155 A Machine Learning-Based Approach for Predicting Surgeons’ Subjective Experience and Skill Levels: Neuroimaging Study

Aim

Measuring cognitive load is important for surgical education and patient safety. Traditional approaches of measuring cognitive load of surgeons utilise behavioural metrics to measure performance and surveys and questionnaires to collect reports of subjective experience. There is a need for more automated, more accurate and objective evaluation methods.

Method

Functional neuroimaging data was collected using wireless NIRS device from sixteen surgeons (11 attending surgeons and 5 surgery resident) and 17 students while they performed two laparoscopic tasks (Peg transfer and String pass). Participant’s subjective mental load was assessed using NASA-TLX survey. Machine learning approaches were used for predicting the subjective experience and skill levels.

Results

The Prefrontal cortex (PFC) activations were greater in students who reported higher-than-median task load, as measured by the NASA-TLX survey. However, in the case of attending surgeons the opposite tendency was observed, namely higher activations in lower v higher task loaded subjects. We found response was greater in the left PFC of students particularly near dorso- and ventrolateral areas. We quantified the ability of PFC activation to predict differences in skill and task load using machine learning while focusing on the effects of NIRS channel separation distance on the results. Our results showed that the classification of skill level and subjective task load could be predicted based on PFC activation with an accuracy of nearly 90%.

Conclusions

The high accuracy of results is encouraging and suggest the integration of the strategy developed in this study as a promising approach to design automated, more accurate and objective evaluation methods.

General Surgery Operating Room Practice in Patients with COVID-19

The virus COVID-19, which emerged in China in December 2019, was announced by the World Health Organization as a pandemic in January 2020. It is known that infection is not severe and may even progress without symptoms in patients who have come into contact with COVID-19. Although various organizations have been informed about how to take measures to protect the patient and the surgeon in case of diseases requiring urgent or elective surgery in people infected with COVID-19 or in cases with high suspicion, there is still no definite judgment between patients, physicians and health authorities. In this study, which was prepared with the initiative of the Turkish Surgical Association, we tried to shed light on what should be done and how surgeons should act in patients whose operation is mandatory in light of the available data.

Diagnosis and management of acute appendicitis. EAES consensus development conference 2015

Unequivocal international guidelines regarding the diagnosis and management of patients with acute appendicitis are lacking. The aim of the consensus meeting 2015 of the EAES was to generate a European guideline based on best available evidence and expert opinions of a panel of EAES members. After a systematic review of the literature by an international group of surgical research fellows, an expert panel with extensive clinical experience in the management of appendicitis discussed statements and recommendations. Statements and recommendations with more than 70 % agreement by the experts were selected for a web survey and the consensus meeting of the EAES in Bucharest in June 2015. EAES members and attendees at the EAES meeting in Bucharest could vote on these statements and recommendations. In the case of more than 70 % agreement, the statement or recommendation was defined as supported by the scientific community. Results from both the web survey and the consensus meeting in Bucharest are presented as percentages. In total, 46 statements and recommendations were selected for the web survey and consensus meeting. More than 232 members and attendees voted on them. In 41 of 46 statements and recommendations, more than 70 % agreement was reached. All 46 statements and recommendations are presented in this paper. They comprise topics regarding the diagnostic work-up, treatment indications, procedural aspects and post-operative care. The consensus meeting produced 46 statements and recommendations on the diagnostic work-up and management of appendicitis. The majority of the EAES members supported these statements. These consensus proceedings provide additional guidance to surgeons and surgical residents providing care to patients with appendicitis.

Solid Gastric Emptying after Highly Selective Vagotomy and Pyloroplasty in Patients with Obstructing Duodenal Ulcer

Before being superseded by medical management, highly selective vagotomy (HSV) without drainage was the procedure of choice for uncomplicated duodenal ulcer. It is also justified for complications, including perforation and bleeding in selected cases. This prospective study evaluated the effects of HSV plus drainage on solid gastric emptying in 20 patients with chronic duodenal ulcer and pyloric stenosis. Patients were treated with HSV plus pyloroplasty (Heineke-Mikulicz pyloroplasty in five patients, Finney pyloroplasty in six patients and Jaboulay gastroduodenostomy in nine patients) and underwent solid-phase gastric emptying scintigraphic studies pre-operatively and 2 months and 6 months post-operatively. Results were compared with those from 10 controls. No significant differences were observed between the different types of pyloroplasty, although emptying was slightly faster in the gastroduodenostomy group. Gastric emptying returned to normal by 6 months post-operatively. In conclusion, HSV plus pyloroplasty is effective and can be used for the relief of stenosis in selected cases of duodenal ulcer.

Predictors of poor outcome in gastrointestinal bleeding in emergency department

AIM: To determine the prognostic risk factors of gastrointestinal bleeding in emergency department cases.

METHODS: The trial was a retrospective single-center study involving 600 patients over 18-years-old and carried out with approval by the Institutional Ethics Committee. Patient data included demographic characteristics, symptoms at admission, past medical history, vital signs, laboratory results, endoscopy and colonoscopy results, length of hospital stay, need of intensive care unit (ICU) admission, and mortality. Mortality rate was the principal endpoint of the study, while duration of hospital stay, required interventional treatment, and admission to the ICU were secondary endpoints.

RESULTS: The mean age of patients was 61.92-years-old. Among the 600 total patients, 363 (60.5%) underwent upper gastrointestinal endoscopy and the most frequent diagnoses were duodenal ulcer (19.2%) and gastric ulcer (12.8%). One-hundred-and-fifteen (19.2%) patients required endoscopic treatment, 20 (3.3%) required surgical treatment, and 5 (0.8%) required angiographic embolization. The mean length of hospital stay was 5.21 ± 5.85 d. The mortality rate was 6.3%. The ICU admission rate was 5.3%. Patients with syncope, higher blood glucose levels, and coronary artery disease had significantly higher ICU admission rates (P = 0.029, P = 0.043, and P = 0.002, respectively). Patients with low thrombocyte levels, high creatinine, high international normalized ratio, and high serum transaminase levels had significantly longer hospital stay (P = 0.02, P = 0.001, P = 0.019, and P = 0.005, respectively). Patients who died had significantly higher serum blood urea nitrogen and creatinine levels (P = 0.016 and P = 0.038), and significantly lower mean blood pressure and oxygen saturation (P = 0.004 and P = 0.049). Malignancy and low Glasgow coma scale (GCS) were independent predictive factors of mortality.

