Turkish Journal of Surgery - 2003; 19(2)

THE EFFECTS OF LEVOFLOXACIN AND INTRAVENOUS IMMUNOGLOBULINS ON SEPSIS DUE TO STREPTOCOCCUS PNEUMONIAE IN SPLENECTOMIZED RATS

2003-04-01

This experimental study was conducted to investigate the effects of levofloxacin and intravenous immunoglobulins (IVIG) on sepsis due to Streptococcus pneumonia in splenectomized rats. Splenectomy impairs the immune response to bacterial infections. Postsplenectomy sepsis is a serious complication that can result in fulminant bacteriemia and even death. Sixty infant Sprague-Dawley rats were randomized into 5 groups containing 12 rats each. All rats were initially anaesthetized by intramuscularly injection of Ketamine (5 mg/kg). In the group 1, after the abdomen was opened, spleen was mobilized. In the other groups, splenectomy was performed. All of this animals (in the groups 2-5) were inoculated with Streptococcus pneumonia seven days after splenectomy. Fifteen hours after inoculation, blood (0.1 cc) was obtained for bacterial counts (cfu) and immediately drug therapy was given. The saline solution, levofloxacin, IVIG, levofloxacin plus IVIG were given in group 2-5 rats respectively. Twenty-four, 48 and 72 hours after initial therapy, blood samples were obtained from all rats for bacterial counts and biochemical examination (Ig G,A,M) and during 72^nd hours rats were sacrificed. After inoculation in the groups 2-5 rats positive cultures were obtained. During 48^th and 72^nd hours, positive cultures (41.7% and 25%) of rats in groups 3 were significantly lower than (100% and 100%) those of group 2 (p<0.05 and p=0.001, respectively). Positive culture ratio (41.7%) in the group 4 was significantly lower than (100%) that of group 2 (p<0.05). During 24^th , 48^th and 72^nd hours, positive cultures (41.7%, 16.7% and 0%) in the group 5 were significantly lower than those of group 2 (p<0.05, p<0.001 and p<0.001). During 24^th , 48^th and 72^nd hours, bacterial counts in the groups 3-5 were significantly lower than those of group 2 (p<0.001). The IgG levels of groups 4 and 5 were significantly higher than those of groups 2 and 3 (p<0.001). The present experimental study has demonstrated that levofloxacin and IVIG, both alone and combine, are useful on sepsis due to 5. pneumonia in splenectomized rats.

ANERGY IN PATIENTS WITH OBSTRUCTIVE JAUNDICE

Dr. Hakan H. AVCI, Dr. Mehmet Altan KAYA, Dr. S�leyman BOZKURT, Dr. Faik �EL�K — 2003-04-01

Background: Surgery in patients with obstructive jaundice carries high risk with its severe morbidity and mortality. Anergy described as impairment in delayed cell mediated immune response carries high complication and sepsis rate, and mortality risk in surgical patients. The relationship of anergy and obstructive jaundice is assessed in a prospective nonrandomized study. Method: Between September 1997- 1999 Multitest technique is used in 57 patients. Antigens are injected in the volar face of forearm and results assessed 48 hours later. Patients are grouped as immunocompetant, relatively anergic and anergic. Results: Preoperatively two patients were relatively anergic in the control group. In the study group 14 patients were relatively anergic and 18 were anergic. In the postoperative assessment 12 patients were immunocompetant, 8 were relatively anergic and 12 were anergic. Conclusion: Being aged, malignancy, sepsis, protein- energy malnutrition, trauma and surgical operations are factors supressing the delayed cell mediated immunity. Patients whom anergic preoperatively and remaining anergic postoperatively has worse prognosis, complications and mortality, in comparison to patients whom anergy is better.

