Turkish Journal of Surgery - 2002; 18(2)

CORRELATION OF PROLIFERATIVE ACTIVITY AND MICROVESSEL DENSITY OF THE TUMOUR WITH STANDARD PROGNOSTIC MARKERS IN INVASIVE BREAST CARCINOMA

2002-06-01

Observation of significant dissemination and recurrence rate even in breast cancer patients evaluated as low risk according to standard prognostic markers suggests influence of other factors effective on clinical course and overall prognosis. Therefore it is emphasized importance of tumour's proliferative activity and metastatic ability in addition to classical parameters. In this study we aimed to analyze correlation of tumour's proliferative activity and microvessel density with standard prognostic markers in patients with invasive breast cancer. Classical parameters as age, size and histologic grade of the tumour, and axilla nodal status were determined in 17 surgically treated patients with stage I and IIA invasive breast carcinoma. Proliferative activity (DNA ploidy and S phase fraction) of the tumours was measured by flow cytometry. Tumour's microvessel density (angiogenesis) was also determined as a marker of metastatic ability. We found T2tumours in 12 (71 %), grade 2 and 3 tumours in 12 (71%), and axilla node positive status in 9 (53%) patients. Angiogenesis levels were significantly higher (p<0.05) in larger (T2) tumours. S phase fraction (p<0.05) and angiogenesis (p<0.05) were significantly increased in patients with axillary metastasis (node positive). Higher S phase fraction levels were found in aneuploid tumours. High S phase and angiogenesis levels, and aneuploidy was observed respectively in 25%, 38%, and 38% of axillary node negative patients. Tumours with high proliferative activity and metastatic ability may exist even in patients with no axillary involvement. Tumour's DNA ploidy and S phase fraction by flow cytometry, and tumour's microvessel density (angiogenesis) are useful markers to evaluate true risk, overall prognosis, and to plan adjuvant treatment in patients which was evaluated as low risk according to standard prognostic markers.

THE EFFECTS OF TOPICAL HYPOTHERMIA, METHYLPREDNISOLONE AND BN 52021 ON HEPATIC ISCHEMIA/REPERFUSION INJURY

2002-06-01

This study was undertaken to investigate the effectiveness of topical hypothermia, methylprednisolone and BN 52021 on ischemia/reperfusion induced liver injury. The liver is one of the organs most vulnerable to ischemia because of its high metabolic state. Occlusion of the portal triad is often required in complex hepatic surgery in order to decrease parenchymal bleeding. Liver failure due to ischemia-reperfusion injury is a serious problem during liver surgery. Fifty male Sprague-Dawley rats (200-225 gr)were divided into 5 groups each containing 10 rats. Midline laparatomy was fulfilled on all the rats under ketamine anesthesia. In group 1 (Sham), the hepatoduodenal ligament was dissected without any drug administration. In group 2 (I/R), the ischemia (for 45 min)/ reperfusion (for 45 min) was performed and received no further treatment. In group 3 (Hypothermia), the ischemia plus topical cooling (for45 min) and reperfusion (for 45 min) was fulfilled. In the group 4 (Steroid), the I/R was performed and methylprednisolone (30 mg/kg) was administered. In group 5 (BN 52021), the I/R was performed and BN 52021 (100 mg/kg) was given before ischemia. Liver, ileum and blood samples (for MDA, ALT, AST, LDH and ileal mucosal injury score)were obtained. The levels of ALT, AST, LDH,MDA (ileal, hepatic) and ileal injury score in group I/R were significantly higher than those of group sham(p<0.0001).When group I/R was compared with group hipothermia, there were no significant differences with regard to AST, ileal MDA and ileal injury score(p>0.05), whereas levels of ALT, LDH and hepatic MDA were significantly higher (p<0.0001,0.0001 <0.000 1, respectively). When group I/R was compared with group steroid and group BN 52021, it was determined that those agents had significant protective effects on hepatic and ileal injuries (p<0.0001).It was determined that topical hypothermia decreased hepatic I/R injury, however had no protective effect on ileal injury. We determined that Methylprednisolone and BN 52021 decreased both hepatic I/R and ileal injury due to splanchnic congestion.

