Wissenschaftliche Artikel - Antalya Obezite | Prof.Dr. Nurullah Bülbüller
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Wissenschaftliche Artikel - Prof.Dr. Nurullah Bülbüller​

Abstract
BACKGROUND:
This prospective randomized study aims to compare outcomes between immediate laparoscopic cholecystectomy (LC) and same admission delayed LC in patients with acute cholecystitis and also to investigate the relation between oxidative stress markers and complication rates in the patients with AC.

METHODS:
This study included 64 patients with AC who were randomly divided into two groups. Patients in Group 1 (n=32) were immediately administered LC, while in Group 2 (n=32) patients underwent transient LC following medical treatment. All patients were operated on their first hospitalization.

RESULTS:
No statistically significant differences were observed between the groups for the comparison of complications, conversion rates, or operation durations (p>0.05). The length of postoperative hospital stay was found to be significantly shorter in group 1 compared to group 2 (1.75 vs 2.93 days; p=0.024). Only the total antioxidant status result was significantly higher in group 1 (p=0.017), but the finding was not correlated with complications.

CONCLUSION:
LC for AC was performed during the first admission was found to be safe, even beyond 72 hours following symptom onset. Pre-operative oxidative stress markers did not correlate with the complication rates.

Abstract
OBJECTIVE:
To evaluate the effect of laparoscopic cholecystectomy performed under different intraabdominal pressure on oxidative stress markers.

MATERIAL AND METHODS:
This prospective, randomized, controlled study examined 90 consecutive healthy patients who underwent elective laparoscopic cholecystectomy with the diagnosis of symptomatic cholelithiasis. The patients were divided into three groups, 30 patients in each. Group 1 included patients who underwent laparoscopic cholecystectomy at a CO2 pneumoperitoneum pressure of 7 mmHg, Group 2 patients who underwent laparoscopic cholecystectomy at a CO2 pneumoperitoneum pressure of 10 mmHg, and Group 3 patients who underwent laparoscopic cholecystectomy at a CO2 pneumoperitoneum pressure of 13 mmHg. Blood samples were collected preoperatively, perioperatively, and postoperatively for measurement of the serum levels of ischemia modified albumin and an analysis of total antioxidant status and total oxidant status. Intra-group comparisons were made.

RESULTS:
Group 1 experienced a significant increase in the postoperative ischemia modified albumin values compared to preoperative ischemia modified albumin values (p=0.013). Group 2 experienced a significant decrease in the perioperative total antioxidant status values compared to preoperative and postoperative total antioxidant status values (p=0.009). Group 3 experienced a significant increase in the perioperative total oxidant status and oxidative stress index values compared to preoperative values (p<0.001). Group 3 experienced a significant increase in the perioperative and postoperative ischemia modified albumin values compared to preoperative values (p<0.001).

CONCLUSION:
Increased levels of oxidative stress markers were detected in patients who underwent laparoscopic cholecystectomy at a high intraabdominal pressure level.

Abstract
Round ligament mesothelial cyst is a rare cause of inguinal mass. Round ligament cysts are generally diagnosed during operation in cases who are operated with a pre-diagnosis of inguinal hernia. In this study, we aim to present two cases, who have applied to our clinic with the complaint of a mass in inguinal region and who are diagnosed as round ligament cyst, together with their ultrasound, magnetic resonance images and operation images.

Abstract
PURPOSE:
To evaluate the effect of a new cross-linked hyaluronan (NCHA) gel on healing of the staple line in an experimental sleeve gastrectomy.

METHODS:
Eighteen rats were randomly divided into three groups. The control group (n = 6) received no medication. In the saline group (n = 6) and NCHA gel group (n = 6), saline and NCHA gel were respectively administered onto the staple line and intraperitoneally into the abdominal cavity after the standard stapling procedure.

RESULTS:
The fibroblast activity and collagen deposition were significantly higher in the NCHA gel group than in the control group (p = 0.00, p = 0.017) and saline group (p = 0.004, p = 0.015). The tissue hydroxyproline protein level was significantly higher in the NCHA gel group than in the control group (p = 0.041). Adhesion formation was significantly lower in the NCHA gel group than in the control and saline groups (p = 0.015, p = 0.041).

