Prognostic significance of metastatic lymph node ratio in gastric cancer: a Western-center analysis

BACKGROUND

Tumor-node-metastasis (TNM) staging is the central gastric cancer (GC) staging system, but it has some disadvantages. However, the lymph node ratio (LNR) can be used regardless of the type of lymphadenectomy and is considered an important prognostic factor. This study aimed to evaluate the relationship between LNR and survival in patients who underwent curative GC surgery.

METHODS

All patients who underwent radical gastric surgery between January 2014 and June 2022 were retrospectively evaluated. Clinicopathological features of tumors, TNM stage, and survival rates were analyzed. LNR was defined as the ratio between metastatic lymph nodes and total lymph nodes removed. The LNR groups were classified as follows: LNR0 = 0, 0.01 < LNR1 ≤ 0.1, 0.1 < LNR2 ≤ 0.25 and LNR3 > 0.25. Tumor characteristics and overall survival (OS) of the patients were compared between LNR groups.

RESULTS

After exclusion, 333 patients were analyzed. The mean age was 62 ± 14 years. According to the LNR classification, no difference was found between groups regarding age and sex. However, TNM stage III disease was significantly more common in LNR3 patients. Most patients (43.2%, n = 144) were in the LNR3 group. In terms of tumor characteristics (lymphatic, vascular, and perineural invasion), the LNR3 group had significantly poorer prognostic factors. The Cox regression model defined LNR3, TNM stage II-III disease, and advanced age as independent risk factors for survival. Patients with LNR3 demonstrated the lowest 5-year OS rate (35.7%) (estimated mean survival was 30 ± 1.9 months) compared to LNR 0-1-2.

CONCLUSION

Our study showed that a high LNR was significantly associated with poor OS in patients who underwent curative gastrectomy. LNR can be used as an independent prognostic predictor in GC patients.

Outcomes of Proximal Versus Total Gastrectomy for Proximal Gastric Cancer: A Propensity Score-Matched Analysis of a Western Center Experience

PURPOSE

In this western study, we aimed to compare perioperative outcomes, postoperative complications, and overall survival in patients who underwent total gastrectomy (TG) or proximal gastrectomy (PG) for proximal gastric cancer (GC).

METHODS

Patients who underwent GC surgery at Marmara University Hospital between January 2014 and December 2021 were evaluated retrospectively. Propensity score matching (PSM) was performed to balance the baseline characteristics of patients undergoing PG and TG. Data on patients' demographics, clinicopathological features of tumors, complications, and survival rates were analyzed. Perioperative outcomes and overall survival of the patients were compared between PG and TG groups.

RESULTS

A total of 212 patients were included in this study, with 53 patients in the PG and 159 in the TG group. After 1:1 matching according to PSM, 46 patients in the PG group were matched to 46 in the TG group. After PSM, there were no differences in clinicopathological outcomes except retrieved lymph nodes. In terms of short-term outcomes, overall perioperative morbidity (Clavien Dindo ≥ 3a) was significantly higher in the PG group (p = 0.01). However, there was no significant difference when the complications were considered separately. In the long-term follow-up, reflux esophagitis was associated with the PG group (p=0.04). In multivariate analysis, positive surgical margin and lymphovascular invasion were significant factors related to overall survival. Overall, 5-year survival was 55% in matched patients. The difference in survival was not statistically significant (57 vs. 69 months, p = 0.3) between the two groups.

CONCLUSIONS

Proximal gastrectomy is applicable to patients up to stage 3 disease, with no difference in overall survival, with caution in early complications and reflux esophagitis. Among all demographic and oncological factors, lymphovascular invasion and resection margin were significantly associated with worse survival.

The role of CT in decision for acute appendicitis treatment

PURPOSE Acute appendicitis is the most common cause of the acute abdomen requiring surgery. Although standard treatment has been surgery, it has been seen in recent years that treatment is possible with antibiotics and non-operative observation. In this study, our aim is to determine whether the CT findings in patients diagnosed with acute appendicitis can be used for directing treatment. METHODS A retrospective analysis was conducted on 138 patients with acute appendicitis who underwent CT between 2015 - 2019. In this study, medical treatment group (n = 60) versus surgical treatment group (n = 78) and successful antibiotic treatment group (n = 23) versus unsuccessful antibiotic treatment group (n = 14) were compared. Appendiceal wall thickness, appendiceal diameter, the severity of mural enhancement, intra-abdominal free fluid, the severity of periappendiceal fat stranding, size of pericecal lymph node, appendicolith, adjacent organ findings and the CT appendicitis score of groups were compared with Pearson Chi-square and Mann Whitney U tests. Multivariable logistic regression was used to identify predictors of surgical treatment, expressed as odds ratios (ORs) with 95% confidence intervals. Diagnostic efficacies of appendiceal diameter, the CT appendicitis score and developed model were quantified by ROC curves. RESULTS Appendiceal diameter (P < .001), adjacent organ findings (P = .041), the CT appendicitis score (P < .001), the severity of periappendiceal fat stranding (P = .002), appendicolith (P = .001) and intra-abdominal free fluid (P <0.001) showed statistically significant differences between the medical and surgical treatment groups. According to the logistic regression test, if the patients with appendiceal diameter ≥13mm (OR = 5.1, 95%CI 1.58 - 16.50), appendicolith (OR = 4, 95%CI 1.17 - 13.63) and intra-abdominal free fluid (OR = 3.04, 95%CI 1.28 - 7.20), surgeons should prefer surgical treatment. The AUCs for the CT appendicitis score, the appendiceal diameter and the model were 0.742 (95% CI 0,659 - 0,824), 0.699 (95% CI 0.613 - 0.786) and 0.745 (95% CI 0.671 - 0.819), respectively. As the successful and unsuccessful medical treatment groups were compared, the only significant parameter was the severity of mural enhancement (P = .005). CONCLUSION CT findings may be helpful in patients with uncomplicated acute appendicitis whose treatment surgeons are indecisive about. We can recommend surgical treatment in cases with appendix diameter ≥13mm, intraabdominal free fluid, appendicolith, high CT appendicitis score and severe mural enhancement.

