Turkish Journal of Surgery - 2008; 24(4)

Editorial

Sad�k K�l��turgay — 2008-10-01

C-reactive protein in gastrointestinal system anastomosis

2008-10-01

Purpose: We aimed to evaluate the accuracy of blood C-reactive protein level for early diagnosis of anastomotic leakage that is ahead of the possible dangerous process after gastrointestinal anastomosis. Materials and Methods: Between 1 January 2007 and 31 June 2007, 93 patients with anastomosis were prospectively evaluated. Postoperative clinical course, hemogram, biochemical examination and blood CRP levels were evaluated on 1.,3., and 5. days postoperatively. Anastomotic leakage was defined clinically. Patients without any clinical anastomotic problem during the follow-up formed group 1 whilst patients with anastomotic problems constituted group 2. Results: There were 43 female, 50 male patients. Anastomotic leakage was present in 9 patients (%9.7). Six of them required additional surgical intervention and 3 of them were treated conservatively. Between groups, there were not significantly difference with regards to demographical data, comorbidities, operative causes, postoperative course, biochemical examination and complications except anastomotic leak. CRP levels were similar at postoperative 1.day, but at 3. and 5. days, there were highly significant differences between groups (p<0.001). White blood cell count was not statistically different at 1. and 3. days after operation in patients with anastomotic leakage., but at 5. day, it was significantly higher (p<0.01). Conclusion: To achieve the early diagnosis of anastomotic leak, the evaluation of the CRP level at 3. day after operation may be helpful for the physician.

Melatonin decreases the nitric oxide response in thyrotoxic rats

2008-10-01

Purpose: Hyperthyroidism results in free radical production and this free radical production results in cell damage. Melatonin, which is an effective hormone in the management of the metabolism, prevents the harmful effects of free radicals like nitric oxide via its direct antioxidant effect. This study was conducted to investigate the role of nitric oxide in experimental hyperthyroidism and the effect of melatonin on nitric oxide. Materials and Methods: Thirty Wistar Albino female rats were randomized into three groups: Group A (negative control group) underwent saline injection; Group B (positive control group) underwent intraperitoneal L-Thyroxine 0.2 mg/kg/day and Group C (treatment group) underwent intraperitoneal L-Thyroxine 0.2 mg/kg/day + melatonin 3 mg/kg/day. After 3 weeks, all rats were decapitated and blood, liver and heart tissue samples were taken. Biochemically, FT3, FT4, TSH and NO levels were investigated. Results: There was a significant change in FT3 levels between Groups A and B, and Groups B and C (p<0.001 and p=0.004, respectively). Concerning FT4 levels, there was a significant change between Groups A and B and Groups A and C (p<0.001 and p=0.02 respectively). Changes in median blood NO levels of Group A, B and C were significantly different (5,93 μM/L; 48,41 μM/L and 42,69 μM/L, respectively) (p<0.001). Heart NO level of Group B is similar to Group A (1,74 �mol/g vs. 1,74 �mol/g). There was also no statistically significant difference between Group B and C, although heart levels decreased in Group C (1,25 �mol/g), (p=0,05). Liver NO levels showed a significant difference between Group A and B, while there was no significant difference between Groups B and C (0,30 �mol/g; 0,46 �mol/g ve 0,41 �mol/g, respectively). Conclusion: Results of this study should be confirmed with future studies conducted with different doses and application time intervals of melatonin. We believe that these future studies will lead melatonin to a major role in the fight against pathologies like hyperthyroidism that affect many systems.

Differentiated thyroid cancers diagnosed initially with distant metastasis

2008-10-01

Purpose: The aim of this study was established as investigating the patients with differentiated thyroid cancers diagnosed initially with distant metastasis. Materials and Methods: The medical records of 531 patients with differentiated thyroid cancers who were treated and followed up in departments of general surgery and nuclear medicine between February 1997 and February 2008 were retrospectively analyzed. Results: There were 9 patients who were initially diagnosed with distant metastasis. The locations of metastases were bone in 7 patients, lungs in 1 patient and scalp in 1 patient. Thyroidectomies were total in 8 patients and near total in one. The types of cancers were papillary in 5 and follicular in four patients. All the patients received radioactive iodine treatment. The median survival time of the nine patients was determined as 103 months. The resections of metastatic lesions in 4 patients with curative intent did not effect survival significantly (p = 0.743). Conclusion: The patients with differentiated thyroid cancers may have long term survival rates with aggressive treatments even with the presence of distant metastasis. Radioactive iodine and thyroid-stimulating hormone suppression with thyroxine subsequent to total thyroidectomy constitute the recommended treatment protocol for these kind of patients.

