The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

The effect of fundus resection on weight loss and ghrelin levels in rats

BACKGROUND

Ghrelin is a 28-amino acid peptide that is isolated mainly from the oxyntic glands of the stomach, especially fundus. Ghrelin administration, either centrally or peripherally, increases food intake and body weight in both rodents and humans. This study evaluates the effects of fundus resection and sclerosing agent injection on ghrelin level and weight loss.

MATERIAL AND METHODS

Thirty rats were divided into three groups. In group 1, NaCl was injected into the submucosal space at the gastric fundus while in Group 2, a sclerosing agent was injected into the latter site. In group 3, gastric fundus was resected. Ghrelin levels and weight were recorded.

RESULTS

In group 1, rats continued gaining weight and ghrelin levels stayed stable. In group 2, rats' weight and ghrelin levels stayed stable and in group 3, while weight stayed stable, ghrelin levels decreased significantly.

CONCLUSION

In rats, the resection of fundus stabilizes weight gain and decreases ghrelin levels. However, in sclerotherapy, although weight gain was stabilized, there was no decrease in ghrelin levels. In humans, the effect of fundus resection on weight gain can usher in a new era of investigation (Tab. 2, Ref. 16).

Serum estradiol/free testosterone ratio can be important predictor for varicose vein recurrence in men

AIM

Recurrent varicose veins are a frustration for both the patient and the surgeon. More investigation of the exact diagnosis, proper practice, and causes for the recurrence of varicose veins is needed.

METHODS

We investigated a total number of 187 patients in a five year period with an estradiol-2/free testosterone (E2/fT) ratio relationship on recurrent varicose veins in men between the ages of 20-50. Fifity years was the maximum age due to the age dependent sex steroid hormone regression that occurs after this age, which may interefere with the assessment. Fifty three men with an elevated E2/fT ratio (group A), and 143 men with no endocrinologic problems (group B) were enrolled in the study and had surgery for varicose veins. After 5 years follow up (mean 3 years), Group A (N.=29) and group B (N.=43) had recurrent varicose veins by clinical and radiologic findings. Venous blood samples were driven from all patients of both groups in the morning to detect the levels of serum E2 and fT levels. Patient history of surgery for varicose veins, physical examination, color duplex ultrasound of both limbs, and classification of CEAP were performed in both groups.

RESULTS

The serum E2/fT ratio was significantly higher in Group A (5.21 ± 0.56) compared to group B (2.54±0.27) in the recurrent varicose vein groups (p ≤ 0.05). Moreover, there was a high correlation between serum E2/fT ratio and the CEAP clinical classification in group A (5) compared to group B (2) (P≤0.05). Also, recurrence rate was higher in group A (54%) compared to group B (32%)(P≤0.05).

CONCLUSION

Elevated serum E2/fT ratio is a precipitating factor for recurrent varicose veins in male patients.

A high oxidative stress index predicts endothelial dysfunction in young male smokers

Experimental studies have shown that smoking was related to endothelial dysfunction via oxidative stress. However, the degree of oxidative stress to be associated with endothelial dysfunction is unknown. Oxidative stress index (OSI) might be a useful and easy way of determining the endothelial dysfunction. Hence, we aimed to evaluate the relationship between OSI and flow mediated dilatation (FMD) in smoking healthy male volunteers. Eighty smoking healthy male volunteers were enrolled in the study. Participants were classified as having normal and abnormal FMD response. In an univariate analysis; systolic and diastolic blood pressures, C-reactive protein (CRP), low-density lipoprotein cholesterol, OSI and lipid peroxidation (LPO) levels were predictive for abnormal FMD response. In a multivariable logistic regression analysis with forward stepwise method, OSI (OR: 3.194, 95% CI: 1.710-5.966, p<0.001) and CRP (OR: 2.082, 95% CI: 1.101-3.939, p 0.024) were found to be independent parameters for predicting abnormal FMD response in young male smokers. The optimal cut-off value of OSI for detecting abnormal FMD response was found to be >3.35, with 100 % sensitivity and 84.1 % specificity. We have shown that critical endothelial dysfunction can easily be detected by OSI in individuals, at risk for developing coronary artery disease, such as smokers (Tab. 3, Fig. 3, Ref. 30). Text in PDF www.elis.sk.