The gastroprotective effect of obestatin on indomethacin-induced acute ulcer is mediated by a vagovagal mechanism

In order to investigate the role of the vagus nerve in the possible gastroprotective effect of obestatin on the indomethacin-induced acute oxidative gastric injury, Sprague-Dawley rats of both sexes were injected subcutaneously with indomethacin (25 mg/kg, 5% NaHCO3) followed by obestatin (10, 30 or 100 μg/kg). In other sets of rats, surgical vagotomy (Vx) or selective degeneration of vagal afferent fibers by perivagal capsaicin was performed before the injections of indomethacin or indomethacin + obestatin (30 μg/kg). Gastric serosal blood flow was measured, and 4 h after ulcer induction gastric tissue samples were taken for histological and biochemical assays. Obestatin reduced the severity of indomethacin-induced acute ulcer via the reversal of reactive hyperemia, by inhibiting ulcer-induced neutrophil infiltration and lipid peroxidation along with the replenishment of glutathione (GSH) stores, whereas Vx abolished the inhibitory effect of obestatin on blood flow and lipid peroxidation, and worsened the severity of ulcer. On the other hand, serosal blood flow was even amplified by the selective denervation of the capsaicin-sensitive vagal afferent fibers, but obestatin-induced reduction in ulcer severity was not altered. In conclusion, the gastroprotective effect of obestatin on indomethacin-induced ulcer appears to involve the activation of the vagovagal pathway.

Minimally invasive thyroid anaplastic carcinoma with long survival

Anaplastic thyroid carcinoma is a highly lethal malignancy. Previously, only five cases of a noninvasive form of anaplastic thyroid carcinoma with excellent prognosis were reported. We report a case of a 68-year-old man who presented with a 3.8 cm thyroid nodule diagnosed by fine needle aspiration biopsy as poorly differentiated spindled and epithelial malignant cells. Lobectomy and isthmusectomy were performed, and the final diagnosis was microinvasive anaplastic thyroid carcinoma arising in a poorly differentiated carcinoma. The patient remains disease-free after six years, even after hemithyroidectomy and radiation treatment. Noninvasive/microinvasive anaplastic thyroid carcinoma appears to be a different disease entity from classical anaplastic thyroid carcinoma, with favorable prognosis and long disease-free survival.

Serum Leptin, Obestatin, and Ghrelin Levels and Gastric Emptying Rates of Liquid and Solid Meals in Non-obese Rats with Roux-en-Y Bypass Surgery or Prosthesis Placement: Implications for the Role of Vagal Afferents

BACKGROUND

The present study aimed to investigate the effects of Roux-en-Y gastric bypass (RYGB) and prosthesis placement on gastric emptying rate in conjunction with serum ghrelin-obestatin-leptin responses in non-obese rats with intact or denervated afferent innervation.

METHODS

Under anesthesia, male Sprague-Dawley rats underwent either sham operation, RYGB, prosthesis, and/or Gregory cannula placement. Three weeks later, liquid or solid gastric emptying tests were performed and serum ghrelin, leptin and obestatin levels were measured.

RESULTS

Both prosthesis placement and RYGB surgery delayed non-nutrient liquid emptying; while solid nutrient emptying was delayed only by RYGB. Nutrient-dependent (acid, hyperosmolal and peptone) delay in liquid emptying was abolished in rats with prosthesis. By vagal afferent denervation, delayed liquid emptying was abolished, while solid emptying was further delayed in rats with prosthesis. Ghrelin and obestatin levels were depressed in prosthesis-placed rats, but RYGB surgery had no impact on both levels. Leptin level was elevated in solid-food-given rats with prosthesis, but not changed in RYGB group, while it was reduced following liquid meal. All the changes observed in ghrelin, obestatin, or leptin levels in response to meal ingestion were reversed with vagal afferent denervation.

CONCLUSIONS

Both RYGB and prosthesis placement had delaying effects on gastric emptying rate of non-obese rats. Our results indicate that the short-term changes in gastric motility and hormone responses induced by volume reduction are reversed by afferent denervation, suggesting that sparing the vagal innervation could be essential for reaching optimum motility and hormone changes expected after bariatric surgery.

Treatment with either obestatin or ghrelin attenuates mesenteric ischemia-reperfusion-induced oxidative injury of the ileum and the remote organ lung

To evaluate the effects of exogenous ghrelin or obestatin on intestinal injury and accompanying pulmonary injury, intestinal ischemia-reperfusion (I/R) was induced in rats by obstructing the superior mesenteric artery for 60min, whereas laparotomy was performed in the sham group. At the beginning of the 90-min reperfusion period, the rats were injected with obestatin (100μg/kg), ghrelin (10ng/kg), or saline intravenously (iv). At the end of reperfusion, the blood, ileum, and lung samples were taken for the histological and biochemical assays. In the saline-treated I/R group, the increased serum interleukin (IL)-1β level, high damage scores, and elevated tissue malondialdehyde level and collagen content in both tissues were significantly reduced by obestatin or ghrelin. Increased ileal myeloperoxidase activity of the saline-treated I/R group was reduced by treatment with obestatin or ghrelin, whereas increased pulmonary myeloperoxidase activity was reduced with administration of obestatin. Increased DNA fragmentation in the ileum of the saline-treated I/R group was reduced by both peptides. Elevated luminol-lucigenin chemiluminescence levels and nuclear factor kappa B (NF-κB) messenger RNA (mRNA) expression in the ileum of the saline-treated-I/R group were significantly decreased by obestatin or ghrelin treatment. I/R-induced depletion of the antioxidant glutathione in both ileal and pulmonary tissues was prevented with either obestatin or ghrelin treatment. Administration of either obestatin or ghrelin exerts similar protective effects against I/R-induced ileal and pulmonary injury, thus warranting further investigation for their possible use against ischemic intestinal injury.

HER-2 incidence in gastric cancer, its association with prognosis and clinicopathological parameters

OBJECTIVE

Human epidermal growth factor-2 (HER-2) overexpression has prognostic value in breast cancer. However, the significance of HER-2 positivity in gastric cancer is controversial. In this study, we investigated the frequency of overexpression of HER-2 and its relationship with clinicopathological findings and impact on survival in gastric cancer.

MATERIAL AND METHODS

Gastric cancer patients, operated in Marmara University Faculty of Medicine, Pendik Training and Research Hospital, General Surgery Department, between January 2012-December 2013 were enrolled in this study. Medical records were retrospectively evaluated. Tissue samples were stained by immunohistochemistry (IHC) method, and were followed by fluorescence in situ hybridization (FISH) in those with positive results. HER-2 expression rates and its association with other histopathological features and survival have been analyzed.

RESULTS

135 patients were enrolled in the study, with 88 (65%) male and 47 (35%) female patients. The median age was 61 (29-84) years. Only 11 patients (8%) were positive for HER-2. HER-2 positive patients were similar to negative patients in terms of age, gender, tumor size, tumor location, tumor T stage, lymph node metastasis, histological type, differentiation, lymphovascular invasion, perinodal, perineural invasion and stage. No significant difference was detected on 1 and 2-year overall and disease-free survival rates between receptor positive and negative groups.