Attitude of surgeons in Ankara about enhanced recovery after surgery (ERAS) protocol

Ali Harlak, Haldun G�ndo�du, Eren Ersoy, B�lent Erkek — 2008-10-01

Purpose: We aimed to evaluate how much the ERAS (Enhanced Recovery After Surgery) protocol is known and used in clinical practice among the surgeons in Ankara. Background: The ERAS protocol advocates major changes about in the perioperative process of elective colon surgery so as to enhance the recovery after surgery. The protocol includes 21 items and these are not easily accepted by the surgeons although most of them are evidence based. Material and Methods: A questionnaire was designed to learn the attitudes of surgeons on ERAS protocol. Results and Conclusions: The results showed us that most of the surgeons do not have enough knowledge about ERAS protocol as a whole. The suggestions on antibiotic prophylaxis and tromboembolism prophylaxis are widely accepted where bowel preparation, the use of drains and oral nutrition suggestions are not.

The comparison of erythrocyte, plasma, and serum antioxidant activities in toxic multinodular goitre patients before and after surgery

Serdar �zba�, Aykut Soyder, L. Didem Kozac�, T�lay Kavak, ��kr� Boylu — 2008-10-01

Purpose: Thyroid hormones enhance the metabolic rate and antioxidant metabolism by increasing the specific mitochondreal enzymes. It has been shown that due to the oxidative stress, components of the antioxidant system in erythrocytes increased in untreated toxic multinodular goitre patients and return to normal levels by using antithyroid drugs. However, it has not been shown that how L-thyroxine replacement therapy after total thyroidectomy effects these changes. Our aim was to compare the antioxidant levels in toxic multinodular goitre patients just before and 3-months after total thyroidectomy. Methods: Erythrocyte, plasma, and serum antioxidant activities (glucose-6-phosphate dehydrogenase, catalase, superoxide dismutase, nitric oxide, glutathione reductase, glutathione peroxidase, ceruloplasmin, malonyldialdehyde, vitamin E and vitamin C) were studied in 13 toxic multinodular goitre patients just before and 3 months after surgery. All the patients were euthyroid when the blood samples were collected. Euthyroidism was sustained with antithyroid drugs before operation and with L-thyroxine replacement therapy after total thyroidectomy. Statistical significance was assessed by Mann-Whitney U-test. Results: The findings showed that there is no significant difference between the erythrocyte, serum and plasma antioxidant enzyme activities, ceruloplasmin, serum tocopherol and, plasma vitamin C levels when the patients were euthyroid either with antithyroid drugs just before surgery or with L-thyroxine replacement therapy 3 months after total thyroidectomy. Conclusions: L-thyroxine replacement therapy after total thyroidectomy in toxic multinodular goitre patients does not affect the erythrocyte, plasma, and serum antioxidant activities, serum tocopherol and plasma vitamin C levels.

Response to neoadjuvant chemoradiation in locally advanced rectal cancer: Dokuz Eyl�l University experience