PANCREATICODUODENECTOMY FOR PANCREATIC CARCINOMA

2003-04-01

This study was designed to evaluate the current results of standard pancreaticoduodenectomy (SPD) and its main modifications including pylorus-preserving pancreaticoduodenectomy (PPPD) and extended pancreaticoduodenectomy (EPD) with resection of portal vein (PV) or superior mesenteric vein (SMV) for pancreatic carcinoma. Pancreatic carcinoma has been rated fifth in cancer related deaths in western countries. Despite dismal prognosis, the only chance for cure is resection by pancreaticoduodenectomy or Whipple's procedure. During the period from 1995 to 2002, a total of 36 patients with histologically proven pancreatic adenocarcinoma were managed and outcomes were analysed for operative parameters, morbidity, mortality and survival rates. Of patients with pancreatic carcinoma, 22 were male and 14 were female with a mean age of 51 (range, 38-69) years. Tumor was located in the head of the pancreas in 29 patients (81 %) and 7 (19%) in the region of the body and tail of pancreas. The surgical procedure involved SPD in 20 patients (56%), PPPD in 9 (21%) and EPD in 7 (19%). The median operative time was 5.9 hours and median intraoperative blood loss was 680 ml. When 5 deaths occurred within 30 days of operation (14% operative mortality), the most common complications were wound infection in 9 patients (25%), pancreatic fistula in 5 (14%) and delayed gastric emptying in 4 (11%). The median survival for the entire series was 18.4 months, with actuarial 1. and 2. year rates of 88% and 54%, respectively. On the other hand, when patients receiving SPD was compared to those receiving PPPD, no significant difference in survival rates was observed (p>0.05). However, median survival in patients who underwent EPD was significantly worse (p<0.05). Prognosis of pancreatic carcinoma remains poor. Surgical resection including pancreaticoduodenectomy and its other technical modifications offer the only curative chance for patients with pancreatic carcinoma. EPD can also be performed with similar morbidity and mortality rates, but without apparent survival benefits in long term.

RESECTIVE SURGICAL APPROACH TO CASES WITH HILAR CHOLANGIOCARCINOMA (RESULTS OF 8 CASES)

2003-04-01

We aim to present the results of 8 patients with Klatskin tumor between January 1999- June 2001. Tumor resection was performed in 8 patients; 4 male and 4 female. Preoperative biliary drainage was performed in 6 patients. Palliative resection was done in 4 patients and curative resection in 4 patients. Right hemihepatectomy was done in 1 patient; in curative resection group. Local tumor resection was performed in 3 patients.1 patient died in early postoperative period (12.5%). 1 year survival and 2 year survival rates are 75% and 50% in curative resection, 75% and 0% in palliative resection group respectively. Klatskin tumor has poor prognosis. Extensive locoregional tumor or metastatic involvement of liver tissue require major or limited liver resection on many occasion. Relief of symptoms such as obstructive jaundice and cholangitis could be achieved by surgical palliation when curative resection is impossible. Surgical palliation can also improve survival by relief of symptoms.

COMPARISON OF THE FOUR-CATEGORY VS FIVE-CATEGORY THYROID FINE NEEDLE ASPIRATION BIOPSY CLASSIFICATIONS

2003-04-01

Objectives: Comparison of the two different classification systems of fine needle aspiration biopsy (FNAB). Evaluation: The evaluation of FNAB results is generally based on a widely accepted classification with four categories: insufficient material, benign, suspicious and malignant lesions. However, occasionally, some aspiration biopsy materials may not correspond to one of these four groups. This may cause difficulty in management of these cases. Recently a new intermediate category is added to alleviate this problem, which formed a new five-category classification system. Method: 236 FNAB and thyroidectomy specimens that were collected during period of 1996 and 2002 at Kocaeli University, Department of General Surgery were evaluated retrospectively. Statistical analyses were done with Chi-square and Fisher's exact tests utilizing InStat software package. Results: Cytopathological samples were grouped as insufficient materials (48), benign (120), suspicious (61) and malignant (7) lesions. Surgical specimens of these samples showed malignant histopathology in 8.3%, 3.3%, 18% and 100%, respectively. Findings were statistically significant in the third group. When five-category system is used to classify the same samples, groups formed as follows: insufficient material (48), benign (120), indeterminate (34), suspicious (27) and malignant (7) lesions. The malignant histopathology was found to be 8.3%, 3.3%, 8.8%, 29.6% and 100%, respectively, resulting in a significant difference in the fourth category. Conclusion: Five-category system in evaluating the FNAB results compared with the four-category may be more definitive in determining the frequency of malignancy.

