy upon diagnosis of penetrating abdominal stab wounds between January 1995 and December 2000, were compared to patients who were subjected to the selective approach upon same diagnosis between January 2001-January 2004. The comparison of the two groups was based on the following factors: age, gender, duration of hospitalisation, physical examination of findings, diagnostic tests, organ injured, surgical technique, and the incidence of unnecessary laparotomy. The morbidity and mortality rates of both approaches were also evaluated. Results: A total of 74 patients were enrolled in the study. Thirty three patients underwent routine laparotomy, whereas 41 patients were managed with selective approach. While the number of negative laparotomies was 30% (10 out of 33) in the laparotomy group, it was only 14% (6 out of 41) in the selective group. Seventeen out of 41 patients in the selective group underwent emergency laparotomy. The remaining 24 were managed conservatively. The emergency laparotomies were regarded as negative in 3 patients and nontherapeutic in 2 (p<0.05). Four patients ended up with delayed laparotomies and all were regarded as therapeutic. In the selective approach group, our findings indicated that 3 patients with peritoneal irritation, one with the evisceration of omentum from the wound, and one with DPL positively underwent unnecessary laparotomies. Conclusion: By selective management of patients with penetrating abdominal stab wounds, the number of unnecessary laparotomies can be diminished. Among selective management patients, whether peritoneal irritation findings, the positive DPL, and evisceration of omentum from the wound still require laparotomy shall be scrutinized. Further prospective tests are needed in patients with stable hemodynamics to determine whether the conservative technique should be opted for.

Results of 21 patients with pancreatic necrosis and/or abscess treated by continous closed lesser sac or site lavage

Mustafa Tireli — 2005-11-01

Purpose: The aim of this study was to evaluate the results of necrosectomy and continuous closed lavage of the lesser sac or site in the treatment of pancreatic necrosis and/or abscess. Background: Despite in its improvement in diagnosis and treatment, acute necrotizing pancreatitis is still associated with a high incidence of mortality and morbidity. The management of sterile necrosis is still controversial. Criteria for surgical intervention in sterile necrosis and choice of technique in debridement of necrosis (conventional passive drainage, continuous lavage of the lesser sac or open abdomen) are still matters of debate. Materials and Methods: Between February 1991 and August 2003, 21 patients with necrotizing pancreatitis were treated with necrosectomy followed by continuous closed lesser sac or site lavage. Results: Among our patients, 11 had infected necrosis and 6 had sterile necrosis. Additionally, two patients had infected necrosis and abscess, and two had pancreatic abscesses. Eight cases of acute attack were managed at another clinic however, upon development of large necrosis or abscesses, these patients were subsequently transferred to our clinic. 13 patients were treated at our clinic right from the start. Reasons for surgery in 21 patients were as follows: absence of definite diagnosis (4), pancreatic abscesses (4), infected necrosis (4), persistence or advancement of organ complication despite intensive therapy (3), presentation of sepsis signs (3), organized necrosis (2) and symptomatic pseudocyst (1). Six patients (28.6 %) were documented with serious organ-system dysfunction. Three patients (14.3 %) died and among those who lived nine patients developed serious complications. The hospitalization period for patients who survived averaged between 10-65 days. (Mean: 34.0). Conclusion: Infected pancreatic necrosis and/or abscess can be treated surgically; but management of sterile necrosis is still controversial. Conservative strategies can be applied succesfully to manage most patients with sterile necrosis. Necrosectomy supplemented by postoperative closed continuous lavage of the site not only offers debridement of devitalized tissue, but also prevents development of new necrosis through nonsurgical removal of necrotic tissue and biologically active and bacterial compounds.

Evaluation of risk factors on wound infection and mortality in general surgery patients