CONCLUSION

Consistent with the literature data, HER-2 positivity rate in this study was approximately 8%, but this positivity has not been found to be associated with either clinical and pathological parameters or overall and disease-free survival.

Spontaneous rupture of extraluminal jejunal gastrointestinal stromal tumor causing acute abdomen and hemoperitoneum

Tumor perforation is accepted as an important prognostic factor along with tumor size and mitotic index in gastrointestinal stromal tumors (GIST). The prognosis is worse in patients with tumor perforation or rupture. A few case reports of small bowel GIST presenting with rupture have been published in the medical literature. We report an unusual case of a 7.5 cm GIST of the jejunum that presented with spontaneous rupture. A previously healthy 46-year-old male patient presented with sudden abdominal pain. Physical examination revealed overt peritonitis, and computed tomography showed a heterogeneous solid mass measuring approximately 6 cm × 5.5 cm arising from the jejunum and massive fluid in the peritoneum. The mass was diagnosed as a GIST originating from the gastrointestinal tract. Emergency laparotomy was performed and intraoperative findings showed massive hemoperitoneum and an outgrowing mass at the jejunum, 50 cm distal to the Treitz ligament. The tumor had ruptured near the wall of the small intestine and it was actively bleeding. Surgical resection of the tumor was performed and the patient was discharged home uneventfully on the third postoperative day. The immunohistochemical characteristics of the tumor revealed it to be a GIST.

Is three-gland-or-less parathyroidectomy a clinical failure for secondary hyperparathyroidism?

OBJECTIVE

To compare the clinical and biochemical outcomes between adequate and inadequate parathyroidectomies in patients with chronic renal failure.

MATERIAL AND METHODS

All secondary hyperparathyroidism patients who were previously operated in the Marmara University Hospital Breast and Endocrine Surgery Unit were planned to be included in the study. Patients were divided into two groups according to their extent of surgery: "adequate" and "inadequate" surgery groups. "Adequate surgery" was regarded as either subtotal (3½) or total parathyroidectomy. Removing fewer than 3½ parathyroids was defined as "inadequate surgery." Demographic, preoperative clinical symptoms, and their severity, as well as biochemical (e.g., tCa, PTH) findings, were recorded. Patients were followed monthly. The course of biochemical findings (tCa, PTH, P, ALP) and symptoms (by a scoring system of 1-4) was determined by comparing preoperative findings to those at the patient's last follow-up. Primary outcome of the study was treatment failure (biochemical persistence/recurrence) rates in both study cohorts. Secondary outcomes of the study were the levels of biochemical findings and improvement rates of clinical symptoms after parathyroidectomy, as well as complication rates related to the initial surgery in each surgery cohort.

RESULTS

Forty-two patients with secondary hyperparathyroidism who underwent parathyroidectomy were included into the study. Twenty-six were male and 16 were female. Median age was 46. Forty (95%) patients had at least one symptom as the indication for surgery, whereas only 2 (5%) patients were asymptomatic, but biochemical findings were the indication. Twenty-two (52%) patients underwent adequate operation, whereas 20 (48%) patients had inadequate operation. Mean follow-up duration after initial parathyroidectomy was 60 [3-244] months. Significantly more patients (n=15; 75%) in the inadequate surgery group had biochemical persistence/recurrence when compared with those (n=8; 36%) who underwent adequate surgery (OR [odds ratio] 5.25; 95% CI 1.38-19.93; p=0.012). However, symptom improvement rates were similar in both adequate and inadequate surgery groups.

CONCLUSION

Although there is high biochemical treatment failure after inadequate parathyroidectomy in patients with renal hyperparathyroidism, clinical symptom improvement rates are also surprisingly high in this patient group. On the other hand, the adequate surgery group also had an increased biochemical failure rate well above expected in longer follow-ups.

Intestinal obstruction due to congenital mesenteric band in an adult patient

We report the case of a 30-year-old male patient who was admitted to the Emergency Department with symptoms and signs of intestinal obstruction. There was no history of abdominal surgery or trauma. Abdomen was distended. Abdominal plain X-ray showed intestinal loops with air-fluid levels in the middle area of the abdomen. Computed tomography showed small bowel dilatation and free fluid in the abdomen. A laparotomy was subsequently performed and the intraoperative findings revealed a band extending from the root of the mesentery to the antimesenteric wall of the jejunum. The band was resected; the postoperative course was uneventful. Congenital bands are extremely rare and usually observed in childhood. This case, therefore, represents an unusual surgical problem in an older individual in whom the diagnosis was clinically unexpected.

Synchronous appearance of gastrointestinal stromal tumor and neuroendocrine tumor in stomach: review of the literature and management strategies

Gastrointestinal stromal tumors represent the most common mesenchymal tumor of the digestive tract. Although the stomach is the most common location for gastrointestinal stromal tumor with the co-primary tumors, the synchronous appearance of a neuroendocrine tumor and gastrointestinal stromal tumor in the stomach is rare. We present here the case of a 48-year-old male with gastric well-differentiated neuroendocrine tumor and gastrointestinal stromal tumor discovered incidentally during surgical treatment of the neuroendocrine tumor. We discuss the current guidelines for the management of small gastrointestinal stromal tumors (&lt;2 cm in diameter) and the gastric carcinoids. We also review the literature for the co-occurrence of gastrointestinal stromal tumor and neuroendocrine tumor in a gastric location.

Protective and therapeutic effects of resveratrol on acetic acid-induced gastric ulcer

Sprague Dawley rats of both sexes were injected with either saline or RVT (10 mg/kg) either before or after acetic acid ulcer induction and decapitated 3, 5 or 10 days after ulcer. In the saline-treated ulcer groups, macroscopically evident ulcers were observed, while RVT-pretreated or RVT-treated groups had lower macroscopic ulcer scores. Likewise, the microscopic damage scores were lower for the RVT-administered groups. Gastric myeloperoxidase activity, malondialdehyde, collagen and tumour necrosis factor-alpha levels, as well as luminol- and lucigenin-enhanced chemiluminescence levels that were elevated in the saline-administered ulcer groups, were depressed with both RVT-pretreatment and RVT-treatment. Moreover, depleted glutathione levels in the ulcer groups were increased back to control levels by both pre- and post-treatments of RVT. Results demonstrate that resveratrol has both protective and therapeutic effects on oxidative gastric damage by suppressing pro-inflammatory cascades, including the activation of pro-inflammatory cytokines, accumulation of neutrophils and release of oxygen-derived free radicals.