2008-10-01

Purpose: The aim of this study was to evaluate the response to neoadjuvant long course chemoradiotherapy (CRT) for patients with locally advanced rectal cancer with or without lymph node metastasis. Materials and Methods: Between 1993 – 2007, 126 patients with locally advanced rectal cancer with or without lymph node involvement were treated at Dokuz Eylul University Medical Faculty Hospital. Prospectively collected data of patients were analyzed. All patients received concurrent CRT. Curative intend surgical resection was performed 4 to 8 weeks after the completion of CRT. Response to neoadjuvant CRT was assessed by comparing the preoperative clinical staging and postoperative pathological evaluation. Histopathological complete response (pCR) was defined as no tumor cells within the specimen. Downstaging of T and/or N stage of the tumor was defined as partial response (PR). Results: Mean age was 57.9 years and 40,5% of patients were female, 59,5% of patients were male. Preoperative staging revealed T3 tumor in 54 (42,8%) of patients and T4 tumor in 58 (46%) of patients. In 32 (25,4%) patients there were no lymph node metastases (cN0) whereas in 94 (74,6%) patients lymph node involvement was detected (cN+). Tumor was located at lower rectum in 61,1% of patients, at mid-rectum in 25,4% of patients, and at upper rectum in 13,5% of patients. Sphincter saving resection was performed in 62,7% of patients. Histopathological complete response was observed in 13 (10,3%) patients. T stage downstaging was observed in 63 (%63) patients, N stage downstaging was observed in 57 (45,2%) patients, and PR was observed in 76 (60,3%) patients. No significant difference was observed between the response to neoadjuvant CRT and tumor localization and sphincter saving resection (P>0.05). Conclusion: Response to neoadjuvant CRT was obtained in majority of the patients. Downstaging was not associated with the rate of sphincter preserving surgery. Surgical resection is still the primary treatment of resectable rectal cancer.

Our experience on feeding ostomies

2008-10-01

Purpose: The aim of the present study is to assess patient's profiles and complications related to the tube placement in patients undergoing Percutaneous Endoscopic Gastrostomy and surgical feeding ostomies. Materials and Methods: The retrospective data of 114 consecutive hospitalized patients who underwent enteral feeding ostomy procedures was evaluated by dividing patients into two separate groups as Percutaneous Endoscopic Gastrostomy Group and Surgery Group. Results: Of the 114 patients, 57 patients underwent surgical feeding ostomy procedures, and other 57 underwent Percutaneous Endoscopic Gastrostomy. The mean age of the patients requiring surgical ostomy was greater than that of the patients with Percutaneous Endoscopic Gastrostomy. All procedures in the surgical group were performed in the operating theater, but procedures in the endoscopy group were performed in intensive care unit (61.5 %), endoscopy suit (34.6 %), or patient wards (3.8 %). The number of patients having cancer in the surgical ostomy group was higher than the Endoscopy group significantly, p<0.001. On the contrary, 93 % of the patients in the Endoscopy group had neurologic problems. Total complication rates in PEG group, surgical gastrostomy and jejunostomy groups were 26.3 %, 25 % and 24.3 %, respectively. Conclusion: In conclusion, PEG procedure has some advantages such as simplicity, low complication rates, lower cost, long term enteral nutrition. For that reason, recently, there is an increase in use of PEG procedure. However, the situation in which the use of PEG is impossible, surgical enteral tube placement techniques are still valid alternatives.

Ascites, chronic duodenal ulcer and pyloric obstruction associated with pneumatosis cystoides intestinalis

Co�kun Polat, �i�dem Tokyol, Senem Sen, Burc Yaz�c�o�lu, Serkan T�rel — 2008-10-01

Pneumatosis cystoides intestinalis is a rare clinical antity which is affecting portions of the gastrointestinal tract. It is characterized by multiple subserosal and submucosal gas cysts of unknown etiology. It is often encountered incidentally when the surgical procedures have been performed for the other causes. A 23-year old male with pneumatosis cystoides intestinalis associated with ascites and pyloric stenosis secondary to a chronic duodenal ulcer has been presented in this case report.

Small bowel perforation after radiotherapy for cervical carcinoma

Habibe �ahin, Engin Ok, Seyit M. Mercanl�gil — 2008-10-01

Obesity is known as one of the most important health problems around the world. A small portion of the patients die because of a direct result of morbid obesity, but a great deal of degenerative diseases are shortening the life span. The risk of surgical mortality for an obese patient is about two thirds more than a patient in normal weight. It was reported that problems with delayed gastric discharge, delayed wound healing, infections of the injury, sternal dehiscence, atrial fibrillation and respiratory system problems are increasing in obese patients. After all, it is claimed that body size and hospital mortality do not have a relation. The basal energy and protein requirements of the obese patients should be calculated accurately and should not be restricted. It is important to start the nutritional support as soon as possible and to provide glycemic control. It is important to decide oral or enteral nutrition as the first method while starting the nutritional support and if necessary to apply parenteral nutrition.