THE EFFECTS OF PROPHYLACTIC ANTIBIOTICS ON THE BACTERIAL TRANSLOCATION DUE TO PRINGLE MANEUVER

SADULLAH G�RG�N, MUSTAFA ALDEM�R, �BRAH�M TA�YILDIZ, M FARUK GEY�K, B�LSEL BA� — 2002-06-01

This study was undertaken to investigate the effectiveness of prophylactic antibiotics (Cefotaxime and Ceftazidime) on the bacterial translocation related to PM in rats. Bacterial translocation may occur in humans and is associated with an increased incidence of septic morbidity. It has been consistently demonstrated in a number of experimental models,including burns,trauma,shock, and surgery. It has been previously determined that the PM causes bacterial translocation. The prophylactic antibiotics may reduce this translocation. Thirty male Sprague-Dawley rats weighed in at 250-300 gr were divided into 3 groups each were containing l0 rats. After being anaesthetized by intramuscularly injection of Ketamine, midline laparotomy was performed to all rats under sterile conditions. In group 1 (Control), the hepatoduodenal ligament was clamped for 40 min. In group 2 (Cefotaxime),following intramuscularly application of Cefotaxime (30 mg/kg) 30 minutes before the surgical procedures, the PM was performed for 40 min. In group 3 (Ceftazidime), Ceftazidime (30 mg/kg) was applied instead of Cefotaxime before the PM. 1ml of blood sample was obtained from the portal vein for blood culture. The MLN biopsy and splenectomy were performed for culture. The positive bacterial cultures, obtained from MLN, spleen and blood, were determined most frequently in group 1. It was found that the positive cultures of group 1 (56.7%) were significantly higher than those of group 2 (6.7%) and group 3 (6.7%) (p=0.006,p=0006,p=0,001,respectively). Microorgonisms, obtained from MLN and spleen,were E.coli, C.pneumonia, Mikst, Candida and E.fecalis (respectively, 61.9%, 14.3%, 9.5%, 9.5%, 4.8%). In both cultures of MLN and spleen, the CFU of the group 1 was significantly higher than CFU of group 2 and 3(p=0.001, p=0.003). In our study, we determined that PM significantly increased bacterial translocation in MLNs, spleen and blood, and prophylactic application of Cefotaxime and Ceftazidime had preventive effect on this translocation.

THE EFFECT OF LOW DOSES LIPOPOLYSACCHARIDE PRETREATMENT IN THE PREVENTION OF BACTERIAL TRANSLOCATION IN ACUTE NECROTIZING PANCREATITIS

2002-06-01

This study was aimed to examine whether low dose LPS could affect bacterial translocation (BT) in acute pancreatitis (AP). Rats were divided into three groups, LPS, control and sham groups. AP was induced in LPS and control groups by pressure injection of 5% taurocholate into the biliopancreatic duct (1.5mL/kg). LPS rats received LPS (50 mg/kg, intraperitoneally); control and sham rats received a similar volume of normal saline as placebo 24 hours before the induction of pancreatitis. At 24 hours postoperatively, blood was drawn from periphery and portal ven for culture, serum AST, ALT, LDH, amylase, endotoxin and TNF-alpha (TNF-alpha) determinations Specimens from MLNs, spleen, liver and cecum were harvested for culture. There was no difference in serum AST, ALT, LDH and amylase levels and the mean pancreatic histology score between LPS and control (p>0.05), respectively. All these parameters were significantly higher in the LPS and control groups compared with sham group (p<0.01). Serum TNF-alpha and endotoxin level were higher in control and LPS groups compared with sham group (p<0.01) and were lower in the LPS group compared with control group (p<0.01 ). Two of 7 LPS rats had BT to MLNs, compared with 6 of 7 rats in control. Four of 7 LPS rats had BT to distant sites such as spleen ,liver, and/or blood, compared with 7 of 7 rats in control. Low dose LPS treatment decreases bacterial spread to distant sites increases serum TNF-alpha and endotoxin levels but does not reduce serum amylase, AST, ALT, LDH levels or ameliorate pancreatic damage in rats with AP.

THE COMPARISON OF ANTERIOR AND PREPERITONEAL MESH REPAIR IN HIGH RISK INGUINAL HERNIAS

CELAL SA�LAM, G�KHAN ADA�, KEMAL DOLAY, G�RSEL SOYB�R, SEFA T�Z�N — 2002-06-01

In recent years the synthetic mesh prothesis are commonly used in the treatment of inguinal hernia. There is still a debate about anterior and posterior application of the prothesis. Between 1997-2000, 116 patients with inguinal hernias were prospectively evaluated. 57 patients were treated by means of preperitoneal approach in first group, and 59 patients were treated via anterior approach of mesh placement in second group. Groups were compared with Fisher's exact X2 test in respect of the localization, bilaterality and type of hernia, smoking habits of the patients, previous opererations, type of anesthesia, drainage, wound infection and recurrence. Student's t test was used to evaluate age, weight, duration of operation and analgezia, volume of drainage, cost effect, hospital stay and follow up period of the groups. There was statistically no difference between the groups for hospital stay and volume of the drainage (p>0.05). On the other hand there was a meaningful difference between the groups regarding the duration of the operation, hospitalization and cost effect (p<0.001). There was no difference regarding the recurrences encountered in 3 patients in the 1st group and 2 patients in the second group treated by anterior mesh placement. There was also no superiority one over the other group for recurrence rates. Anterior approach was found to be superior to preperitoneal approach regarding the duration of hospital stay, drainage, analgezia and cost effectivity.