Coagulation dynamics and platelet functions in obstructive jaundiced patients

BACKGROUND

All of the body systems are affected by increased levels of bilirubin. The aim of this study is to investigate the function of platelets and clotting dynamics in patients with obstructive jaundice.

METHODS

Liver function tests, serum CRP, PT, PTT and hemogram were measured in 23 patients with obstructive jaundice. Thromboelastography (TEG) was done for the evaluation of coagulation dynamics, while platelet function assay (PFA 100) was used to evaluate platelet functions. Blood samples were obtained at two occasions, before the drainage and 3 weeks after the relief of the obstruction.

RESULTS

Hypercoagulation was detected in 80% of patients. Maximum strength, elasticity, coagulation indices of the clot were correlated with increased concentrations of direct bilirubin. Although maximum strength of coagulum usually represents increased activity of platelet function, membrane closure times with PFA 100 were found to be prolonged in 30% of patients, reduced values were determined in 17% of patients. No demonstrable effect on coagulation parameters and platelet function were detected after drainage procedures regardless of modality.

CONCLUSIONS

Even though there is a general assumption about the increased bleeding tendency in obstructive jaundiced patients, we could not demonstrate reduced clotting activity by measuring with either PFA or TEG. On the contrary we observed tendency for hypercoagulation independent of increased prothrombin times. The most probable cause of this effect is the increased activity of fibrin polymers on platelet membrane.

Oxytocin alleviates hepatic ischemia-reperfusion injury in rats

Various mechanisms have been proposed for the pathogenesis of postischemic hepatic injury, including the generation of reactive oxygen metabolites. Oxytocin (OT) possesses antisecretory, antiulcer effects, facilitates wound healing and has anti-inflammatory properties. Hepatic ischemia-reperfusion (I/R)-injury was induced by inflow occlusion to median and left liver lobes ( approximately 70%) for 30 min of ischemia followed by 1h reperfusion in female Sprague-Dawley rats under anesthesia. I/R group (n=8) was administered intraperitoneally either OT (500 microg/kg) or saline at 24 and 12 h before I/R and immediately before reperfusion. Sham-operated group that underwent laparotomy without hepatic ischemia served as the control. Rats were decapitated at the end of reperfusion period. Hepatic samples were obtained for the measurement of myeloperoxidase (MPO) activity, malondialdehyde (MDA), glutathione (GSH) and collagen levels and histopathological analysis. Tumor necrosis factor-alfa (TNF-alpha) and transaminases (SGOT, SGPT) were assayed in serum samples. I/R injury caused significant increases in hepatic microscopic damage scores, MPO activity, collagen levels, transaminase, serum TNF-alpha levels. Oxytocin treatment significantly reversed the I/R-induced elevations in serum transaminase and TNF-alpha levels and in hepatic MPO and collagen levels, and reduced the hepatic damage scores. OT treatment had tendency to abolish I/R-induced increase in MDA levels, while GSH levels were not altered. These results suggest that OT has a protective role in hepatic I/R injury and its protective effect in the liver appears to be dependent on its inhibitory effect on neutrophil infiltration.

Ghrelin ameliorates pancreaticobiliary inflammation and associated remote organ injury in rats

The present study was designed to evaluate whether ghrelin could reduce organ injury and systemic inflammation induced by pancreaticobiliary obstruction. In Sprague-Dawley rats, either the bile duct (BDL) or common pancreaticobiliary duct (PBDL) was ligated or a sham operation was applied. BDL or PBDL rats received either ghrelin (10ng/kg) or saline intraperitoneally immediately before the surgery and once a day until the rats were decapitated at 72h. The pancreas, liver, lung and kidney were removed for the histological analysis, and for the determination of malondialdehyde (MDA), glutathione (GSH) levels and myeloperoxidase activity (MPO). MDA and MPO levels in all the tissues, which were elevated in PBDL group (p<0.05-0.001), were reversed back to control levels in ghrelin-treated rats. In BDL group, elevations in hepatic MDA and MPO levels (p<0.001) were also abolished by ghrelin treatment. In contrast to saline-treated group with severe pancreatic damage, ghrelin-treated rats demonstrated a moderate pancreatic and hepatic destruction accompanied with reduced pulmonary and renal damages. The results illustrate that ghrelin protects the hepatic and pancreatic tissues, as well as remote organs against oxidative injury, by a neutrophil-dependent mechanism.

Use of Resterilized Polypropylene Mesh in Inguinal Hernia Repair: A Prospective, Randomized Study

BACKGROUND

Inguinal hernia repair consumes considerable health-care resources worldwide. Open mesh repairs are commonly used and the feasibility of using a resterilized mesh, which is a general practice in certain countries, has not been evaluated.

STUDY DESIGN

In this randomized prospective study, original and resterilized meshes were used in two groups of patients with unilateral inguinal hernia. Microbiologic changes, textile mechanical properties, overall complication rates, and cost-effectiveness of resterilized mesh were investigated. A time period of 3 years was determined for patient enrollment to this pilot feasibility study, with the goal of 100 patients in each group.

RESULTS

Ninety-one patients were enrolled in the original group and 93 in the resterilized mesh group. Median followup was 735 and 739 days and calculated interquartile ranges were 454 and 513 days, respectively. Average tensile strength of the original polypropylene mesh changed slightly with resterilization, as maximum load decreased from a mean of 66.6 to 58.2 N/cm. Overall complication rates were similar in the two groups. The 6.6% infection rate in the original mesh group was not statistically different from the 7.5% rate in the resterilized group (p = 0.80, relative risk = 0.88, 95% confidence interval, 0.31-2.51). There was only one recurrence in the original mesh group in the 21st month. Use of a resterilized mesh decreased the overall cost of operation by decreasing the cost of mesh from 15.9% to 8.3% of the total amount.

CONCLUSIONS

Use of a resterilized mesh for inguinal hernia repair is feasible without considerable changes in infection and recurrence rates.

Early Prediction of Normocalcemia after Thyroid Surgery

Hypocalcemia is the principal factor that determines length of hospital stay after thyroid surgery. Seventy-nine patients who underwent thyroidectomy were prospectively evaluated in order to define risk factors for postoperative hypocalcemia. Serum samples were taken postoperatively at 8, 14, 24, and 48 hours to measure total calcium levels. The slope of change in serum calcium level between each sample time was calculated. Patients were also examined for age, gender, surgical indications, type and extension of surgery, thyroid function, presence of substernal extension, initial operation versus reoperation, and application of parathyroid autotransplantation. All comparisons were made between hypocalcemic and normocalcemic groups. Hypocalcemia occurred in 15 (19%) patients. In univariate analysis, type and extent of thyroidectomy, serum calcium levels at each time point, as well as the slope of change in serum total calcium levels between 8 and 14 hours were found to be significantly predictive of normocalcemia. All patients who underwent hemithyroidectomy and who had a positive or neutral slope of calcium change after surgery remained normocalcemic. By multivariate logistic regression analysis, only the slope of change in calcium levels within the first 14 postoperative hours independently predicted calcium status after thyroidectomy. All patients who undergo unilateral thyroid surgery who have a positive/neutral slope of change in serum total calcium levels within the first 14 hours after surgery can be safely discharged early if they have no other risks.

