Turkish Journal of Surgery - 2004; 20(2)

Letter to editor

Dr. Mehmet K�r�at BOZKURT, Dr. Murat �ALIKAPAN — 2004-03-01

THE EFFECTS OF ALFA-TOCOPHEROL, ASCORBIC ACID AND PENTOXIFYLLINE ON BACTERIAL TRANSLOCATION IN COMMON BILE DUCT LIGATED RATS

2004-03-01

This study was conducted to investigate the effects of alfa-tocopherol, ascorbic acid and pentoxifylline on the bacterial translocation in an animal model of obstructive jaundice. Prolonged biliary obstruction gives rise to numerous changes in the liver and the host defense system. The increased biliary duct pressure may induce translocation of bacteria from the biliary tract into bloodstream and lymphatic system. Fifty rats were randomized into 5 groups containing 10 rats each. All rats were initially anaesthetized by intramuscularly injection of Ketamine (25 mg/kg). The abdomen was opened and the common bile duct was identified and divided after ligation using 5-0 silk. Sham operated rats (group 1) had a similar incision followed by mobilization of the common bile duct, without ligation or division. In group 2 rats, only common bile duct ligation was performed. In group 3, 4 and 5 rats common bile duct ligation was performed and alfa-tocopherol, ascorbic acid and pentoxifylline were administered for 21 days. The animals were sacrificed at the end of the 21^st day, and serum levels of total bilirubin, ALT, AST, ALP and GGT were measured. Mesenteric lymph nodes, liver, spleen and blood were cultured. The bacterial translocations of rats in groups 1-5 were 0%, 82.5%, 25%, 30% and 20%, respectively. Bacterial translocation significantly increased in the mesenteric lymph nodes, liver, spleen and blood of rats in group 2 compared to group 1 (p<0.001). Bacterial translocations of the mesenteric lymph nodes, liver, spleen and blood in group 2 was significantly higher than those of group 3-5 (p<0.05). There was no significant difference between treatment groups (p>0.05). The predominant pathogens obtained from the mesenteric lymph nodes, liver, spleen and blood were Esherichia coll (42.9%), Klebsiella spp. (23.8%) and Proteus spp. (19%). The bacterial counts, colony-forming units per gram tissue (cfu/g), were found significantly higher in mesenteric lymph nodes, liver, spleen and blood of rats in group 2 than those of group 3, 4 and 5 (p=0.001). The present experimental study has demonstrated that, during obstructive jaundice, administration of alfa-tocopherol, ascorbic acid and pentoxifylline reduce the incidence of bacterial translocation.

THE EFFECT OF EXTERNAL/ INTERNAL DRAINAGE OR ORAL ADMINISTRATION OF BILE COMPONENTS ON HEPATIC REGENERATION IN OBSTRUCTIVE JAUNDICED RATS WITH PARTIAL HEPATECTOMY

2004-03-01

In the present study, the effects of internal and external drainage and oral administration of bile components on hepatic regeneration of obstructive jaundiced rats with hepatectomy were studied by evaluating the immunohistochemical criteria. Common bile ducts of rats were cannulated and the catheter was bent and ligated to produce obstructive jaundice. On the third day of the obstruction, rats underwent 50 % hepatectomy. Then, the ligated catheters of the rats were surgically inserted into the duodenum for internal drainage (ID) or inserted into the bladder for external drainage (ED). Rats in the ED groups were orally given saline (S), cholesterol-lecithin (CL) or bile salt (BS) for 3 or 7 days. On the 3^rd or 7^th day of the treatments, rats were decapitated, blood samples were taken for the analysis of hepatic function tests, liver wet weights were recorded and hepatic samples were stored to assess PCNA and Ki-67 by immunohistochemical methods. On the third day, the hepatic regenaration rates with PCNA method in the CL group were significantly higher when compared to saline-treated external drainge and internal drainage groups. On the seventh day, the hepatic regeneration rates were significantly lower compared to the bile duct ligation group. On the third day, the hepatic regenaration rates determined by Ki-67 method were significantly higher in the CL group. On the seventh day, the hepatic regeneration rates of the S-treated ED group were found to be significantly lower compared to the internal drainage group and the BS-treated ED group. In conclusion, external drainage group which received only saline demonstrated lower hepatic regeneration compared to internal drainage group in both the early and the late periods. It is found that when CL and BS are given in the external drainage groups, especially in the early period, regeneration rates reach higher values and become even higher than that observed in the internal drainage group. However in the late period, CL or BS administrations in the external drainage groups approximate the regeneration rates to those of internal drainage group.