CONCLUSION: Prognostic factors for gastrointestinal bleeding in emergency room cases are malignancy, hypotension on admission, low GCS, and impaired kidney function.

STEAP4 and HIF-1α gene expressions in visceral and subcutaneous adipose tissue of the morbidly obese patients

AIM AND BACKGROUND

Obesity is a multifactorial disease in which environmental and genetic factors play an integrated role. Determining such target genes will help to elucidate the mechanisms underlying complex diseases such as obesity and diabetes which are usually seen together. Present study investigates the expression levels of STEAP4 and HIF-1α in visceral and subcutaneous adipose tissue.

PATIENTS AND METHODS

30(6M) morbidly obese patients undergoing bariatric surgery were included in the study. The patients were grouped according to the BMI as Group I (BMI <50kg/m(2)) and Group II (BMI ≥50kg/m(2)). Samples from visceral (omentum) and subcutaneous adipose tissues were obtained from each patient and real-time PCR (qPCR) was carried out for STEAP4 and HIF-1α gene expressions. Correlations between expression levels and clinical parameters were analyzed.

RESULTS

Mean age of the patients recruited to the study was 37.4 (18-64) years. Mean BMI was 46 (36-60) kg/m(2). STEAP4 expression in visceral adipose tissue was significantly higher than subcutaneous tissue. Visceral STEAP4 expression was also found to be reduced with increased BMI. It was also lower in patients with HbA1C over 6. Furthermore, expression of subcutaneous and visceral HIF-1α was significantly higher in Group II. There was a significant correlation between BMI, glycosylated hemoglobin, STEAP4 and HIF-1α gene expression.

CONCLUSIONS

Obesity and related disease are linked with the fact that there is a low grade inflammation in the adipose tissue of the obese individuals. Counter-regulatory processes such as STEAP4 protein family are overwhelmed by the proinflammatory stimuli. HIF-1α expression is increased due to tissue hypoxia and pro-inflammatory stimuli in the obese individuals, which results in increased visceral STEAP4 expressions.

ESTES guidelines: acute mesenteric ischaemia

PURPOSE

Acute mesenteric ischaemia (AMI) accounts for about 1:1000 acute hospital admissions. Untreated, AMI will cause mesenteric infarction, intestinal necrosis, an overwhelming inflammatory response and death. Early intervention can halt and reverse this process leading to a full recovery, but the diagnosis of AMI is difficult and failure to recognize AMI before intestinal necrosis has developed is responsible for the high mortality of the disease. Early diagnosis and prompt treatment are the goals of modern therapy, but there are no randomized controlled trials to guide treatment and the published literature contains a high ratio of reviews to original data. Much of that data comes from case reports and often small, retrospective series with no clearly defined treatment criteria.

METHODS

A study group of the European Society for Trauma and Emergency Surgery (ESTES) was formed in 2013 with the aim of developing guidelines for the management of AMI. A comprehensive literature search was performed using the Medical Subject Heading (MeSH) thesaurus keywords "mesenteric ischaemia", "bowel ischaemia" and "bowel infarction". The bibliographies of relevant articles were screened for additional publications. After an initial systematic review of the literature by the whole group, a steering group formulated questions using a modified Delphi process. The evidence was then reviewed to answer these questions, and recommendations formulated and agreed by the whole group.

RESULTS

The resultant recommendations are presented in this paper.

CONCLUSIONS

The aim of these guidelines is to provide recommendations for practice that will lead to improved outcomes for patients.

The effects of obstructive jaundice on the brain: An experimental study

BACKGROUND/OBJECTIVE

The study aims to evaluate the alterations in the brain due to oxidative stress and lipid peroxidation resulting from obstructive jaundice.

METHODS

Forty-one Wistar albino rats were used in this study. Simple laparotomy was performed in the sham group (n = 5). In the remaining 36 rats, the common bile duct (CBD) was found and ligated. They were divided into six groups. Group I, Group II, and Group III were sacrificed at the 3(rd), 7(th), and 14(th) day of ligation, respectively. In Group Id, Group IId, and Group IIId ligated bile ducts were decompressed at the 3(rd), 7(th), and 14(th) day, respectively. One week after decompression these rats were also sacrificed and samples were taken.

RESULTS

After the CBD ligation, serum levels of bilirubin and malondialdehyde were found to be increased progressively in parallel to the ligation time of the CBD. After decompression these values decreased. In electron microscopy evaluation, the damage was found to be irreversible depending on the length of the obstruction period. In Group II, the damage was mostly reversible after the internal drainage period of 7 days. However in Group III, the tissue damage was found to be irreversible despite the decreased values of oxidative stress and bilirubin.

CONCLUSION

Ultrastructural changes in brain tissue including damage in the glial cells and neurons, were found to be irreversible if the CBD ligation period was >7 days and did not regress even after decompression. It is unreliable to trace these changes using blood levels of bilirubin and free radicals. Therefore, timing is extremely critical for medical therapies and drainage.

Improved oxidative status in major abdominal surgery patients after N-acetyl cystein supplementation

Background

Increased levels of reactive oxygen species during and after surgery may affect inflammatory response, post-operative adhesion molecule formation, and hemodynamic stability. The glutathione redox cycle is an important regulator in oxidative stress and its reduced forms scavenge free radicals. N-acetyl cysteine, a precursor of reduced glutathione, is considered as a potentially therapeutic wide spectrum agent in clinical practice. We therefore examined whether N-acetyl cysteine improves some biochemical parameters in cancer patients undergoing major abdominal surgery.

Methods

Thirty-three patients diagnosed with pancreas, stomach, rectum, colon malignancies, and undergoing major abdominal surgery at Ankara Numune Training and Research Hospital were randomly divided into two groups; control (CON) and N-acetyl cysteine (NAC). The NAC group had 1,200 mg N-acetyl cysteine starting two days before the operation day, in addition to isonitrogenous and isocaloric total parenteral nutrition of 1.2 g/kg protein, 25 kcal/kg, and 60:40 carbohydrate/fat ratio. Blood and urine samples were drawn two days before the operation, on operation day, and on the first, third, and fifth days post-operation.

Results

Plasma malondialdehyde was significantly lower in the NAC group (P < 0.001). N-acetyl cysteine treatment did not affect plasma levels of vitamin A, C or E. The NAC group exhibited a higher ratio of reduced glutathione to oxidised glutathione (P = 0.019). Urinary nitrate level was also significantly lower in the NAC group (P = 0.016).

Conclusion

The study demonstrated the clinical importance of N-acetyl cysteine supplementation on antioxidant parameters in abdominal surgery patients. In these patients N-acetyl cysteine and vitamin administration can be considered as an effective method for improvement of oxidative status.