Laparoscopic cholecystectomy: is it a conscious preference among Turkish patients with symptomatic gallstones?--prospective study

Laparoscopic cholecystectomy (LC) has the advantages of early return to full daily activity, early return to work, and better cosmetic result, as well as quickly resolving pain. Yet how this information about the procedure influences a patient's attitude toward laparocopy is not known. In this study we analyzed the factors that play role in the decision-making process of patients who choose laparoscopic surgery, and we also evaluated patients' knowledge of laparoscopy and their expectations. A questionnaire was used in evaluating 98 patients suffering from symptomatic cholelithiasis scheduled for elective laparoscopic cholecystectomy between January 2001 and January 2002. Females constituted 81% of the study population. Most of the patients (56%) were housewives. While 45% of the patients had an educational status of primary school degree only, 14% had graduated from a university. Forty-three patients described their level of knowledge about laparoscopy as "low" (had only heard about laparoscopy). In 61% of the patients the surgeon was the sole decision maker about the type of the operation. Almost none of the patients had a preference for the time of discharge from the hospital after surgery, and only three of the actively working patients offered a time interval for return to work. From this study we concluded that most patients have inadequate information about laparoscopic surgery, that the type of operation is dictated mostly by the surgeon, and that early discharge and early return to work are not important for many patients.

Melatonin protects against pancreaticobiliary inflammation and associated remote organ injury in rats: role of neutrophils

Although the role of oxidative stress in acute pancreatitis (AP) has been studied in several animal models, little data are available regarding AP induced by pancreatic duct obstruction. We characterized the protective effects of melatonin on pancreaticobiliary inflammation and associated remote organ injury. In Sprague-Dawley rats, either the common pancreaticobiliary duct (PBDL; n = 28) or bile duct (BDL; n = 28) was ligated or a sham operation was applied (n = 14). Either melatonin (10 mg/kg) or vehicle (saline; 1 mL/kg) was administered intraperitoneally (i.p.) immediately before the surgery and twice a day until the rats were decapitated at 6 or 72 h. The pancreas, liver, kidneys and lungs were removed and tissue samples were stored for the determination of malondialdehyde (MDA) and glutathione (GSH) levels and myelopreoxidase activity. The results demonstrate that pathogenesis of acute obstructive pancreatitis involves not only the oxidative damage of the pancreatic and hepatic tissues, as assessed by increased MDA and reduced GSH levels, but the lungs and kidneys are also challenged by oxidant injury. Similarly, hepatic oxidative injury caused by cholestasis was also accompanied by pulmonary, renal and even pancreatic damage. The biochemical findings were also verified histologically. Melatonin, probably because of its free-radical scavenging and antioxidant activity, which involves an inhibitory effect on tissue neutrophil infiltration, protected all the affected tissues.

The use of bonewax to control massive presacral bleeding

Massive presacral bleeding during retroperitoneal resection is unusual, and can be difficult to control. We describe a technique for managing this complication whereby bonewax is pushed through the presacral fascia and periosteum directly into the bleeding point in the sacrum, followed by abdominal packing. This maneuver proved successful for achieving hemostasis when we recently encountered this intraoperative complication.

Enterogastric brake in rats with segmental bowel resection: role of capsaicin-sensitive nerves

1. Unabsorbed nutrients in the distal gut inhibit upper gastrointestinal motility. 2. The aim of the present study was to investigate changes in gastric motility following segmental resections and to evaluate the role of capsaicin-sensitive afferent neurons that may be responsible for these changes. 3. Wistar albino rats of both sexes (200-250 g) were used. Under aseptic conditions and anaesthesia (100 mg/kg ketamine), a baby-feeding tube was placed distal to the resection in either the ileum or caecum for intraluminal perfusion of saline or 20 lipid. In one group of rats, capsaicin was perfused (0.6) for afferent denervation. One group of rats underwent jejunal and ileal resections with end-to-end anastomosis of the remaining segments and were cannulated distal to these anastomosis. Ten days after the surgery, the percentage gastric emptying of a solid meal was calculated. 4. Intra-ileal (18) and intracaecal (34) lipid perfusions delayed gastric emptying compared with groups perfused with saline (54 and 74, respectively; P< 0.001 and P< 0.01). The delay in gastric emptying by ileal perfusion was significantly greater than that following caecal perfusion (P< 0.05). With both resections, gastric emptying was delayed compared with sham groups (P< 0.05-0.01). Local administration of capsaicin abolished the inhibitory effect of lipid on gastric emptying in healthy intact rats and in the jejunal-resection group, whereas a partial reversal was seen in the ileal-resection group. 5. In conclusion, the present data demonstrate that in both healthy intact rat groups and in short bowel groups, capsaicin-sensitive extrinsic neurons participate in brake mechanisms of the distal gut.

Estrogens ameliorate remote organ inflammation induced by burn injury in rats

OBJECTIVE AND DESIGN

The present study was designed to investigate the role of sex steroids in burn-induced remote organ injury.

MATERIAL OR SUBJECTS

Male Wistar albino rats were given burn trauma (n=39), and underwent castration or sham operation at 2 h following the burn injury.

TREATMENT

Rats were injected sc with either 17beta estradiol benzoate (E2, 10 mg/kg) or an androgen receptor blocker cyproterone acetate (CPA, 25 mg/kg) or vehicle, immediately after burn and at 12 h.

METHODS

At 24 h of burn insult, rats were decapitated. Blood samples for RIA of testosterone, estradiol and tumor necrosis factor (TNF)-alpha and the tissue samples for myeloperoxidase activitiy (MPO) were taken. ANOVA student's t test was used for statistical analysis.

RESULTS

Castration, antiandrogen and E2 treatments increased plasma estradiol levels and depressed burn-induced elevation in serum TNF-alpha levels. In the liver and lung, burn-induced increase in MPO was reduced by E2 and castration, while CPA was effective in reducing neutrophil infiltration only in the liver.