Using oxidant and antioxidant levels to predict the duration of both acute peripheral and mesenteric ischemia

OBJECTIVE

The aim of this study was to determine the relationship between oxidative stress markers and the duration of ischemia in rat mesenteric and peripheral ischemia models.

METHODS

Forty rats were divided into five equal groups, as follows: rats in Group I (control group) were sacrificed to determine the baseline characteristics of the serum markers; the superior mesenteric artery was clamped via a simple laparotomy to induce mesenteric ischemia in Groups II and III; the right common femoral artery was clamped to induce peripheral ischemia in Groups IV and V. Blood samples were taken at 2 (Groups II and IV) and 6 (Groups III and V) hours after these procedures. The serum total oxidative status (TOS), total antioxidant capacity (TAC), oxidative stress index (OSI) and paraoxonase-1 (PON-1) enzyme activities were evaluated in the samples obtained from each group.

RESULTS

The OSI level of the control group was 91.00±5.46 (mean ± SD). The OSI levels taken 2 hours after the induction of mesenteric ischemia and peripheral ischemia were significantly higher (194.50±11.16 and 301.75±19.98, respectively (p<0.05)). However, these levels decreased to 151.88±17.02 (mesenteric ischemia) and 108.88±9.46 (peripheral ischemia) after 6 hours. The PON-1 levels of Group III (mesenteric ischemia at 6 hours) (99.75±7.26), Group IV (peripheral ischemia at 2 hours) (96.88±4.09), and Group V (peripheral ischemia at 6 hours) (111.25±10.33) were slightly elevated over that of the control group (87.38±5.31). However, the PON-1 level of Group II (mesenteric ischemia at 2 hours) (42.88±3.14) was lower than that of the other groups (p<0.05).

CONCLUSION

Despite the increment of oxidative markers in early periods of ischemia (2(nd) hour), which was a hypoxic response of ischemic cells, they have decreased markedly in prolonged ischemia. This might have been caused by the opening of some collateral circulation or the destruction of the ischemic cells.

Iloprost reduces myocardial edema in a rat model of myocardial ischemia reperfusion

OBJECTIVE

Myocardial ischemia severely reduces myocyte longevity and function. Extensive interstitial edema and cell damage occur as a result of myocardial reperfusion injury. Current therapies are directed at prevention of ischemia-induced damage to cardiac tissue. Iloprost is a novel pharmaceutical agent for the treatment of ischemia.

METHODS

Twenty rats were segregated into four experimental groups. The procedure control group consisted of four rats undergoing a sham operation. The remaining 16 rats were divided into two equal groups. The first group (control group) received a continuous intravenous infusion of physiological serum immediately prior to the procedure. Iloprost was administered by a continuous intravenous infusion into the right jugular vein at an infusion rate of 100 ng/kg/min for 30 minutes prior to reperfusion in the experimental group (study group). Following the infusion treatments, ligation of the left coronary artery was conducted for 30 minutes to induce myocardial ischemia. The rats were euthanized 24 hours after reperfusion and cardiac tissue was harvested from all specimens for analysis.

RESULTS

Histological examination revealed three myocardial tissue specimens with grade II damage and five myocardial tissue specimens with grade III reperfusion injury in the control group. However, the study group consisted of two grade III myocardial tissue specimens, five grade II myocardial tissue specimens and one grade I myocardial tissue specimen. Moreover, a statistically significant reduction in myocardial edema was observed in the study group (p=0.022).

CONCLUSION

Our results support the hypothesis that iloprost enhances protection against cardiac ischemia reperfusion injury. This protective effect may be associated with vasodilation, antioxidant or anti-edema mechanisms.

Evaluating the effectiveness of spleen autotransplantation into the liver and the omentum

BACKGROUND

Experimental research into the viability and functionality of splenic tissue placed in the liver and the omentum.