Current adjuvant therapeutic approaches for pancreatic cancer

Pancreatic cancer continues to be the fourth leading cause of death despite advancements in surgical and adjuvant therapeutic approaches. In the present review, the current cytotoxic therapeutic approaches and advanced targeted therapies are objectively discussed with consideration to the current literature.

Relationship between LYVE-1, VEGFR-3 and CD44 gene expressions and lymphatic metastasis in gastric cancer

AIM: To investigate the expression levels of lymphatic vessel endothelial hyaluronan receptor-1 (LYVE-1), vascular endothelial growth factor receptor-3 (VEGFR-3) and CD44 genes and the relationship between their levels and clinicopathological parameters in gastric cancer.

METHODS: Tissue samples were obtained from 33 patients (8 females) with gastric cancer. mRNA levels of LYVE-1, VEGFR-3 and CD44 in normal and tumor tissues were quantitatively measured using real time polymerase chain reaction. The results were correlated with lymph node metastasis, histological type and differentiation of the tumor, T-stage, and presence of vascular, perineural and lymphatic invasions. The distribution of molecules in the tissue was evaluated using immunohistochemistry.

RESULTS: LYVE-1, CD44 and VEGFR-3 gene expression levels were significantly higher in gastric cancer than in normal tissue. While there was no correlation between gene expressions and clinicopathologic features such as histologic type, differentiation and stage, gene expression levels were found to be increased in conjunction with positive lymph node/total lymph node ratio and the presence of perineural invasion. A significant correlation was also found between LYVE-1 and CD44 over-expressions and perineural invasion and lymph node positivity in gastric cancers. When the distribution of LYVE-1 antibody-stained lymphatic vessels in tissue was evaluated, lymphatic vessels were located intra-tumorally in 13% and peri-tumorally in 27% of the patients. Moreover, lymph node metastases were also positive in all patients with LYVE-1-staining.

CONCLUSION: LYVE-1, VEGFR-3 and CD44 all play an important role in lymphangiogenesis, invasion and metastasis. LYVE-1 is a perfectly reliable lymphatic vessel marker and useful for immunohistochemistry.

A new technique for inducing and releasing obstructive jaundice in rats

AIM

It was the aim of this study to develop a simple, effective and reversible model of obstructive jaundice in rats.

MATERIAL AND METHOD

Totally, 24 rats were divided into 3 groups: the sham group including sham-operated control rats who underwent laparotomy only (n = 8), the common bile duct standard ligation technique (CBD-SL) group including rats with CBD ligation using silk (n = 8), and the CBD new ligation technique (CBD-NL) group consisting of rats with CBD ligation by a new technique (n = 8). After release of the ligations, the CBD-SL group continued as the CBD-SL releasing group, and the CBD-NL group as the CBD-NL releasing group.

RESULTS

It was observed that all the CBD ligated rats were both clinically and biochemically jaundiced but they were relieved after reversing the procedure.

CONCLUSION

We present a simple, effective and reliable rat model which is suitable for studies which require a reversal of obstructive jaundice in rats.

The correlation between reactive oxygen species and histopathology of the liver, gut, and kidneys in animals with elevated intra-abdominal pressure

BACKGROUND

Clinical and experimental studies have shown that the laparoscopic procedure provides a typical model of ischemia-reperfusion injury in the organs by oxygen-derived free radicals. A pneumoperitoneum produces ischemia during insufflation and reperfusion during desufflation. The aim of this study was to assess the causative role of free radical-mediated reactions in tissue damage under different intra-abdominal insufflation pressures.

MATERIALS AND METHODS

Thirty five mature New Zealand white rabbits were assigned to three groups of 10 animals. In groups 1, 2, and 3, the designated pressures of 10, 15, and 20 mm Hg, respectively. The remaining 5 animals underwent laparotomy, using a 10-cm midline incision taken as group 4 (control). Blood samples were collected before (0 minutes) and at the end of the procedure (60 minutes). After the collection of the last blood samples, all animals were sacrificed and the samples from the liver, kidney, and gut were obtained for histologic evaluation and also measurements of tissue malondialdehyde (MDA) levels.

RESULTS

The nitric oxide levels were not changed in groups 1 and 2, but increased significantly in group 3. Tissue MDA levels were significantly higher in groups 1 and 2 than groups 3 and 4. Histopathologic examination of the kidney revealed some findings of reversible hypoxic cell injury, including acute cellular swelling, vascular congestion, and some early findings of irreversible injury, such as lysis of the cytoplasmic membrane in all groups and focal parancymal bleeding area in only group 3 as a consequence of increased pressure. Liver histology revealed cellular swelling and karyorhexis in hepatocytes in group 1, whereas only congestion and sinusoidal dilatation was observed in groups 2 and 3.

CONCLUSION

Our experimental study showed that abdominal insufflation causes ischemia and free radical production, which seems responsible for the cell damage that occured during laparoscopic surgery.

Effect of erythropoietin on oxidative stress and liver injury in experimental obstructive jaundice

BACKGROUND

To evaluate the time-dependent effects and pathophysiological mechanism of erythropoietin (Epo) on oxidative stress and liver injury resulting from obstructive jaundice in common bile duct-ligated rats.

METHODS

Wistar Albino rats were divided into 5 groups, each including 8 rats. The sham group underwent laparotomy only, while the Non-Epo-3 and Non-Epo-7 groups underwent common bile duct ligation and were sacrificed 3 and 7 days, respectively, after the operation. The Epo-3 and Epo-7 groups underwent common bile duct ligation and Epo treatment and were sacrificed 3 and 7 days, respectively, after the operation. Blood and tissue samples were collected from all groups for the determination of oxidative injury and hepatocellular damage. Serum total and direct bilirubin levels, alkaline phosphatase, reduced glutathione (GSH), nitric oxide (NO), malondialdehyde (MDA) and white blood cell counts were measured.

RESULTS

Significantly higher NO and MDA levels were found in Non-Epo groups than Epo groups. Significantly lower GSH levels were found in the Non-Epo-7 group than the Epo-7 and sham groups. Hepatocellular damage was also found to be reduced in Epo groups.

CONCLUSIONS

In the present model, while common bile duct ligation increased oxidative injury and hepatocellular damage, treatment with Epo attenuated oxidative injury and hepatocellular damage by decreasing NO and increasing GSH.