CONCLUSION

We propose that treatment with estrogens or antiandrogens might be applicable in clinical situations to ameliorate systemic inflammation induced by burn.

Bombesin improves burn-induced intestinal injury in the rat

This study was designed to determine the effect of exogenous bombesin (10 microg/kg/day, subcutaneously, three times a day) on intestinal hypomotility and neutrophil infiltration in the early and late phases of burn injury (partial-thickness, second-degree burn of the skin). In acute (2 h after burn injury) or chronic (3 days after) burn groups, intestinal transit was delayed, which was reversed by bombesin treatment. In the acute burn group, but not in the chronic group, increased MPO activity was also reduced by bombesin treatment. The results demonstrate that bombesin ameliorates the intestinal inflammation due to burn injury, involving a neutrophil-dependent mechanism.

The delays in intestinal motility and neutrophil infiltration following burn injury in rats involve endogenous endothelins

This study was carried out to investigate the role of endogenous endothelins in intestinal motility following bum injury by using a nonselective endothelin-1 (ET-1) antagonist and to evaluate the ET-1-mediated reactive oxygen metabolite formation and neutrophil infiltration following burn injury. In 2 h and 3 day postburn groups, transit indices were significantly decreased as compared to corresponding sham groups. Transit index was not significantly changed by PD156252 pretreatment in the 2 h postburn group, whereas the delay in transit was abolished in the ET-antagonist treated 3 day postbum group. In the 2 h postburn group, tissue-associated myeloperoxidase (MPO) activity value was found to be increased compared to corresponding sham group, while PD156252 pretreatment partially reversed this effect. Although MPO activity levels were not significantly different between 3 day postburn and corresponding sham groups, MPO levels showed a significant increase in ET antagonist-treated group as compared to the corresponding burn group. In the early phase of the burn, there was no significant difference in protein oxidation levels among the groups. In the 3 day postburn group, protein oxidation levels in ET-antagonist-treated group showed an increase compared to its corresponding burn group. In conclusion, the results demonstrate that endogenous endothelins have an important role in the systemic response to burn injury, as observed by a delay in intestinal motility and an infiltration of neutrophils. Although the results of the animal studies are not readily applicable to burned patients, the present study may suggest that the burned patient's condition should be carefully evaluated to secure a proper and early enteral feeding.

Primary torsion of the omentum mimicking acute appendicitis: report of a case

A case of primary omental torsion seen in a 26-year-old man is discussed. All signs and symptoms mimicked acute appendicitis. The patient underwent emergency laparotomy in which a normal appendix and serohemorrhagic fluid in the pelvis were observed. The pathological diagnosis was a primary torsioned omentum which was thus excised. This case helps to emphasize the importance of a routine exploration of the abdomen when serohemorrhagic fluid is found at the time of laparotomy in the absence of any pathological condition in the pelvis.

Endothelin release is augmented with captopril in rat ischemia-reperfusion injury of the liver

The reactive oxygen metabolites (ROMs) and the vascular endothelial factors such as endothelins (ETs) and thromboxane A2 (TxA2) were found to be mediators of the reperfusion component of ischemia-reperfusion (I/R) injury. Captopril (CPT), a sulfydryl (-SH) group containing angiotensin-converting enzyme inhibitor, has been shown to reverse I/R injury by its ROM scavenging effect. In this experimental study, the effects of CPT and BM 13.177 (a TxA2 receptor antagonist) were assessed on liver I/R injury in rats. Four groups of Wistar albino rats were either sham-operated, control, CPT or BM 13.177-treated. The middle and left lateral hepatic arteries and portal veins were occluded in each group but the sham and the corresponding agents were given to the animals prior to I/R injury. After I/R injury, blood was drawn from the suprahepatic inferior vena cava for ET-1-like activity assay and liver tissue samples were obtained for the determination of prostaglandin E2 (PGE2), leukotriene C4 (LTC4) and histopathologic examination. PGE2 and ET-1 levels were increased significantly in the control group compared with the sham-operated group. In the CPT group, LTC4, PGE2 and ET-1 levels were significantly increased compared with the control group, while only ET-1 levels were not different from those of the control group in the BM 13.177-treated group. It is concluded that ET-1 release increases in response to I/R injury in rat liver and CPT further increases this release. It also appears that CPT has a stimulatory effect on arachidonic acid metabolism in addition to its free radical scavenging effect.

BQ-123, a specific endothelin (ETA) receptor antagonist, prevents ischemia-reperfusion injury in kidney transplantation

We studied the effects of the specific endothelin (ETA) receptor antagonist, BQ-123, on reperfusion injury in a rat model of kidney transplantation. First, Sprague-Dawley rats were divided into three groups: a sham nephrectomy (SNEPH), an autotransplantation (AUTO-Tx), and an allotransplantation (ALLO-Tx) group. In a fourth group, ALLO-Tx + BQ, allografts were flushed with 20 micrograms BQ-123 containing cold Ringer's lactate before transplantation. For the allograft groups, kidneys from white Wistar albino rats were transplanted into allogeneic Sprague Dawley recipients. Grafts were allowed 120 min of reperfusion after 40 min of cold ischemia. ET-1,2 plasma concentrations in the renal venous blood, and kidney tissue prostaglandin (PG) E2 and leukotriene (LT) B4 levels were studied. Diene conjugates (DC), hydroxyalkanals (HAA), hydroxyalkenals (HAE) and malondialdehyde (MDA) levels, as the products of lipid peroxidation, and protein carbonyls (PC) and protein sulphydryls (PS), as the parameters of protein oxidation, were also analyzed in the kidney tissue. Plasma ET concentrations increased significantly in the AUTO-Tx and ALLO-Tx groups (P < 0.05 and P < 0.01, respectively) but this increase was reversed in the ALLO-Tx + BQ group. None of the lipid peroxidation products except DCs (P < 0.05) increased in the AUTO-Tx group, whereas they all increased in the ALLO-Tx group (P < 0.01). Protein oxidation parameters also changed significantly (P < 0.01) in the ALLO-Tx group but did not in the AUTO-Tx group (P < 0.05). The differences in PGE2 and LTB4 levels were not significant. Histopathologic examination revealed prominent glomerular and tubular injury in the AUTO-Tx and ALLO-Tx groups but less in the ALLO-Tx + BQ group. In the last group, all parameters of lipid peroxidation (P < 0.001 for all) and PCs decreased, and PSs were preserved (P < 0.001 for both) when compared with the AUTO-Tx and ALLO-Tx groups. We conclude that BQ-123, in addition to inhibiting the binding of ET-1,2 to the ETA receptor, may also inhibit the release and/or synthesis of ET-1,2 and prevent reperfusion injury in kidney transplantation.