METHODS

There were 4 groups in this study. First group: sham laparotomy, 2nd group: splenectomy, 3rd group: splenectomy and splenic autotransplantation into the greater omentum and 4th group: splenectomy and splenic autotransplantation into the liver. Blood levels of haemoglobin, leukocytes, thrombocytes, immunoglobulin G (IgG), immunoglobulin M (IgM) and complement protein 3 (C3) were studied 1 day before and 6 weeks after the procedure. At the end of 6 weeks, scintigraphy was performed. Splenic tissue in the liver and the omentum were subjected to macroscopic and histopathologically.

RESULTS

Pre- and postoperatively, no significant differences were found in terms of haematological and immunological measurements of groups I, III and IV. An increase in the numbers of thrombocytes and leukocytes and a decrease in the levels of IgG, IgM and C3 were observed in the postoperatively in group II.When the postoperative hematological and immunological values of the second group are compared to those of groups III and IV, the difference was significant in terms of levels of thrombocyte, leukocyte and IgM; insignificant in terms of levels of IgG and C3. In the microscopic and scintigraphic analyses the spleen tissue was found to be viable in all of the six rabbits in groups III and IV.

CONCLUSIONS

The liver is a suitable organ for splenic autotransplantation (Tab. 6, Fig. 2, Ref. 17).

Serum ischaemia-modified albumin level is an irrelevant predictive factor for ischaemic duration in mesenteric ischaemia

BACKGROUND

Acute mesenteric ischaemia is an emergency condition that requires urgent and expeditious diagnosis and immediate surgical or medical intervention. The initial hours are critical for the recovery of the affected bowel segment. Thus, its clinic diagnostic biomarkers are important when it comes to reducing mortality and morbidity rates.

METHODS

Twenty-four male Sprague-Dawley rats were included in the study. The rats were divided into three equal groups. Those in Group I were sacrificed to determine the basal serum values of ischaemia-modified albumin (IMA) after a simple laparotomy. The superior mesenteric artery (SMA) was clamped in a simple laparotomy in Groups II and III; blood samples were taken at 120 minutes in Group II and 360 minutes in Group III. The serum IMA levels were identified from the blood samples and the results obtained were compared statistically.

RESULTS

The serum IMA levels were determined to be 22±6 (22) μ/L, 34±7 (34) μ/L and 36±4 (37) μ/L in Groups I, II and III, respectively. The differences between the groups were not statistically significant.

CONCLUSION

Our results showed that the serum IMA level is not an appropriate biomarker for acute mesenteric ischaemia. Additionally, the IMA level is not an appropriate biomarker for the detection of ischaemia duration. However, future studies should be conducted to clarify the efficacy of serum IMA levels under different ischaemic conditions.

A comparison of sutureless and antibacterial suture abdomen closure

PURPOSE

This experimental study aimed at comparing the cyanoacrylate abdomen closure to the effectiveness of triclosan coated polidioxanone abdomen closure.

METHODS

The abdomen layers were closed with 3/0 polidioxanone suture in the first group. In the second group, the layers were closed with triclosan coated polidioxanone suture in a single layer. The abdomen layers of rats in the third group were attached with cyanoacrylates without sutures. The rats were sacrificed on the 14th day and the adhesive level was recorded. The incision resistance strength was measured. The tissue was examined blindly in the terms of inflammatory cell infiltration, capillary proliferation, fibrosis and micro-abscess by the pathologist.

RESULTS

No significant difference was determined between the 1st and 2nd groups in the terms of inflammatory cell infiltration, capillary proliferation, collagen deposition, fibroblast activity, adhesive and tissue distension strength. The fibrosis and adhesive rate of the 3rd group was significantly higher than the 1st and 2nd groups statistically. The tissue distension strength was lower than in the other groups and the differences between the groups were found to be significant (p < 0.05). No significant difference was determined between the groups in the term of micro-abscess.

CONCLUSIONS

Antibacterial suture is not superior to the conventional suture. It is concluded that cyanoacrylate is not an appropriate molecule for abdomen closure (Tab. 1, Fig. 3, Ref. 17).

Diagnosis and follow up of patients with primary cardiac tumours: a single-centre experience of myxomas

OBJECTIVE

In this study, 12 patients who were diagnosed as having cardiac tumours and were operated on in the Department of Cardiovascular Surgery following referral from the Department of Cardiology were enrolled between January 1995 and October 2007.