2005-11-01

Purpose: The aim of this study was to evaluate the risk factors in wound infection and mortality. Background: Wound infection is the most common complication of general surgery patients (2-12%). Mortality rate is an important factor in assessing a clinic's success, but data interpretation should be based on evaluation of certain criteria. Materials and Methods: Between September 2002 and October 2003, the following data collected from 2174 of patients admitted to our clinic was recorded: demographic features, hospitalisation indications, associated diseases, ASA scores, type of operation, hospital stay, intensive care unit stay and rates of wound infection and mortality. Results: Of these patients, 42.5% were men and 57. 5% were women. Median age was 50 (14-92). Two hundred and five (9.4%) patients were hospitalised for observation, medical treatment or investigation and 1969 of them (90.6%) were operated. Wound infection rate was noted as 3.9% (n=77) among all operated patients. All evaluated parameters, except for age (p=0,635) and presence of associated diseases (p=0.631), have been found to be significantly influential in wound infection. For all the related factors, logistic regression analysis was done and only the indication of hospitalisation (p<0.0001) and the lenght of hospital stay (p<0.0001) were found to be statistically significant. Mortality rates were 1.2% and 1.4% respectively for all hospitalised patients and operated patients. All evaluated parameters but gender (p=0.322) and preoperative hospital stay (p=0.103) were found to be statistically significant. Logistic regression analysis was done for all these related parameters and only the intensive care unit stay was determined as a significant factor relating to mortality (p<0.0001). Conclusion: In conclusion, causes of wound infection and mortality are multifactorial, and detailed scoring systems are necessary for prediction of wound infection and mortality rate.

Suction drain usage in treatment of pilonidal sinus disease

Erdem Nalbant, �rfan Ba�p�nar, G�ltekin Erdo�an, S. Erpulat �zi� — 2005-11-01

Purpose: We aimed to evaluate the efficacy of suction drains in total excision and primary closure as treatment of pilonidal sinus disease. For this purpose we designed a clinical prospective study. Materials and Methods: Between September 2004 and February 2005, 64 patients were operated for pilonidal sinus disease by total excision and primary closure under spinal anesthesia. Patients were divided into two groups: In group I (28 patients) suction drains were used, whereas in group II (36patients) no drains were used. Both groups were compared for complication rate, timeline for suture removal and return to normal daily activities. Results: All patients were male and mean age was 22.2 (20-27). The mean age and body mass indices were similar in group I and II. The complication rate was 3.5 % (1 patient) in group I and 5.8 % (2 patients) in group II. The difference between the complication rates was not statistically significant (p=0.712). There was no difference between the duration of operation, time of suture removal and returning to normal daily activities in both groups. Conclusion: Total excision and primary closure is one of the most popular operative techniques of surgical treatment for pilonidal sinus disease. Suction drain usage in this method does not decrease hematoma, seroma and surgical site infection; nor does it affect the time period to return to normal daily activities.

Hemodynamic and metabolic effects of nitrous oxide and carbon dioxide insufflation in laparoscopic repair of inguinal hernias

Fahrettin Acar, Dr. Faruk Aksoy, Metin Belviranl�, Sema Tuncer — 2005-11-01

Purpose: The aim of this study is to compare hemodynamic and metabolic effects of CO2 and N2O insufflation into extraperitoneal area. Background: In treatment of inguinal hernia, a laparoscopic technique is widely applied to total extraperitoneal hernia (TEP) in some clinics. Due to the fact that CO2 used in the extraperitoneal area contains higher hypercarbia and acidosis compared to N2O, this leads to search for alternative gas in this area. Materials and Methods: Between September 2003 and July 2004, 24 male patients who underwent one-sided inguinal hernia operation with TEP under general standard anaesthesia, have participated in this study. We used CO2 for insufflation in 12 patients (mean age; 42�18 years) and N2O in 12 patients (mean age; 46�16 years). Prolen greft was used in both groups during repair and, throughout the operation, hemodynamic and metabolic parameters were recorded at 0, 5, 15, 30, and 45th minutes. Results: Parameters obtained from these two groups such as heart rate (HR), partial CO2 pressure (PaCO2), end-tidal CO2 pressure (PETCO2), mean arterial pressure (MAP), and total gas amount insuffleted during operation were found to be significantly higher in the CO2 group than in the N2O group (p<0,001). In contrast; pH, O2 saturation (SpO2), and partial O2 pressure (PaO2) were determined as lower in CO2 group than in N2O group throughout the operation (p<0,001). Furthermore, visual pain score (VPS) was significantly lower in N2O group. Between the two groups, no major difference was observed in terms of endtidal N2O pressure (PETN2O). Conclusion: In the laparoscopic interventions, N2O insufflation to the extraperitoneal area does not lead to the hemodynamic and metabolic changes, whereas CO2 insufflation has detrimental effect on hemodynamic levels by causing hypercarbia and acidosis. Moreover, in the postoperation period, VPS was lower in members of the N2O insufflated group than those in the CO2 insufflated group. Consequently, in the laparoscopic surgery, during extraperitoneal inguinal hernia repairment, N2O gas has more advantage than CO2 gas.