CONCLUSIONS:
New cross-linked hyaluronan gel could be an effective approach to improve staple line wound healing and prevent potential leakage after sleeve gastrectomy. Moreover, NCHA gel helps to prevent adhesion formation without compromising healing of the staple line.

Abstract
OBJECTIVE:
In this study, we aimed to describe the findings associated with gastric pathology and to identify the prevalence of Helicobacter pylori (H. pylori) in patients undergoing laparoscopic sleeve gastrectomy (LSG).

PATIENTS AND METHODS:
Gastric specimens of a total of 291 patients (225 females, 66 males; mean age: 42 years; range: 18 to 60 years) who underwent LSG for the treatment of morbid obesity were analyzed. Histopathologic diagnoses and their relation with body mass index (BMI), age and gender were evaluated.

RESULTS:
In the histopathological examination of sleeve specimens, 58 patients (19.93%) had chronic gastritis, 102 patients (35.05%) had chronic active gastritis, 27 patients (9.27%) had follicular gastritis, 47 patients (16.15%) had active follicular gastritis, one patient (0.34%) had a glomus tumor, and one patient (0.34%) had a gastrointestinal stromal tumor. The gastric mucosa was normal in 55 patients (18.90%). Intestinal metaplasia was detected in eight patients (2.74%). The H. pylori test result was positive in 126 patients (43.29%). There was no statistically significant difference between the pathological diagnoses and age and sex of the patient.

CONCLUSIONS:
Our study results suggest that the prevalence of chronic active gastritis and H. pylori positivity is high in morbidly obese Turkish patient population. No significant difference was found between the pathological diagnosis in obese patients with LSG operation in terms of age and sex.

Abstract
PURPOSE:
To evaluate intraocular pressure (IOP) and extraocular orbital vessels with color Doppler ultrasound (CDU) and investigate the effects of obesity on retrobulbar blood flow.

METHODS:
Fifty-nine patients were included in this prospective study. Patients were divided into two groups according to body mass index: Group 1 (31 obese patients) and Group 2 (28 non-obese patients). IOP was measured with a Goldmann applanation tonometer, and CDU was used to evaluate the retrobulbar vessels.

RESULTS:
The mean IOP was 18 ± 6.68 mmHg in the obese group and 13.71 ± 1.60 mmHg in the control group (p<0.001). When the CDU values for the central retinal artery were compared between the groups, the pulsatility index was found to be significantly lower in the obese group than in the control group (p<0.001). When the CDU values for the ophthalmic artery (OA) were compared between the groups, the peak systolic velocity (p<0.001) and end-diastolic velocity (p=0.002) values were found to be significantly lower in the obese group than in the control group.

CONCLUSIONS:
Obese patients have a higher mean IOP and lower flow velocity than non-obese patients. Increased IOP together with decreased retrobulbar blood flow, particularly in obese individuals, may increase the risk of glaucoma development.

Abstract
INTRODUCTION:
Obesity is an important modifiable etiological factor associated with several diseases. There is strong evidence that urinary incontinence (UI) is positively correlated with body mass index (BMI).

AIM:
One of the many benefits experienced by obese patients after bariatric surgery is decrease in UI. To investigate this correlation, we aimed to examine the effects of weight loss on UI in female patients who had undergone laparoscopic sleeve gastrectomy (LSG).

MATERIALS AND METHODS:
Obese female patients (n=120), ≥18 years of age, and planning to undergo LSG were included in this prospective study. We administered the International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form (ICIQ-UI-SF) and Incontinence Impact Questionnaire (IIQ-7) to the patients prior to surgery and 6 months after the surgery. Using the collected data, we determined the incidence of UI and examined the relationship between the preoperative and postoperative BMI and UI values.

RESULTS:
The mean age of the patients was 39.19 (standard deviation [SD] =9.94) years and the mean preoperative BMI was 46.17 (SD =5.35). Of the 120 patients, 72 (60%) complained of UI preoperatively. Among these 72 patients, 23 (31.95%) described urge incontinence, 18 (25%) stress incontinence, and 31 (43.05%) mixed-type incontinence. At 6 months postoperatively, the percentage of excess weight loss was 70.33% (SD =14.84%). For all three UI subtypes, the 6-month postoperative ICIQ-UI-SF and IIQ-7 scores decreased significantly compared to the preoperative scores (P<0.05).