METHODS

The symptoms, clinical findings, diagnostic methods, localisation of masses and surgical applications were recorded retrospectively.

RESULTS

There were 10 female (83%) and two (17%) male patients; their ages ranged from 35 to 70 years (mean 68.7 years). Twelve patients were diagnosed with myxomas, nine of which were located within the left atrium and three in the right atrium. The most common symptoms at clinical presentation were those associated with heart failure or embolisation. Diagnosis of the tumours was made by echocardiography in all patients. The masses were completely resected in eight patients and the interatrial septae were partially excised with mass resection in two patients. The defect was reconstructed with a pericardial patch in one of the patients, and primarily reconstructed in the other. We carried out debridement with mass resection in another case. Femoro-popliteal aorto-iliac thrombo-endarterectomy was performed with mass resection in a further case.

CONCLUSION

Atrial myxomas are the most common primary cardiac tumours. They can cause valvular or inflow-outflow tract obstruction, thrombo-embolism, arrhythmias, or pericardial disorders. Most atrial myxomas are benign but due to non-specific symptoms, early diagnosis may be a challenge and they must be removed by surgical resection. Diagnosis and follow up with the collaboration of cardiology and cardiovascular surgery departments is important for meticulous care of these patients.

Hartmann colostomy with LigaSure

PURPOSE

While LigaSure is commonly used for blood vessel closure, our aim was to research the effectiveness of using the latter tool for the purpose of closing intestines in rats.

METHODS

Twenty Wistar albino rats were divided into two groups per 10 each. In Group 1, the sigmoid colon was cut from its middle and its distal was closed with 4/0 silk. In Group 2, on the other hand, the sigmoid colon was divided from the middle with LigaSure LS1200 probe and its distal was closed with LigaSure. In both groups, the proximal sigmoid colon was entered by means of colostomy with 4/0 silk to the left part of the abdomen. Operation durations, adhesion levels and explosion pressures were recorded. Tissue samples were taken for tissue hydroxyproline level.

RESULTS

While the average duration of the operation was 25.7 minutes in Group 1, it was 18.8 minutes in Group 2 and the difference between them was significant in favour of LigaSure. (p<0.001). Stump explosion pressure was 181.4 (160-190) mmHg in average in the suture group (Group 1), and 173.3 (150-190) mmHg in the LigaSure group (Group 2) and the difference between them was not statistically significant. Tissue hydroxyproline level was 123.6 (13-232) in Group 1, and 123.3 (32-216) in Group 2 and no significant difference was determined between the groups. Adhesion level between the groups was also similar.

CONCLUSIONS

This study experimentally shows that the duration of effective stump closure as part of Hartman colonostomy can be shortened with LigaSure (Tab. 1, Fig. 4, Ref. 12).

Is the naphthalene sulfonate H-acid biodegradable in mixed microbial cultures under aerobic conditions?

Synthetically prepared wastewater originating from the H-acid (4-Amino-5-hydroxy-2,7-naphthalene disulfonic acid) manufacturing process was subjected to respirometric analysis for evaluating the level of achievable biodegradation in the presence of this commercially important azo dye precursor. For this purpose, H-acid was mixed with synthetic substrate having the same characteristics as sewage at a concentration and composition being typical for H-acid manufacturing wastewater. Experimental results indicated that H-acid was not biodegradable under activated sludge treatment conditions even after prolonged acclimation periods. The results were also confirmed by model evaluation of oxygen uptake rate profiles. H-acid also did not inhibit the biodegradation of synthetic sewage but accumulated as soluble inert COD in the treated wastewater.