The prevalence of factor V (G1691A), MTHFR (C677T) and PT (G20210A) gene mutations in arterial thrombosis

BACKGROUND

Factor V (FV) [G1691A], methylenetetrahydrofolate reductase (MTHFR) [C677T] and prothrombin (PT) [G20210A] mutations are all well-recognized genetic risk factors for venous thrombosis. Although their prevalence in coronary artery disease has been established through debate, their role in patients with arterial thrombosis remains to be clarified. We investigated the prevalence rates of FV, MTHFR and PT gene mutations in patients with arterial thrombosis and in healthy controls.

METHODS

All subjects and controls were from Central Anatolia. Thirty (8F) patients with median (range) age of 63 (16-88) years and 90 (52F) healthy controls with median (range) age of 31 (20-73) years were studied. DNA was extracted using conventional methods (proteinase K/phenol-chloroform) followed by PCR amplification and restriction endonuclease digestion (using Hinf I and Hind III). Digested PCR products were identified using agarose gel electrophoresis and stained with ethidium bromide.

RESULTS

The prevalence rates of MTHFR and PT gene mutations were not significantly different between the groups. The prevalence rate of FV mutation was significantly higher in patients with arterial thrombosis. Coinheritance of FV and MTHFR was found in 67% of patients, which was significantly higher in arterial thrombosis, suggesting the MTHFR mutation as a synergistic risk factor for thrombosis in patients with FV mutation. PT gene mutation has no effect on arterial thrombosis.

CONCLUSION

The increased prevalence rate and coexistence of both FV and MTHFR found in this group of patients suggest that these mutations might increase the risk of arterial thrombosis.

Serum D-lactate: a useful diagnostic marker for acute appendicitis

BACKGROUND/AIMS

Acute appendicitis is the most common acute surgical infection seen in emergency department. The present study aims to evaluate the sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) of the serum D-lactate levels as a marker for the diagnosis of acute appendicitis. D-lactate is the stereoisomer of the mammalian L(+)-lactate, and is produced by indigenous bacteria (Escherichia coli, Klebsiella, Bacteroides, Lactobacillus) in the gastrointestinal tract. Once obstruction occurs, appendix is a good medium for bacterial proliferation, and ischemic injury leads to an increase in D-lactate levels.

METHODOLOGY

A total of thirty-two consecutive patients with the suspicion of acute appendicitis were prospectively included in the study. Patient characteristics, ultrasonography (US) and laboratory assessment including white blood cell (WBC), C-reactive protein (CRP), D-lactate and intraoperative findings, histology results, clinical outcome were evaluated.

RESULTS

WBC level above 10(9)/L had an accuracy of 66%, whereas a CRP level above 5 mg/L had an accuracy of 75%. We observed that when the D-lactate level was greater than 0.25 mmol/L in acute appendicitis, the specificity was 60%, the false negative rate was 25% and the accuracy was 90%. The false negative rate of CRP (67%) was higher than that of D-lactate levels (25%). Ultrasound had a sensitivity of 96%, specificity 40% and accuracy 87% in our study.

CONCLUSIONS

We found positive correlations between serum D-lactate levels and acute appendicitis and serum D-lactate had the lowest false negative rate among the other parameters. Therefore, we conclude that D-lactate might be a simple and reliable diagnostic marker for appendicitis.

The effect of erythropoietin on healing of obstructive vs nonobstructive left colonic anastomosis: an experimental study

Background

Anastomotic leakage is an important problem following primary resection in the left colon and is even more prominent when obstruction is present. We aimed to evaluate the possible effects of erythropoietin on the healing of anastomosis under both obstructive and non-obstructive states.

Methods

Forty male Wistar albino rats were divided into four groups. In group I, two cm left colonic resection and primary anastomosis were done. In group II, left colon were completely ligated and 24 hours later animals were re-operated for segmental resection. The same procedures were performed for rats in group III and IV in respect to group I and II and, 500 IU/kg a day erythropoietin were given in the latter two groups for seven days. For the quantative description of anastomotic healing mechanical, biochemical and histopathological parameters were employed on the seventh day and the animals were sacrificied.

Results

Although erythropoietin had positive effects on bursting pressure in group IV when compared to group II, it has no effect in group III. Despite the increased tissue hydroxyproline levels in group IV, erythropoietin failed to show any effects in group III.

Erythropoietin had positive effects on neovascularization, fibroblast proliferiation and storage of collagen in group IV.

Conclusion

We failed to find any direct and evident effects of erythropoietin on healing of left colonic anastomosis. On the other hand, erythropoietin might prevent negative effects of obstruction on healing.

Lymphoscintigraphy in detection of the regional lymph node involvement in gastric cancer

INTRODUCTION

Involvement of regional lymph node is a critical sign in prognosis of gastric cancer. Radiological techniques are commonly used to evaluate the extension of gastric cancer. But their sensitivity and specificity are low especially in the early stage. Our aim was to assess the value of gastric lymphoscintigraphy in identifying regional lymph node involvement in patients with gastric cancer, as compared to the abdominal ultrasonography, computed tomography and postoperative histopathological evaluation.

PATIENTS AND METHODS

50 patients (12 females) with a median age of 61 years (range, 35-73 years) were included in the study. Pre-operative staging in all cases included upper gastrointestinal endoscopy and biopsy, followed by ultrasound, computed tomography and lymphoscintigraphy. 148 MBq Technetium-99m lymphoscint was injected around the tumour during endoscopy and immediately after injection, anterior, lateral and posterior images were taken in 5-min intervals using a gamma camera. Findings were compared to the findings of other tests. The sensitivity, specificity, positive predictive value, and negative predictive value of each test were calculated and compared.

RESULTS

Histologically, 68% of cases (34/50) had metastasis in regional lymph nodes and all cases were accurately diagnosed by lymphoscintigraphy. Lymphoscintigraphy was significantly more sensitive for detecting lymph node involvement (P < 0.01). Both abdominal ultrasonography and CT had very low sensitivity in identifying lymph nodes.

CONCLUSIONS

Lymphoscintigraphy is a promising test in the identification of regional lymph nodes pre-operatively in patients with gastric cancer. It might help the surgeon to plan the extent of dissection before surgery which may decrease postoperative complications related to unnecessary extensive lymph node dissection.

Falciform Ligament in the Management of the Residual Cavity for Liver Hydatidosis: New Surgical Technique

INTRODUCTION

Hydatid disease is a common condition worldwide and continues to be a significant societal problem in many countries of all continents. Alhough other treatment options are also available, surgery remains the cornerstone of therapy for hepatic hydatid disease. Omentoplasty seems to be an efficient technique for managing the residual cavity, but it has some shortcomings and might be difficult in secondary cases. Therefore we describe a new technique using the falciform ligament as a flap instead of omentum for managing the residual cavity, as it is more anatomic and a better option for liver cysts.