LAPAROSCOPIC ABDOMINOPERINEAL RESECTION: EARLY RESULTS (IN ELEVEN PATIENTS)

2004-03-01

The aim of this study was to assess the perioperative findings and to discuss the early results of laparoscopically done abdominoperineal resection. Prospective registry data of 11 patients with rectal carcinoma treated by lapa-roscopy between August 2000 and July 2003 were analyzed. Intraoperative complication was not observed and the conversion rate was zero. Postoperative complications occured in five patients (partial intestinal obstruction in three patients, partial perineal wound dehiscence in one, and intestinal fistula in one). According to the TNM classification system, two patients had stage I, three patients had stage II, and six patients had stage III rectal cancer. The median follow was 15 months, and there were no port site or local recurrences. Distant metastasis was observed in one patient. Laparoscopic abdominoperineal resection is a complex but technically feasible procedure. At certain centers experienced in open colorectal operations and laparoscopic interventions. However, the operation time is longer during laparoscopic procedure, and well-organized operating team is mandatory.

MIRIZZI'S SYNDROME

2004-03-01

Mirizzi's syndrome is a rare complication of long-standing gallstone disease. The aim of this retrospective study was to evaluate our patients with Mirizzi's syndrome, according to their presentation, work up, operative findings, choice of operative repair, complications and long-term follow up results. Between September 1997 and June 2003, a total number of 1620 patients were operated for biliary tract diseases at our clinic and from this patient population, 24 patients (1,5% ) were considered to have Mirizzi's syndrome. Among them, 9 (37% ) had a Type 1 lesion and 15 (63%) a Type 2 lesion. The correct preoperative diagnosis could be done only in 3 (12%) patients. Open surgery was the choice of treatment in all cases in which two of them were operated laparoscopically at the beginning but converted to open surgery due to intensive adhesions around Calot triangle and acquired abnormalities of the biliary tract. Cholecystectomy was done in patients with Type 1 lesions and different operative strategies including, primary common bile duct repair with gallbladder flap, T-tube drainage, choledochoduodenostomy or Roux- en-Y hepaticojejnostomy were done in type 2 lesions according to intraoperative findings. The coexistence rate of gallbladder carcinoma was 4%. Also the mortality was seen in the same patient due to external biliary fistula. There was no complication due to benign biliary stricture during follow up period of mean 42 months. As a conclusion, Mirizzi's syndrome must be considered in differential diagnosis of patients with obstructive jaundice. Eventhough there are many advances in radiological and endoscopic diagnostic modalities, Mirizzi's syndrome has still a complex challenge for surgeons regarding its clinical behaviour, diagnosis and surgical treatment.

SIMULTANEOUS REPAIR OF BILATERAL INGUINAL HERNIAS

Dr. Ramazan ERYILMAZ, Dr. Mustafa �AH�N, Dr. FG Murat AKDA� — 2004-03-01

To investigate the treatment value of simultaneous repair of bilateral inguinal hernias compared with unilateral hernias. Bilateral inguinal hernia consists of 12% of all inguinal hernias. Simultaneous repair of bilateral inguinal hernia has been controversial since Bassini repair was described. In this study, 452 inguinal hernias (407 unilateral and 45 bilateral) were included between July 1998 and July 2002. Simultaneous bilateral inguinal hernia repair was compared with unilateral hernia repair in terms of length of hospital stay, time of return to normal activity, surgical site infection, urinary retention and recurrence with Mann Whitney-U test and chi square test. Mean follow-up was 27 (range: 2-50) months. There was no difference between simultaneous bilateral hernia repair and unilateral hernia repair in terms of length of hospital stay and time of return to normal activity with Mann Whitney-U test and in terms of surgical site infection and recurrence with chi square test (p>0.05). Urinary retention was significantly higher in the simultaneous bilateral hernia repair group as compared with the unilateral hernia repair group (p<0.05). Simultaneous repair of bilateral inguinal hernias does not lead to a significant increase in morbidity and it is safe and cost effective.

CARCINOMA OF THE BREAST IN MALES

2004-03-01

Male breast cancer accounts for less than 1% of all breast cancers in men, and is more often diagnosed at a more advanced stage. The aim of this study was to present our clinical data of the patients with breast cancer in male. In this study, 10 males who were treated with diagnosis of breast cancer between January 1980 and May 2002, were analyzed retrospectively. The mean age was 59 years old (range, 39-76). Six tumors were localized in right breast and four in left breast. The preoperative pathological diagnosis was made by excisional biopsy in 3 cases, tru-cut biopsy in 3 cases, fine needle aspiration biopsy and frozen section in 3 cases, frozen section in 1 case. While one patient was treated with radical mastectomy, nine patients underwent modified radical mastectomy. The stages of patients were as follows; two patients (20%) in stage I, five stage (50%) IIa, two (20%) stage IIb, and one (10%) stage lllb. The histopathological diagnoses of all cases were invasive ductal carcinoma. Disease free median survival was 36 (range, 6-72) months. In conclusion; in most respects the clinical, histopathologic and prognostic factors of male breast cancer are similar to that of carcinoma of the breast in women, and treatment should be guided by similar principles. It appears that the prognosis for male patients with carcinoma of the breast is good if the appropriate treatment is undertaken at early stage