Gastric functions in portal hypertension. Role of endothelin

This study investigated the effects of portal hypertension on gastric motor and secretory functions and the role of endothelin in rats. Control; sham-operated; endothelin-A receptor blocker, BQ 485 (1 microgram/kg)-treated; portal hypertensive; and portal hypertension +, endothelin-A receptor blocker-treated rats were subjected to tests of gastric secretory, motor, and mucosal function studies as well as gastric wall polymorphonuclear infiltration. Portal hypertension was induced by partial portal vein ligation. Portal hypertension suppressed gastric acid and total fluid secretion and delayed gastric emptying. An increase in mucosal permeability and no alteration in gastric wall myeloperoxidase activity were observed. The effects of portal hypertension on gastric secretory, motor, and mucosal functions were reversed by treatment with endothelin-A receptor blocker, BQ-485. It is concluded that portal hypertension suppresses the gastric motor and secretory functions and endothelin plays an important role in the pathophysiology of gastric alterations associated with portal hypertension.

The effect of thermal injury on gastric emptying in rats

Gastric distension and gastrointestinal discomfort are common complications of burn injuries. This study was designed to examine the effect of thermal injury on the emptying rate of liquids in conscious rats fitted with stainless steel cannulae in the body of the stomach. In rats with partial-thickness burns emptying of the hyperosmolal saline was found to be delayed (P < 0.5) with respect to control only during the chronic phase of injury. However, full-thickness burns delayed hyperosmolal saline emptying in both acute and chronic phases, together with delayed saline emptying in the acute state. Thermal injury did not influence the gastric emptying of peptone and acid solutions, which activate different pathways to delay gastric emptying. Delayed gastric emptying of hyperosmolal solutions may be explained by increased sympathetic and opiatergic nervous activities, resulting in reflex relaxation of gastric smooth muscle.

The involvement of muscarinic receptors in gastric liquid emptying in the conscious rat following Roux-en-Y-antrectomy

The gastric emptying of liquid test meals is dependent on resistance to flow at the pylorus and on pressure gradients between the duodenum and the body of the stomach. In the present study, we investigated the role and subtypes of muscarinic receptors during gastric emptying of various liquid test meals in conscious rats with gastric fistula after Roux-en-Y antrectomy. In the control rats with gastric fistula but with intact reflex pathways and pylorus, the non-selective muscarinic antagonist atropine (7 mg/kg i.p.) and M1-selective pirenzepine (7 mg/kg i.p.), acting possibly on M1 receptors, delayed saline emptying by suppressing cholinergic tone and thus relaxing the body of the stomach and contracting the pyloric sphincter. On the other hand, in Roux-rats saline and hyperosmolal saline emptying were not significantly affected, while the inhibitory effect of HCl was completely reversed. Furthermore, peptone-induced delay of gastric emptying in control rats was also reduced in Roux-rats. Pirenzepine abolished the facilitating effects of Roux-en-Y operation on acid and peptone emptying and M2-selective antagonist AF DX-116 (7 mg/kg i.p.) did not have any inhibitory effect in this regard. In conclusion, Roux-en-Y gastrectomy without vagotomy does not slow gastric emptying of liquids, and it reverses the inhibitory effects of peptone and acid through an atropine- and pirenzepine-sensitive pathway.

Captopril increases endothelin serum concentrations and preserves intestinal mucosa after mesenteric ischemia-reperfusion injury

Endothelial cells modulate the tone of the underlying smooth muscle by generating endothelium-derived relaxing and constricting factors. Captopril (CPT), unlike other angiotensin-converting enzyme (ACE) inhibitors, contains a sulfhydryl (-SH) group and can act as a free radical scavenger. Iloprost (ILO) is a synthetic analogue of prostacyclin and mimics the effects of this compound. This study was designed to investigate the effect of ILO and CPT on the mechanism of endothelin (ET) release after mesenteric ischemia-reperfusion (I/R) injury in the rat. Sprague-Dawley rats were divided into five groups: sham-operated, control, ILO (25 micrograms/kg), CPT (10 micrograms/kg), and ILO + CPT. The superior mesenteric artery was occluded for 30 min and then allowed 90 min of reperfusion, except in the sham-operated group, and the corresponding agents were given to the treated groups prior to I/R injury. After I/R injury, portal venous blood was obtained for ET assay, and ileal tissue samples were also obtained for the determination of malondialdehyde (MDA), prostaglandin E2 (PGE2) and leukotriene C4 (LTC4) and for histopathological examination. MDA levels were significantly lower in the CPT, ILO and, ILO + CPT groups than in the control group, indicating the inhibition of lipid peroxidation in all groups. ET levels increased in the control group, and this increase was reversed with ILO. In the CPT group, ET levels were significantly increased, and the addition of ILO did not affect this increase. Significant cytopreservative effect was achieved with ILO and CPT, the latter being more prominent histopathologically. CPT exerts a significant protective effect on the intestinal mucosa after I/R injury. This protection is accomplished by increased ET levels and seems to be unrelated to its inhibitory effect on lipid peroxidation and also unrelated to the arachidonic acid cascade.

The effect of Iloprost (ZK 36374) on isolated and transplanted pancreatic islet cells

Several methods have been described for the prolongation of survival of isolated and transplanted islet cells. To investigate the effect of a stable prostacyclin analogue, ZK 36374 (Iloprost) on isolated and allotransplanted islet cell function, we studied 6 groups of rats: Group 1 (n = 7) animals underwent pancreatectomy and their islets were isolated and cultured by standard techniques. Group 2 (n = 8) animals were treated the same, except for the addition of Iloprost to the culture solutions. Group 3 (n = 7) animals were treated as group 1, but the isolated islets were transplanted to the subcapsular space of the left kidney of group 5 (n = 7) animals. Group 4 (n = 8) animals were treated as group 2, and the isolated islets were transplanted to group 6 (n = 8) animals. The insulin levels in the culture media obtained in group 1 and 2 were measured. In groups 5 and 6 blood glucose levels were measured and intraperitoneal glucose loading tests were performed. Histological examination was performed for both isolated and transplanted islets. The results showed that both insulin levels and histologic evaluation were better for group 2 than group 1. Animals in group 6 reached normoglycemia on the fifth day following transplantation while it was the ninth day for group 5. The intraperitoneal glucose loading test was tolerated better by group 6 animals. We conclude that Iloprost may be responsible for the improved results which seem to be due to its cytoprotective effect.

How minimally invasive is laparoscopic cholecystectomy?