METHODS

From April 2004 to October 2005, a total of 20 patients (11 women) with a median age of 43 years (range 23-66 years) underwent partial cystectomy-falciformoplasty for hydatid liver disease. The falciform ligament was prepared as a flap in all patients during the initial step of the operation and, after partial cystectomy and evacuation of the cystic components, the flap was inserted into the cystic cavity and fixed with sutures. A single drain was inserted into the subhepatic area.

RESULTS

Cysts were located in the right lobe of the liver in 14 patients and mean diameter of the cyst was 10 cm (range 7-25 cm). The mean duration of the operation was 40 minutes (range 35-69 minutes), and the mean postoperative hospital stay was 4 days (range 3-7 days). None of the patients had any major complications. Only two patients had persistent drainage for 7 days, which stopped spontaneously. The median follow-up was 9 months (range 2-19 months). Patients underwent duplex ultrasonography (US) to check the viability of the flap and the residual cavity at 1 week, 1 month, and 3 months postoperatively. US did not reveal any collection, the cavities were fully collapsed, and blood flow to the falciform ligaments was seen to be viable.

CONCLUSIONS

Using the falciform ligament as a flap for management of the residual cavity is an easy, safe, effective new technique with few complications. It might be a good choice in patients with hydatid liver disease.

Intraoperative lymphatic mapping and sentinel lymph node biopsy using radioactive tracer in gastric cancer

BACKGROUND

Gastric cancer continues to be a significant health problem around the world. Surgical resection with a lymph node dissection remains the only potentially curative treatment with gastric cancer. Determination of the extent of lymph node dissection required on the basis of actual node involvement in patients with gastric cancer is important as less extensive dissection may reduce postoperative morbidity and mortality rates. The current study examines the feasibility and reliability of sentinel lymph node biopsy in gastric cancer.

METHODS

A total of 32 patients who underwent gastrectomy with extended lymphadenectomy were enrolled in this study. A total volume of 148 MBq (2 mL) technetium-99m-radiolabeled, filtered sulphur colloid solution was injected into the primary lesion under gastroscopy 2 hours before the operation. Lymph nodes were examined as soon as possible by a hand-held gamma probe during the operation, without significant manipulation of the stomach or greater omentum. A sentinel lymph node (SLN) was defined by a level of radioactivity 10 times higher than the background.

RESULTS

Thirty-one of 32 patients had successful SLN biopsy, with a success rate of 97%. The sensitivity, specificity, positive predictive value, and negative predictive value of SLN biopsy were 100%, 95%, 90%, and 100%, respectively.

CONCLUSIONS

SLN biopsy using gamma probe in gastric cancer is a feasible procedure with high sensitivity and accuracy. This technique may be of a great benefit to surgeons in planning the extend of lymph node dissection in gastric cancer.

Recurrent acute pancreatitis due to a hydatid cyst of the pancreatic head: a case report and review of the literature

CONTEXT

Primary pancreatic hydatid disease is rare and there have only been a few cases of recurrent acute pancreatitis due to a hydatid cyst of the pancreas.

CASE REPORT

We describe a case of recurrent acute pancreatitis in which the definitive diagnosis of hydatid cyst of the pancreatic head was only made during a repeat operation and the patient subsequently underwent total pericystectomy.

CONCLUSION

A hydatid cyst of the pancreas is an extremely rare condition but it may be a causative factor for recurrent acute pancreatitis, especially in endemic areas. In this case, pericystectomy might be the procedure of choice in order to release the pressure.

Outcomes of emergency surgical treatment in malignant bowel obstructions

BACKGROUND/AIMS

Malignant bowel obstructions are still a challenging problem for surgeons and carry high morbidity and mortality risk. The aim of this study was to review the presentation and outcomes of malignant bowel obstructions and to identify the risk factors related with poor prognosis.

METHODOLOGY

One hundred and twenty-five patients underwent emergency surgical treatment for malignant obstructions between January 1997 and January 2002. Data included age, sex, past medical history, presenting symptoms; physical findings on admission, American Society of Anesthesiologists (ASA) class, operative details, postoperative complications, length of hospitalization and hospital mortality were reviewed retrospectively.

RESULTS

Seventy-three (58%) of the patients have poor performance status on admission. Potentially curative resection was performed in 74 (60%) patients. Surgical treatment was palliative in 43 (34%) patients. Extended bowel resections were utilized in 20 (16%) patients. Our hospital mortality rate was 21%, and postoperative morbidity rate was 31%. Coexisting cardiopulmonary diseases, presence of generalized perforation, poor general condition and extended bowel resections appeared to be related with unfavorable outcomes.

CONCLUSIONS

Emergency surgical treatment for malignant obstruction may be curative in selected patients with good performance status.

Histoacryl blue versus sutured left colonic anastomosis: experimental study

BACKGROUND

Cyanoacrylates have been advocated as a protective seal in colonic anastomosis to prevent leakage. In order to assess the effects of n-butyl-2-cyanoacrylate on left colonic anastomosis it was compared to the sutured anastomosis in the rat.

METHODS

Forty male Wistar albino rats were divided into two groups of 20 each. On days 3 and 7, 10 animals in each group were killed. The comparisons between n-butyl-2-cyanoacrylate and sutured groups were made with respect to outcome measures including anastomotic leakage, anastomotic stricture, peritonitis and wound infections, and adhesion formation, anastomotic bursting pressure, histological appearance of the anastomotic area.

RESULTS

Although the adhesion formation was significantly more extensive in the n-butyl-2-cyanoacrylate group on day 3 (P < 0.001), there was no significant difference between the groups on day 7. The more inflammatory reaction also occurred in the n-butyl-2-cyanoacrylate group. The mean +/- SD anastomotic bursting pressure was significantly higher in the suture group than in the n-butyl-2-cyanoacrylate group (63 +/- 14 mmHg vs 43 +/- 8 mmHg) on day 3. The bursting pressure was also found to be higher on day 7 in the suture group (187 +/- 26 mmHg vs 49 +/- 12 mmHg, P < 0.0001). The suture group had a significantly higher bursting pressure on day 7 compared to day 3 (P < 0.05).

CONCLUSIONS

Left colonic anastomosis with n-butyl-2-cyanoacrylate in rats does not improve the healing process; on the contrary, it has a negative influence during the first week. As a consequence, the routine use of n-butyl-2-cyanoacrylate in colonic anastomosis in the clinical situation does not appear to be justifiable.