Type I plasminogen activator inhibitor 4G allele frequency is associated with chronic venous insufficiency

Chronic venous insufficiency (CVI) is a common disease associated with poor quality of life. Genetic polymorphisms causing coagulation abnormalities may account for some of the CVI pathogenesis. Type I plasminogen activator inhibitor (PAI-1) is responsible for fibrinolytic system regulation, and plasma levels of PAI-1 are strongly correlated with PAI-1 4G/5G gene polymorphism. The association between PAI-1 4G/5G gene polymorphism and CVI was investigated. In 34 consecutive patients with clinically overt CVI, the PAI-1 4G/4G polymorphism was detected in three cases (8.8%); the 4G/5G polymorphism was detected in 28 (82.4%). In 34 age- and sex-matched controls, the PAI-1 4G/4G polymorphism was detected in one case (2.9%) and the 4G/5G polymorphism was detected in 14 cases (41.2%). The PAI-1 4G allele was found significantly more frequently in CVI patients than in controls. The 4G allele was associated with a 3.25-fold increase in CVI risk. Thus, a relationship between CVI and the PAI-1 4G allele is apparent.

Docking of novel reversible monoamine oxidase-B inhibitors: efficient prediction of ligand binding sites and estimation of inhibitors thermodynamic properties

Monoamine oxidase (MAO, EC 1.4.3.4) is a flavoenzyme bound to the mitochondrial outer membranes of the cells, which is responsible for the oxidative deamination of neurotransmitter and dietary amines. It has two distinct isozymic forms, designated MAO-A and MAO-B, each displaying different substrate and inhibitor specificities. They are the well-known target for antidepressant, Parkinson's disease and neuroprotective drugs. Elucidation of the x-ray crystallographic structure of MAO-B has opened the way for molecular modeling studies. In this research 12 reversible and MAO-B selective inhibitors have been docked computationally to the active site of the MAO-B enzyme. AutoDock 3.0.5 was employed to perform the automated molecular docking. The result of docking studies generated thermodynamic properties, such as free energy of bindings (DeltaG(b)) and inhibition constants (K (i)) for the inhibitors. Moreover, 3D pictures of inhibitor-enzyme complexes afforded valuable data regarding the binding orientation of each inhibitor in the active site of MAO-B.

Critical appraisal of respirometric methods for metal inhibition on activated sludge

This paper evaluates the merit of oxygen uptake rate measurements for the assessment of metal inhibition on activated sludge. For this purpose, experiments are conducted to calculate EC50 levels of nickel and hexavalent chromium using the ISO 8192 procedure, yielding results that are highly variable and difficult to correlate, depending on the type of substrate and the initial food to microorganism ratio. Similar experiments based on continuous respirometric measurements to give the entire oxygen uptake rate profile provide a much better insight on the impact of inhibition on different biochemical processes taking place in the reactor. The results indicate that percent reduction of the amount of dissolved oxygen utilized after an appropriate reaction time is a much better index for the assessment of the inhibitory effects.

Effect of biochemical storage on the denitrification potential of acetate in sequencing batch reactors

This study evaluates the effect biochemical storage on the denitrification potential (N(DP)) of acetate. The fate of bacterial storage is evaluated in a sequencing batch reactor system operated in a sequence of anoxic/aerobic phases, fed with acetate as a pulse and continuously under anoxic conditions. N(DP) is defined based on system stoichiometry both for direct growth and storage on acetate. Experimental results do not support conceptual calculations based on system stoichiometry, yielding a higher denitrification potential, N(DP), for continuous feeding than the N(DP) obtained with pulse feeding, due to partial utilisation of the stored PHB within the anoxic phase. The nitrate, acetate and poly-beta-hydroxybutyrate (PHB) profiles obtained in the experimental studies were used in model calibrations for two different feeding patterns. Results of model simulations confirm the experimental results and evaluate the effects imposed on the denitrification potential by sludge age and the anoxic volume ratio.

Respirometric assessment of biodegradation characteristics of the scientific pitfalls of wastewaters

This paper provides an overview of common problems encountered when using oxygen uptake rate (OUR) measurements for the assessment of wastewater characteristics and process kinetics. Emphasis is placed upon pitfalls that would lead to significant errors. It covers model dependency of the OUR measurements and the need to select appropriate models; interpretation of OUR perturbations as a way to identify new model components and processes; the need for simultaneous observation of relevant model components and multicomponent modelling for appropriate evaluation of OUR measurements; parameter identifiability problems and the effect of active biomass concentration and the endogenous decay rate on model simulation and calibration. Relevant experimental OUR data from previous studies are presented to illustrate and underline common scientific pitfalls.