THE PROGNOSTIC IMPORTANCE OF APACHE III SYSTEM IN THE SURGICAL INTENSIVE CARE UNIT

H�SEY�N BO�A, SUAV� �ZKAN, ALPER AKINO�LU, HALUK DEM�RY�REK — 2002-06-01

With this prospective study, we aim to determine whether scoring on the APACHE III score can predict the development of mortality in critically ill surgical patients. Many prognostic systems were used for this way. In these systems, the effects of the type and severity of the disease, physiological status and age of the patients, responses to the therapy were evaluated and tried to estimate the prognosis of the patients. APACHE III prognostic scoring system is one of these systems developed for the same is effective in predicting the mortality rates. During a one-year period, 150 patients were evaluated prospectively with APACHE III at surgical intensive care unit at university of �ukurova. Student t test and chi square test were used in evaluating the relations between APACHE III score and age of the patients, duration of hospital stay and the rate of morbidity and mortality. The statistical significance was found between the increased APACHE III scores and the rate of the mortality (P<0.05). The mean age of the survivors were 49 � 17.9 year-old and 60 � 13.8 year-old for non- survivors. The mean APACHE III scores was 31.5 � 15.8year-old for survivors,.56.2 � 16year-old for non-survivors. For both survivors and non-survivors ,the statistical significance was found with increased age. Our hospital is the single of tertiary reference hospital around its region, therefore all of the critically ill patients were referred to this hospital. All of the mortal patients were sent postoperatively, in spite of the insufficient number of the nurses and supplementary personel was seen to effect the increased rate of the mortality. It was concluded that APACHE III scoring system can be used for prediction of the severity of the diseases and standartization of clinical researchs in surgical care unit. It was accepted that the coordinance and multidisciplinary approach of the doctors ,nurses and supplementary personel in the intensive care unit is the most important factor of the prognosis of the patients.

JURIDICAL REPORTS AND SURGEONS

AL� RIZA T�MER, � HAM�T HANCI — 2002-06-01

Result of a survey which were analyzied the knowledge of the surgeons about the forensic medical certificates on the loss of professional working capacity, severity of harm, possible threat for survival, temporary or permenant reports were discussed and typical errors were described in this article.

OUR CLINICAL EXPERIENCE OF PYLONIDAL SINUS TREATED WITH PRIMARY PARTIAL CLOSURE AND COMPARISON WITH LITERATURE

2002-06-01

It can be said pylonidal sinus is still an unsolved problem because there are still discussions about it's ethology and many different therapeutic apporaches are applied. We made a retrospective study of 90 patients in Dr.L�tfi K�rdar Kartal Research Hospital First General Surgery Clinic between 1.1.1997.- 1 .2000. These 90 patients had pylonidal sinus and primary partial closure was applied to all of them. Demographic properties of the patients, operation technique, hospitalization, wound healing, time away from work, hospital costs, complications and recurrence rates are evaluated and compared with other literature. 3 of the patients(0.3%) have been operated with the same reason while others were simple cases. 17(18%) of the cases were female and 73 (81%) were male. Mean age of the patients was 26.39 � 6.56. Length of operation time was 17.10 � 4.79 minutes. Hospitalization was 3.98 � l.48 days. Wound healing took 28.80 � 4.79 days. 3 of the patients had wound infection and were treated. The bleeding of l patient because of a hemorrhage was controlled under local anesthesia at postoperature period. Hospitalization cost was 300.67 � 74.33 US $. Our patients returned back to their jobs in about 22.56 � 5.32 days. We have not seen any recurrences in our series. As a result primary partial closure had short operation time, minimal complications and low recurrence rate in pylonidal sinus treatment. That's why we think that primary partial closure is a preferrable technique.

THE SPECTRUM OF GENERAL SURGERY IN A RURAL HOSPITAL

SUAV� �ZKAN, FULYA CAN �ZKAN — 2002-06-01

The spectrum of surgical practice seen in rural areas are pertinent because our literature is replete with articles concerning the need for general surgeons in these regions. With this respect, we aim to define the types of surgery performed by rural surgeons with its morbidity and mortality rates, and to compare our surgical experience with our surgical residency program in this study. Nine hundred and ninety four patients undergone surgical procedures by two surgeons in a rural community hospital were retrospectively reviewed from September 1997 through September 2000 and compared with the surgical residency program in the University of �ukurova, General Surgery Department. The morbidity and mortality rates were alse detected. Patients undergone surgery in rural hospital with populations fewer than l00.000. There were only one postoperative death. Overall morbidity was 4%. Case types were as follows: hernioraphy 347 (34.8%); coloproctology (including haemorroidectomy, fistulectomy, lateral internal sphincterotomy etc.) 394 (39.5%); hepatobiliary 65 (6.5%); pediatric surgery 69 (6.9%); gynecology 45 (4.5%) and urology 13(1.2%). During residency program, any pediatric surgery and only one gynecologic surgery were performed by the same authors. We concluded that a large volume of surgery was performed with low morbidity and mortality rates and low costs in the rural hospital. The operative experience of surgical residents was differed from rural surgeons. We recommend a selected surgical track in selected training programs to prepare graduates better for rural practice. Senior level rotations for orthopedic, gynecologic and pediatric surgery and mentorship with rural surgeons would be optimal.