THE RISK OF MICROCARCINOMA IN PATIENTS WITH MULTINODULAR GOITER

2003-04-01

The aim of this study is to evaluate the frequency of microcarcinoma in multinodular goiter cases operated in the Department of General Surgery, Kocaeli School of Medicine. Microcarcinoma of the thyroid has been reported to be found as much as 22% of autopsy series and 24% of thyroidectomy samples with the preoperative diagnosis of benign diseases. Recently, authors recommend identical therapeutic approach for both micro and frank carcinomas because of the similar frequencies of local and distant metastasis and recurrence in both situations. There were nine cases (3.1 %) of papillary microcarcinoma within totally 288 operated patients with multinodular goiter. Bilateral subtotal thyroidectomy was performed in five cases, lobectomy plus subtotal lobectomy in four cases. A case with three different foci and one case at the age of 51 years who had bilateral subtotal thyroidectomy in the initial operation were reoperated for completion thyroidectomy. There was not any residual tumor or any other focus in the resected tissues of these cases. A patient with two foci of carcinoma denied the second operation. As a result, it can be said that microcarcinoma is found in considerable percent of patients with multinodular goiter. When the surgeon has confronted with this situation, he/she must evaluate the patient about the risk factors and perform completion thyroidectomy when needed.

THE EFFECT OF SURGICAL EXPERIENCE TO EARLY SURGICAL COMPLICATIONS IN RENAL TRANSPLANTATION

2003-04-01

The effect of early surgical complications is an important factor on the success of long-term results after renal transplantation. The purpose of this study was to determine the effect of surgical experience to early surgical complications in renal recipients. Between May 13, 2000 and May 22, 2002, 117 patients underwent renal transplantation at our institution, including 77 male (66%) and 40 female (34%) with a mean age 34 years. Living related and cadaveric renal transplantation were performed in 58 and 59 cases respectively. Iliac vessels were used for vascular anastomosis and extra peritoneal ureteroneocystostomy was performed by Lich-Gregoir tech-1 nique for urinary reconstruction in practically all the cases. The patients were followed by doppler ultrasound, renal scan, symptoms and laboratory findings. During observation 12 complications (10%) developed, including urinary leakage (9 cases), renal artery thrombosis (2 cases) and bleeding (1 case). During the early postoperative period no graft and patient was lost due to surgical complications. We used χ² or Fischer exact test to determine significant risk factors and outcomes. There was a significant difference between the initial period (30 cases) and the further period (87 cases) (p=0.047). The complication rate was not found significantly different when the donor origin was considered (p=0.15). We conclude that instutional surgical experience is the most important factor in occurring early surgical complications after renal transplantation.

MESH PLUG METHOD IN INGUINAL HERNIA REPAIR

2003-04-01

There are many methods in inguinal hernia repair, but the ideal method is yet to be established. We designed a prospective study to evaluate the results of mesh plug usage in inguinal hernia repair. Many new methods have been proposed for surgery of inguinal hernia in the recent years. When these methods are considered several features should be kept in mind like; the simplicty and feasibility of the technique and post operative comfortability, time lapse before going back to work, recurrence rates and coast effectivity which are all the priorities of today's people. Low recurrence rates, short operation time and open tension-free repair procedures are the favorites of these methods in the recent years. 140 patients with inguinal hernia were treated with 156 mesh plug repair between November 2000 and November 2002. A total of 1 56 patients with 124 unilaterally and 16 bilaterally were operated for inguinal hernia. Recovery period and recurrence rates were determined in the post operative follow up. Mean operation time was 36.5±11.4 min. All of the patients went back to work after an average of five (3-7) days. Patients were asked to come for routine controls on 7^th , 30^th postoperatives days, from November 2001 until November 2002. Hematoma was seen in 8 patients and local sensitivity loss was detected in 3 patients. There were not any other complications like infection, orchites and plug migration. There was no recurrence for the mean follow-up of 18±4.8 months (2-24 months). Being an invasive tension-free repair method with limited dissection from a small incision, mesh plug is effective with low-cost, easy appliance, low recurence rates and short recovery times.

Question

2003-04-01

Question 1: Dr. Mehmet K�r�at BOZKURT¹ Answer 1: Dr. Nurullah B�LB�LLER² Question 2: Op. Dr. Mehmet Faik �Z�EL�K³ Answer 2: Dr. Hedef �ZG�N⁴