Biological treatability of raw and ozonated synthetic penicillin formulation effluent

Chemical pre-treatment of synthetic Procaine Penicillin G (PPG) effluent with ozone (applied dose = 1440 mg/h; treatment duration = 60 min) at pH = 7 was investigated. Successive biological treatability studies were performed with raw, ozonated penicillin formulation effluent and synthetic readily biodegradable substrate as simulated domestic wastewater. The PPG effluent additions were adjusted to constitute approximately 30% of the total COD in the reactor. Ozonation of PPG effluent resulted in practically complete removal of the parent pollutant accompanied by 40% COD abatement. Speaking for the raw PPG effluent, prolonged acclimation periods were necessary to obtain significant COD removal efficiencies. Batch activated sludge treatment experiments and respirometric studies have demonstrated that the selection of true retention time is extremely crucial for having high amount of slowly hydrolysable substrate or complex wastewater, like pharmaceutical effluent. The effect of ozonation time on biological treatability performance of PPG has been evaluated in the study. Pre-ozonation of PPG effluent did not improve its ultimate biodegradability.

Effect of ozonation on the biological treatability of a textile mill effluent

Ozonation applied prior to biological processes, has proved to be a very effective chemical treatment step mostly for colour removal when soluble dyes are used in textile finishing operations. Its impact on biological treatability however has not been fully evaluated yet. This study evaluates the effect of ozonation on the quality of wastewater from a textile mill involving bleaching and reactive dyeing of cotton and synthetic knit fabric. The effect of ozonation on COD fractionation and kinetic coefficients defining major biological processes is emphasised. The results indicate that the extent of ozone applied greatly affects the remaining organic carbon composition in the wastewater. The relative magnitude of different COD fractions varies as a function of the ozone dose. Ozonation does not however exert a measurable impact on the rate of major biological processes.

The management of liver hydatid cysts by percutaneous drainage

OBJECTIVE

To investigate the effect of percutaneous drainage on liver hydatid cysts.

DESIGN

A retrospective case study.

SETTING

Department of Surgery, Selçuk University, Konya, Turkey.

PATIENTS

Forty-five patients with 83 liver hydatid cysts (types I and II according to the classification of Gharbi and colleagues) followed up for a mean of 30 months (range from 14 to 36 months).

INTERVENTION

The cysts were drained percutaneously with ultrasonographic guidance and then irrigated with 0.05% silver nitrate solution through a fine needle. Albendazole was administered 48 hours before percutaneous drainage and for 2 months after the procedure to prevent the implantation of spilled scolices.

MAIN OUTCOME MEASURES

Complications of the procedure, decrease in size of the cyst cavity, recurrence and dissemination of the cysts.

RESULTS

All the cysts were treated successfully by percutaneous drainage. Anaphylactic shock developed in 1 (2.2 %) patient, and mild allergic reactions were observed in 2 (4.4 %) patients during the interventional procedure. Follow-up ultrasonography and CT demonstrated a statistically significant (p < 0.01) decrease in the mean cyst size. Recurrence and dissemination were not observed during the follow-up period.

CONCLUSION

Percutaneous fine-needle aspiration and drainage is effective for managing cystic liver hydatid disease in selected cases.

Does estrogen cause low conversion rates in laparoscopic cholecystectomies for acute and chronic cholecystitis in women?

Laparoscopic cholecystectomy is the preferred treatment for symptomatic cholelithiasis. Severe local inflammation and scar formation are commonly responsible for conversion to open surgery. Fibrosuppressive effects of estrogen on peritoneal inflammatory conditions could provide low, dense fibrosis or scar formation around the gallbladder and make laparoscopic cholecystectomy easier in women and we believe that male sex is a conversion factor in laparoscopic cholecystectomy.

A scientific approach to wastewater recovery and reuse in the textile industry

Wastewater recovery and reuse in industries requires all the basic steps of quality management. It should involve a comprehensive in plant survey of processes with wastewater generation, identification of recoverable streams, and treatment requirements for reuse. It should equally undertake evaluation of wastewater quality remaining after segregation of the recovered portion, with specific emphasis on technological implications of appropriate treatment and compliance with effluent limitations. In this study, all these factors were experimentally assessed and evaluated for a knit fabric processing textile plant.