Bilateral vocal cord paralysis developed following hemithyroidectomy in a patient with chronic inflammatory demyelinizing polyneuropathy

Serpil Bilgin Akya�c�, T�rkay K�rdak, Nusret Korun — 2005-11-01

Purpose: Nodular thyroid disease is a common pathology in adult population and most of the patients may have coexistent diseases. Chronic inflammatory demyelinizing polineuropathy (CIDP) can be one of these diseases characterized with demyelinization and remyelinization of the peripheral nerves. Symptoms occur depending on the nerve involved. The disease may rarely involve the recurrent laryngeal nerve (RLN) and cause symptomatic or subclinical vocal cord paralysis. Results: A 47 year-old, female patient with CIDP has developed a nodule, 4 cm in diameter, in the right lobe, causing symptoms of pressure. The patient underwent right hemithyroidectomy. During the operation right RLN was identified and preserved, left lobe was palpated over the strap muscles as it was normal. Frozen section was reported as benign. The operation was completed without left side exploration. Three hours after the operation, difficulty in breathing developed and vocal cord examination indicated complete paralysis on the left and incomplete paralysis on the right side. Tracheatomy was performed. This patient hasn't had a vocal cord examination as she had no neck surgery before, but demyelinizing neurological diseases can cause vocal cord paralysis by involving RLN. We thought that left side vocal cord paralysis was not the result of the operation, but from her coexistent demyelinising disease. Conclusion: We concluded that in these cases, preoperative vocal cord examination can be helpful in estimating and reducing postoperative complications.

Alternating concepts in preoperative fasting

Eren Ersoy, Haldun G�ndo�du — 2005-11-01

Elective surgery is performed on approximately 5% of the population in developed countries. The operation is usually performed in the overnight fasted state, called ''Nil Per Os''. However this fasting causes both physical and metabolic stress like dehydration, anxiety and particularly insulin resistance. Postoperative insulin resistance causes hyperglicemia and defects on wound healing which results as a longer hospitalization period. This increases both morbidity and cost. In order to prevent the postoperative insulin resistance, researches are focused on alternative regimens instead of Nil Per Os application. Although feeding before general anesthesia increases the risk of aspiration, recent studies showed that especially clear liquids can safely be allowed 2 hours prior to surgery. On the other hand clear liquids do not prevent the metabolic effects of fasting. These studies include the development of a carbohydrate rich drink which has been tested and showed to be safe in the preoperative situation. By means of this liquid preoperative insulin resistance, dehydration, anxiety and hospitalization period are decreased and the well being state of the patient is increased significantly. Regarding to recent changes set in many countries, we should revise our own preoperative fasting regimens for more beneficial strategies.

Ord. Prof. Dr. A. Burhaneddin Toker: T�rk Cerrahisine Katk�lar�*

Ertu�rul G�ksoy — 2005-11-01

Ord. Prof. Dr. Ahmet Burhaneddin Toker, who has been one of the former directors of the Department of General Surgery, Cerrahpasa Medical School, Istanbul University, made great efforts and contributions to the Hospital of Cerrahpasa for 30 years, before and after this latter became a "University Clinic". Therefore he became a personality who leaded the progresses and reforms, in not only Cerrahpa�a but also the whole remaining family of Turkish Surgery. He performed the first distal and total gastrectomy in 1928 and 1950 respectively and was also amongst the pioneers of the traumatology in Turkey. He first published Turkish Journal of Surgery and was an active member in the foundation of Turkish Surgical Society. He also had the first "Certificate for the Specialization in Surgery" in 1928, after passing the exam. Ord. Prof. Dr. Toker was born in 1890 at Van and graduated from the Istanbul Medical School in 1910. He went to Germany in 1913 to make his residency in surgery and has worked in Hamburg for six years as a staff resident He returned back to his home country in 1921. Thereafter, being the operator and the clinical director of the Department of Surgery, he transformed his clinic into a modern and nationwide popular one. Subsequent to the "University Reform", the world famous German surgeon Ord. Prof. Dr. Rudolf Nissen has been assigned as the "Director of the 1st Surgery Clinic" in August 1, 1933, and the clinic was moved from Haydarpa�a to Cerrahpa�a. Dr.Burhaneddin Toker was first assigned to the staff of Dr. Nissen as an associate professor; five months later he became professor. Nissen went to U.S.A. because of his sickness and Dr. Toker became the director by proxy in 1939 and subsequent to definitive departure of Nissen, the new director of 1st Surgery Clinic at Medical School. He had the degree of "Ordinarius Professor" in 1943 and leaded the formation of new traumatology, cardiovascular surgery, neurosurgery and anesthesia departments. He died in August 20, 1951.