To determine the extent of surgical stress induced by open (n = 20) and laparoscopic (n = 20) cholecystectomy, postoperative serum cortisol, growth hormone, and insulin responses were determined for each group. The groups were similar regarding age, sex distribution, and duration of the surgical procedures. The open cholecystectomy group had significant elevations of serum cortisol, growth hormone, and insulin levels 8 h after surgery (p < 0.05). The increased cortisol and growth hormone levels returned to preoperative control values 48 h after surgery. In the laparoscopically operated group, although all hormones increased after surgery, only the increase in growth hormone was statistically significant (p < 0.05). Serum cortisol and growth hormone levels gradually returned to control values 48 h after surgery, but the increased serum insulin levels remained significantly high in both groups 24 and 48 h after surgery (p < 0.05). It is concluded that acute surgical stress induced by open cholecystectomy is more severe than that induced by laparoscopic surgery as reflected by serum hormone determinations. However, the hormonal convalescence rate was similar for both groups. It appears that laparoscopic cholecystectomy is "minimally invasive" concerning the hormonal responses.

Effect of verapamil and iloprost (ZK 36374) on endothelin release after mesenteric ischemia-reperfusion injury

In this experimental study we studied the effect of verapamil and iloprost on endothelin release in ischemia/reperfusion (IR) injury of the rat intestine. Endothelin levels in the portal blood and malondialdehyde (MDA), PGE2, and LTC4 levels in the intestinal tissue were determined. The MDA levels increased in the control group and this increase was reversed with iloprost, verapamil and both. The change in the LTC4 levels was insignificant between the groups. Iloprost reduced PGE2 and endothelin release, but verapamil was not as effective and no synergistic effect was encountered. The increased PGE2/LTC4 ratio was also reversed in the experimental groups, verapamil being less effective. Endothelin release seems to be related to both PGE2 levels and the PGE2/LTC4 ratio after mesenteric IR injury.

Surgical treatment of hepatic hydatid cysts

Ninety-two surgical procedures were carried out in 82 patients with 92 hepatic hydatid cysts. The most common complication of the hydatid cyst was biliary rupture (17.3%) followed by infection of the cyst cavity (5.4%). Omentoplasty was carried out for uncomplicated cysts (38.0%) with a low morbidity (14.2%) and short hospital stay (mean 12.8 days). External tube drainage was carried out in 30.5% of patients. The morbidity rate was 67.8% and the mean hospital stay was 19.8 days. No single method can be recommended for the treatment of hepatic hydatid cysts but the choice of the surgical method must be made according to the complications of the cyst. Omentoplasty is the procedure of choice for uncomplicated cysts with a low complication rate and relatively short hospital stay. External tube drainage is recommended for infected cysts and a biliary drainage procedure must be added to external tube drainage for cysts with intrabiliary rupture.

The cytoprotective effects of verapamil and iloprost (ZK 36374) on ischemia/reperfusion injury of kidneys

We investigated the cytoprotective effects of verapamil, a Ca channel blocker, and of iloprost (ZK 36374), a stable prostacyclin analogue, on ischemia/reperfusion (I/R) injury in Wistar albino rat kidneys that were subjected to 60 min of warm ischemia and reperfusion. The groups included sham, ischemia-untreated (ISCH), verapamil-treated (VER), iloprost-treated (ILO), and verapamil + iloprost (VER + ILO)-treated rats. The 7-day survival of all the treated groups was better than that of the ISCH group. The creatinine concentration on the 3rd day was significantly lower in the VER + ILO group than in the ISCH group. Serum creatinine on day 3 was also low in the VER + ILO groups compared to the ISCH group, although the differences were not significant. The creatinine values on day 7 were significantly lower in the VER and ILO group than in the control, VER, or ILO groups. The malondialdehyde (MDA) concentrations of the kidney cortex tissue after reperfusion in all groups were higher than normal. The tissue-reduced glutathione (GSH) concentrations of the kidneys sampled immediately after reperfusion were significantly lower in the ISCH group than in all of the other treated groups. These results indicate that although verapamil and iloprost have independent cytoprotective effects on 60-min warm ischemia/reperfusion injury of rat kidneys, the protection afforded when both drugs are combined is synergistic. The mechanism of cytoprotection is not limited to the suppression of lipid peroxidation, and a nearly complete protection of reperfusion injury can be obtained by such an intervention.

A case of inappropriate non-neoplastic secretion of TSH treated with bromocriptine

A 67 year old patient with overt signs of hyperthyroidism had high serum TSH values in addition to high T3 and T4 values. Initial treatment with propyltiouracil (PTU) reduced the high serum thyroid hormone levels but TSH levels were further increased. With an augmented TSH response to TRH and negative sella tomography, diagnosis of inappropriate secretion of TSH was made. PTU was stopped and bromocriptine 10 mg daily given with perfect result in 18 weeks. The patient is euthyroid on bromocriptine therapy.

Importance of testing stapled rectal anastomoses with air

OBJECTIVE

To compare the air test (insufflation of air through the anus after the peritoneal cavity has been filled with saline) and the completeness of doughnuts as indicators of the integrity of stapled rectal anastomoses.

DESIGN

Prospective open study.

SETTING

Marmara University Hospital, Istanbul, Turkey.

SUBJECTS

23 patients with sigmoid and rectal carcinoma.

MAIN OUTCOME MEASURES

Correlation between positive air test, completeness of doughnuts, and clinical anastomotic breakdown.

RESULTS

Two patients were withdrawn (one had a handsewn anastomosis and in one the air test was omitted). Five patients had positive air tests, and in four of these the doughnuts were complete. The leaks were repaired with additional sutures in three patients, and two were given covering colostomies. There was only one clinical anastomotic breakdown.

CONCLUSION

The air test enabled the surgeon to repair or protect five anastomoses (24%). The completeness of the doughnuts was an reliable test of anastomotic integrity.

Significance of intracystic pressure in abdominal hydatid disease

A prospective study was performed in 32 patients (24 female, eight male) with 50 abdominal hydatid cysts, to assess whether intracystic pressure (ICP) could predict viability. The median ICP, measured during operation, was 35 cmH2O for 31 viable cysts and zero for nine non-viable cysts located in the liver (P < 0.05). The median ICP was significantly higher in cysts located in the left lobe of the liver than in those in the right (P < 0.05). The ICP was not significantly different in unilocular or multilocular cysts. ICP increased as the diameter of the cysts increased. The sensitivity of the indirect haemagglutination test was 86 per cent and the specificity 75 per cent. It is concluded that measurement of ICP is a simple and reliable method for assessment of the viability of abdominal hydatid cysts.