Transanal electrovaporisation of rectal tumours

OBJECTIVE

To present our early results with endoscopic transanal electrovaporization of rectal tumours.

DESIGN

Retrospective study.

SETTING

Department of Surgery, Faculty of Medicine, University of Selçuk.

SUBJECTS

10 patients, 4 with malignant and 6 with benign lesions.

INTERVENTIONS

Vaporization of the tumour using a new ridged roller electrode, the VaporTrode, and a standard 24F urological resectoscope.

MAIN OUTCOME MEASURES

Morbidity and recurrence.

RESULTS

There were no complications and all adenomas were vaporized completely. 2 patients with obstruction required a further treatment 3 and 5 months later because of recurrence. Median duration of operation was 22.5 minutes (range 10-38) and median duration of hospital stay was 3 days (range 1-4).

CONCLUSION

The VaporTrode is a safe and potentially useful tool for transanal excision of rectal tumours, the long term efficacy of which should be tested in larger series of patients.

Open drainage versus overlapping method in the treatment of hepatic hydatid cyst cavities

In order to compare the results of open drainage and overlapping methods, 58 consecutive patients with uncomplicated hepatic hydatid disease were investigated between January 1990 and January 1997. The cavities were obliterated by overlapping method in 26 patients and were left open into the peritoneal cavity following partial pericystectomy in 32 patients. Postoperative complications and follow-up results of ultrasonography (US) and computed tomography (CT) were compared between the two groups. In total, there were 56 cysts in the obliterated group and 83 cysts in the open drainage group. There was no significant difference in age, sex, mean diameter of the cysts, US features of the cysts according to the Gharbi classification, and median follow-up. Mean hospital stay was 10 days in the overlapping group and 7.5 days in the open drainage group (P = 0.033). No postoperative complication was observed in the obliterated group and nearly half of the cyst cavities could not be detected in the early postoperative period by US and CT. Pleural effusion (n = 1) and biliary fistula (n = 1) were detected in the open drainage group which disappeared spontaneously. In the open drainage group, US and CT surveillance revealed that the cyst cavities were reduced in size and the echo pattern was changed in the early postoperative period, whereas the appearance changed into pseudotumor view in the late postoperative period. In conclusion, the cyst cavities disappear perfectly in the overlapping group. Treating the cyst cavity by open drainage is an easy, effective and safe technique. Open drainage can be a 'method of choice' for patients with multiple hydatid cysts and for cysts where management is difficult or unamenable to other methods, but the residual cyst cavities may be misinterpreted as a new cyst by an inexperienced radiologist.

[Serum and tissue silver levels after burns treated with silver compounds]

This study was performed in order to investigate serum and tissue silver levels in burns which were used 10 percent silver nitrate as a topical agent. We formed four groups of animals and pulverized 10 percent silver nitrate solution to the first group (GI) that included ten rabbits of which backs were burned by boiling water and silver sulphadiazine cream to second group (GII) with nine rabbits. We carried out 10 percent silver nitrate solution to the first control group (GIII) and silver sulphadiazine cream to the second control group (GIV) each of which had seven animals with unburned skin. We obtained blood samples from every animal before and after application of topical agent on the 1st, 3rd, 7th, 15th, 21st and 28th. We determined serum and tissue silver levels by atomic absorption spectrophotometer in kidney and liver of the animals which were sacrificed on the 28th day. In first and second groups we found that serum silver values reached on 3rd day to the maximum level and then the values decreased gradually. We also determined that diminution of the serum silver levels were prominent following on 15th day. It was shown that there was no silver in the serum on 28th day except four animals. The silver deposition in the liver was much more than in the kidney. Between these two groups there was significant difference neither in the serum on the same days nor the tissue silver levels. According to these data it was concluded that serum and tissue silver levels with 10 percent silver nitrate used in burns produced no difference from that of 1 percent silver sulphadiazine cream.