A rare primary location of echinococcal disease: report of a case

A case of primary hydatid disease, a rare location, is presented. The patient was a 20 year old female who presented with complaining of painful mass in the right hypochondrium 2 months before presantation. This cyst was strongly adherent to the two layers of m.rectus abdominis fascias. It was completely removed. No other site of hydatid disease was found and the patient remained well postoperatively.

New technique for inguinal hernia repair

We compared a new fascia transversalis based hernioplasty with mesh repair techniques which leave the fascia transversalis intact. We prospectively randomized 180 consecutive patients with inguinal hernia to undergo one of the three hernia repair techniques. Hernias were repaired either by using the new fascia transversalis repair-Coskun's hernia repair (FTR), based on the plication of fascia using continuous sutures and followed by a second layer of interrupted or continuous sutures between inguinal ligament and conjoint tendon to distribute the tension, or one of the two mesh repair techniques: anterior (Lichtenstein) or posterior (preperitoneal) repair. Parameters such as age, sex, hernia cause, operation time, type of anesthesia, surgeon's seniority, complications, hospital stay and follow-up were evaluated. Recurrence rates were determined through clinical examination. Effect of prostatism, co-morbid disease, operation time, complications and Nyhus type of hernia on recurrences were also analysed. Most patients in each group were operated on under general anesthesia (78% vs. 80% vs. 85% for FTR, Lichtenstein, and preperitoneal repair, respectively) and by surgeons in training (average 78%). Patients were followed up for a median of 36 months. FTR had less complications and an acceptable time for operation whereas preperitoneal repairs needed more seniority, longer operation time, and caused more complications. There were only 3 (1.6%) recurrences, none in the FTR group and two the in Lichtenstein group during first postoperative year. There was no recurrence in preperitoneal repair group. All patients with recurrences had an operation time longer than 60 min and were operated on by surgeons in training. Two patients with recurrences had prostatism symptoms and chronic cough. We conclude that the new FTR is as effective as mesh repair (either anterior or posterior) with an acceptable rate of recurrences, fewer complications, and that it can be performed by the surgeons in training.

Does serum hexosaminidase activity play a role in the diagnosis of strangulated bowel obstruction? An experimental study

Strangulation is associated with an increased risk of mortality and morbidity in patients with mechanical bowel obstruction. The accurate and early recognition of the presence of strangulation is important to allow safe nonoperative treatment. A number of studies have shown that there was no single and reliable test to detect or exclude the presence of strangulation. The aim of this study was to evaluate the role of serum hexosaminidase (Hex) levels in recognition of strangulation in an experimental model of closed loop small bowel obstruction. Forty-two Wistar albino rats were divided into four groups: I, control (n = 5); II, sham laparotomy (n = 5); III, simple obstruction (n = 16); and IV, strangulation groups (n = 16). Activity levels of total Hex and its fractions (Hex A and B) were assayed in serum samples obtained from rats after 3 and 8 hr. Samples of small bowel were also evaluated histologically. Histological evaluation of bowel sections obtained from the strangulation group after 8 hr, revealed transmural hemorrhagic infarction in all animals with a mean +/- SD total Hex activity of 978.25 +/- 150 nmol/hr/ml, which was significantly higher than that in the other groups (P < 0.001). Although sections of bowel from the strangulation group after 3 hr showed severe ischemic injury, the activities of total Hex, Hex A, and Hex B were not different from those of the control, sham, and simple obstruction groups. Histological examination of these groups did not show any sign of ischemia. Total Hex, Hex A, and Hex B activities in the strangulation group were all significantly greater than the activities seen in the simple obstruction group (P < 0.001, for all). In conclusion, increased serum hex levels indicate irreversible transmural infarction only in the late period of strangulation in the closed loop small bowel obstruction model. It seems unuseful for detecting reversible and/or irreversible ischemia in the early period of strangulation.

[The role of nitric oxide in trauma and infection]

Nitric oxide (NO) is a very important molecule for homeostasis. It is involved in several pathological conditions ranging from hypertension to septic shock. It is synthesized from L-arginine, which is catalyzed by nitric oxide synthase (NOS). Both constitutional and inducible NOS are involved in NO synthesis. While NO produced by constitutional NOS is required for normal physiologic processes, excessive production by inducible NOS results in injury and tissue damage. Induced NO may be either protective or damaging in acute inflammatory conditions. As a result of pluripotent activities, NO presents as a paradoxical phenomenon in almost all conditions in which confusing aspects arise concerning the pathophysiology. This article reviews the role of NO in trauma and infections.

The evaluation of the peak flow velocity and cross-sectional area of the femoral artery and vein following totally extraperitoneal vs preperitoneal open repair of inguinal hernias

BACKGROUND

Both totally extraperitoneal (TEP) and preperitoneal (PPOR) approaches involve the placement of prosthetic material preperitoneally. As the prosthetic material overlies the femoral artery and vein, we aimed to assess its effect on the velocity and the diameter of the artery and vein, using colour Doppler ultrasonography in both approaches.

METHODS

Eighty patients with unilateral groin hernia were prospectively randomised to have either TEP repair (n = 40) or PPOR (n = 40). All patients underwent colour Doppler ultrasound study 6 months after the procedure, and all patients were followed up for 5 years to evaluate real recurrence rates.

RESULTS

Our study revealed that neither mean diameter nor mean flow velocity is changed by the insertion of the mesh preperitoneally. Change was only observed in the peak systolic femoral arterial blood velocity, which was significantly decreased in the PPOR group. We also found that no patient in this study developed a clinically significant deep-vein thrombosis during 6 months of follow-up.

CONCLUSIONS

It is concluded that the insertion of a prosthetic mesh during TEP or PPOR does not influence the mean peak flow velocity and the cross-sectional area of the vessels in the inguinal region and can be used safely for open and laparoscopic preperitoneal approaches.

The effects of verapamil vs. allopurinol on intestinal ischemia/reperfusion injury in rats. "An experimental study"

BACKGROUND/AIMS

Although studies have reported that xanthine oxidase inhibitors or calcium channel blockers attenuate the ischemia-reperfusion injury in several organ systems, no comparative study exists on the significance of each of these pathways. To study this, in anesthetized Wistar Albino rats, a surgical model for intestinal ischemia-reperfusion injury was employed.

METHODOLOGY

In experimental animals, after laparotomy, the superior mesenteric artery was occluded for 30 min, followed by a 2-h period of reperfusion; control rats underwent only a sham laparotomy procedure. One group of experimental animals was pretreated intraperitoneally with the calcium channel blocker verapamil (0.3 mg/kg), another group with the xanthine oxidase inhibitor allopurinol (100 mg/kg), the third group received no pretreatment. Plasma lactate, malondialdehyde and glutathione levels as well as intestinal tissue malondialdehyde and glutathione levels were measured to assess for possible protective effects. Histologic evaluation of the extent of injury was also performed.

RESULTS

Irreversible tissue damage was depicted in the untreated group, and partially in the allopurinol pretreatment group by histologic examination. Ischemia-reperfusion injury was reversible in the verapamil group. The laboratory results also supported these findings.

CONCLUSIONS

Protective effects of verapamil on ischemia-reperfusion injury have been found to be significantly (p<0.0001) more effective compared to allopurinol.

Comparison of the effects of continuous and intermittent portal triad occlusion (PTO) in rats

BACKGROUND/AIMS

It has previously been shown that prolonged ischemia of the liver had a mortal course and a method of intermittent occlusion of the hepatic pedicle was defined in order to minimize the damage to the liver. The present experimental study aimed to compare the effects of continuous and intermittent occlusion of the hepatic pedicle on the liver by measuring serum lactate, serum MDA malondialdehyde and glutathione levels and by evaluating the histologic changes in the liver tissue.

METHODOLOGY

Thirty male Wistar albino rats weighing 300 +/- 50 g were divided into three groups of ten animals. Group 1 underwent a sham operation. Animals in group 2 underwent continuous portal triad occlusion (PTO group) for 30 minutes following laparotomy. The remaining ten animals in group 3 underwent intermittent occlusion consisting of 10 minutes of occlusion followed by 10 minutes of reperfusion for a total period of 30 minutes of ischemia. Blood samples were collected at the 1st and 6th postoperative hour for analytical evaluation. After sacrificing the animals, liver samples were obtained for histologic evaluation.

RESULTS

The serum lactate levels were significantly higher in both portal triad occlusion groups than in the control at the 1st hour. While lactate levels also increased at the 6th hour in the continuous PTO group, it decreased to the level of control values in the intermittent PTO group. The difference between continuous and intermittent groups was also significant. Despite the unchanged malondialdehyde levels in the control group, malondialdehyde levels were significantly increased at the first and sixth hour in both PTO groups and the levels were also significantly higher than control values. Malondialdehyde levels of intermittent PTO groups at the first and sixth hour were both significantly lower than continue PTO groups. Whole blood glutathione levels were not changed in control groups with time, levels increased significantly in both PTO groups. Glutathione levels were higher than control values in both PTO groups at the first hour. While it turned to its basal value in intermittent PTO groups at the 6th hour, it was still significantly higher in the continuous PTO group. When both PTO groups were compared, glutathione levels were found to be significantly higher in the continuous group both at the first and sixth hour than in the intermittent PTO group. Histopathologic evaluation also showed that there was less damage in the intermittent PTO group than in the continuous PTO group.

CONCLUSIONS

Our results show that continuous portal triad occlusion resulted in significant oxidative stress and cell damage as confirmed by increased serum lactate and blood malondialdehyde levels. The blood glutathione levels are increased due to a greater requirement in response to increased oxidative stress induced by portal triad occlusion. It is also confirmed that intermittent portal triad occlusion is safer as it causes less oxidative stress and cell damage so that its use is strongly suggested whenever portal triad occlusion is required.

The evaluation of the patients admitted to a burn center in Turkey

BACKGROUND

Burns constitute an important part of the accident-related deaths due to high morbidity and mortality.

METHODS

The medical records of 778 (279 female) patients who were treated during last three years period were retrospectively analyzed concerning age, gender, the cause of the burn, the month when the burn occurred, admission date, duration of the hospital stay, area of the burn. The relationship between these parameters and the mortality was analyzed.

RESULTS

The average age of the patients was 20 years. The burns were related to accidents in 87% patients, abuse in 8%, co-morbid diseases in 3% and suicidal attempts in 2%. In 48% of the cases there were hot fluid burns and in 37% (284) fire-flames. The burns were due to electrical burns in 13% patients and to other reasons in the remaining 2%. One hundred and seventy - two patients had fatal courses. The mortality rate was 75% in 12 patients who were above 60 years. Average burn area was 24% (10-100) and average hospital stay was 13 days.

CONCLUSION

As most of the burns were due to accidents, the number of burns might be reduced by prioritizing preventive measures and better results could be obtained when the quality and the number of the burn centers is increased.

Emergency bowel surgery in the elderly

BACKGROUND/AIMS

Emergency bowel operations are commonly performed in emergency units and carry high morbidity and mortality risk, particularly in elderly patients. The aim of the present study was to review the presentation, management and outcome of bowel emergencies in elderly patients.

METHODS

The records of 248 patients (91 females, 157 males) aged over 65 years, undergoing emergency bowel operation during a five-year period, were reviewed. Patient's age, sex, details of presentation, past medial history, presence of coexisting diseases, and type of surgical procedures were noted, and their effects/any unfavorable outcomes were all analyzed. Data were evaluated by using SPSS 9.0 for Windows statistical program. A p value less than 0.05 was accepted as significant.

RESULTS

Mean age was 72.5 years. There were 85 (34%) isolated small bowel emergencies (SBE) and 153 (62%) isolated large bowel emergencies (LBE). The most common disease in SBE was mesenteric ischemia in 67 (27%), followed by adhesions, 26 (10%). Malignant bowel disease in 59 (24%) and sigmoid volvulus in 43 (17%) accounted for the majority of LBE. Sixty-five percent (161) of patients presented with obstruction and 46 (19%) patients had bowel perforation. Malignant disease, volvulus and mesenteric ischemia carried high resection rates (82%, 78% and 76%, respectively). Overall morbidity and mortality rates were 42% (105) and 28% (70), respectively.

CONCLUSIONS

Emergency bowel operations have poor outcome in the elderly. Nature and extent of disease, presence of coexisting cardiopulmonary disease, late admission and presence of peritonitis significantly affect management and outcome of elderly patients with bowel emergencies.

Staging laparoscopy for gastric cancer

Surgical resection remains the only potentially curative treatment of patients with gastric cancer. Evaluation of surgery and other treatments depends on accurate staging of the disease. The objective of the study was to compare staging laparoscopy with ultrasonography, endoscopic ultrasound, computed tomography, and histology for serosal infiltration, lymph node metastasis, peritoneal seeding, and hepatic metastasis. Diagnostic laparoscopy was carried out in 48 patients. Prelaparoscopic staging in all cases included upper gastrointestinal endoscopy and biopsies followed by endosonography, ultrasound, and computed tomography. Preoperative combined examination using CT and laparoscopy was superior when compared with each modality alone or the combinations of the other tests. The present study showed that preoperative evaluation of patients with laparoscopy is superior to all other diagnostic tests. We also found that laparoscopy and computed tomography were better in accurately assessing the serosal infiltration, peritoneal seeding, and hepatic metastases, which thus allows the surgeon to choose more effective treatment modality.

The effect of immunonutrition on bacterial translocation, and intestinal villus atrophy in experimental obstructive jaundice

BACKGROUND & AIMS

Spontaneous bacterial infection and septicemia due to increased bacterial translocation (BT) in patients with obstructive jaundice result in significant morbidity and mortality. The present study evaluates the effects of enteral nutrition with immune enhancing feeds on BT and intestinal villus histopathology promoted by obstructive jaundice.

METHODS

Fifty male Wistar-albino rats weighing 250-300g were assigned into five equal groups of 10. Animals in Groups I, II, and III were fed with standard chow, those in Group IV were given glutamine 1g/kg/day and the remaining 10 animals in Group V were fed with an arginine, omega-3 fatty acids, and RNA-supplemented enteral diet for (1g/kg/day amino acid and 230 kcal/kg) 7 days preoperatively. Group I underwent sham operation and the remaining animals in all other groups underwent common bile duct ligation. After operation, Group I had standard chow, Groups II and IV had glutamine, Groups III and V had an arginine omega-3 fatty acids, and RNA-supplemented enteral diet for 7 days. All animals were sacrificed on the 8th postoperative day and evaluated both biochemically and histopathologically. Samples from blood, liver, mesenteric lymph nodes and spleen were cultured under aerobic conditions.

RESULTS

Significantly less BT was observed in groups fed with an arginine, omega-3 fatty acids, and RNA-supplemented enteral diet or glutamine in pre-and postoperative periods as compared to others (P<0.001). Histologic evaluation also showed significant reduction in villus atrophy in these groups.

CONCLUSIONS

Enteral immunonutrition using glutamine or arginine, omega-3 fatty acids, and RNA-supplemented enteral diet during both pre-and postoperative periods seems to reduce BT and decrease atrophy of intestinal mucosal villi in rats with obstructive jaundice.

What happens to the lost gallstone during laparoscopic cholecystectomy?

Iatrogenic gallbladder perforation with resultant spillage of bile and gallstones is common during laparoscopic cholecystectomy. Although it's assumed to be harmless, several complications may occur as a result of spillage. We present a 57-year-old woman with localized abdominal pain in the upper abdomen, jaundice, and itching because of retained stones in both common bile duct (CBD) and the abdominal cavity, who had undergone laparscopic cholecystectomy three years previously. After reoperation, stones in the CBD were removed after CBD exploration and a T-tube was inserted. A mass (8 x 5 cm) located in the gastrocolic omentum, which was not reported on imaging studies, was found coincidentally and was totally excised. Investigation of the mass resulted in the discovery of eight gallstones located in the abcess-like central cavity, which was surrounded by fibrous tissue. The patient had an uneventful recovery. Despite the unaffected long-term sequelae, any patients with gallbladder perforations and spillage should not be considered for extension of antibiotic prophylaxis to avoid early complications. Whenever gallstones are lost in the abdominal cavity, every effort should be made to find and remove them to prevent late complications.

Prevention of adhesions by bioresorbable tissue barrier following laparoscopic intraabdominal mesh insertion

Intraabdominal adhesions represent a significant problem because of the morbidity associated with adhesive disease, including small bowel obstruction, difficulties in reoperative surgery, and possibly chronic pain. Coating solution of sodium hyaluronate (Sepracoat; Genzyme Production-Surgical Products, Cambridge, MA) was studied in New Zealand white rabbits to determine its potential role for prevention of postoperative adhesions following laparoscopic intraabdominal mesh insertion. A 2-cm polypropylene mesh was inserted laparoscopically to the left iliac fossa and fixed to anterior abdominal wall using a single prolen suture. Group 1 (n = 10) acted as the control group. Mesh was coated using 4% sodium hyaluronate in phosphate buffered saline (Sepracoat) in Group 2 (n = 10). Fourteen days later, all animals underwent diagnostic laparoscopy, and findings were recorded. All animals then were killed, the abdominal cavities were inspected, and adhesions were graded from 0 to 4. All meshes were removed and sent for histologic examination. The degrees of inflammation, fibrosis, and congestion were scored. No adhesions were seen on trocar sites on both groups. Eight of 10 animals in the control group and 5 of 10 animals in the study group had intraabdominal adhesions. The scoring of adhesions revealed that study group had only one (10%) significant adhesion, whereas the control group had eight (80%; < 0.001). Our study suggests that the Sepracoat reduces the incidence and severity of abdominal adhesions following laparoscopic mesh insertion and should be considered as a prophylactic agent, especially in those undergoing laparoscopic transabdominal mesh repair for hernia.

New technique for finding the ruptured bile duct into the liver cysts: scope in the cave technique

Communication with the biliary tree is the most frequent complication of hepatic hydatid disease. This may result in fistula formation after surgical management of liver hydatidosis. Although frank ruptures are usually diagnosed preoperatively and managed surgically, simple openings may result in biliary fistula formation. It is very difficult to accurately diagnose a small hole in the cyst during surgery in most patients. We describe an easy and reliable technique for finding the point of communication via direct visualization using a telescope during conservative surgery for hepatic hydatidosis.

Factors influencing mortality in spontaneous gastric tumour perforations

Spontaneous perforation of gastric cancer is a serious complication with a very high incidence of mortality. In order to evaluate the prognostic factors influencing mortality in patients with gastric tumour perforations and to clarify the optimal surgical treatment, the records of patients at one centre during a 5-year period were evaluated retrospectively. Between 1995 and 2000, 14 patients with perforated gastric cancer were operated on in the Emergency Surgical Unit of a Turkish Hospital. This figure represents 3% of all the patients with gastric cancer who were treated during the same period. The hospital mortality was 36% in patients with perforations. The duration of symptoms suggesting perforation and the presence of pre-operative shock were predictive factors of mortality. It was concluded that those patients with pre-operative shock and delayed diagnosis should be treated with extra caution to decrease mortality. Perforation and peritonitis must be treated initially and elective radical surgery delayed.