CONCLUSION:
LSG results in a clinically significant improvement in most common types of UI, regardless of patient reproductive history, existence of comorbid conditions, and smoking status.

Abstract
PURPOSE:
To investigate changes in optical coherence tomography parameters in morbidly obese patients who had undergone laparoscopic sleeve gastrectomy (LSG).

METHODS:
A total of 41 eyes of 41 morbidly obese patients (BMI ≥ 40) who had undergone LSG were included in study. The topographic optic disc parameters, central macular thickness (CMT), total macular volume (TMV), and retinal ganglion cell layer (RGCL) were measured by spectral-domain optical coherence tomography (SD-OCT). Subfoveal choroidal thickness (SFCT) was measured by enhanced deep imaging-optical coherence tomography (EDI-OCT).

RESULTS:
The mean CMT was 237.4 ± 24.5 μm, 239.3 ± 24.1 μm, and 240.4 ± 24.5 μm preoperatively, 3 months postoperatively, and 6 months postoperatively, respectively (p < 0.01). The mean TMV was 9.88 ± 0.52 mm(3), 9.96 ± 0.56 mm(3), and 9.99 ± 0.56 mm(3) preoperatively, 3 months postoperatively, and 6 months postoperatively, respectively (p < 0.01). The mean RGCL was 81.2 ± 6.5 μm, 82.7 ± 6.6 μm, and 82.9 ± 6.5 μm preoperatively, 3 months postoperatively, and 6 months postoperatively, respectively (p < 0.01). The mean SFCT was 309.8 ± 71.8 μm, 331.0 ± 81.4 μm, and 352.7 ± 81.4 μm preoperatively, 3 months postoperatively, and 6 months postoperatively, respectively (p < 0.01). No statistically significant differences were found between the preoperative values and 3- and 6-month postoperative values in rim area (p = 0.34), disc area (p = 0.64), vertical cup/disc ratio (p = 0.39), cup volume (p = 0.08), or retinal nerve fiber layer (p = 0.90).

CONCLUSIONS:
Morbidly obese patients who undergo LSG experience a statistically significant increase in CMT, TMV, SFCT, and RGCL at 3 months and 6 months after surgery.

Abstract
OBJECTIVE:
To investigate the effect of laparoscopic sleeve gastrectomy (LSG) on the levels of obestatin and ghrelin hormones and body mass index (BMI) in morbidly obese patients.

PATIENTS AND METHODS:
The study included 30 morbidly obese patients who had LSG. Five cc blood samples were taken from the patients preoperatively and at postoperative months 3 and 6. After serum extraction, the levels of obestatin and ghrelin hormones and the levels of fasting insulin and glucose were studied using the enzyme-linked immunosorbent assay (ELISA) method. The homeostatic model assessment of insulin resistance (HOMA-IR) score was calculated. Preoperative and postoperative 3- and 6-month BMI were calculated. Kruskal-Wallis Analysis of Variance, Bonferroni-Dunn Test, Spearman’s correlation test, and Pearson’s correlation test were used for statistical analysis.

RESULTS:
BMI of the patients were statistically significantly reduced at postoperative months 3 and 6 compared to preoperative values, and at postoperative month 3 compared to month 6 values (p < 0.001). Ghrelin values were higher at postoperative month 6 compared to the preoperative and postoperative month 3 values (p < 0.001). Obestatin values of the patients were lower at postoperative month 6 compared to the preoperative and postoperative month3 values (p < 0.001). Insulin and glucose values were statistically significantly lower at postoperative months 3 and 6 compared to preoperative values (p < 0.001), whereas there was no difference between months 3 and 6. HOMA-IR score was significantly lower at postoperative month 3 compared to preoperative values (p < 0.001).

CONCLUSIONS:
LSG enables effective weight loss and glucose regulation in obese patients. LSG has also effects on obestatin and ghrelin hormones, which are coded by the same gene and have opposing effects, and the associated mechanisms of which are still controversial. Obestatin produces a feeling of satiety, whereas ghrelin initiates eating by producing a feeling of hunger. The patients were observed to have increased ghrelin and reduced obestatin postoperatively due to a negative energy balance.

Abstract
OBJECTIVE:
To investigate changes in body mass index (BMI) and nesfatin-1 levels in patients with morbid obesity who had undergone laparoscopic sleeve gastrectomy (LSG).

PATIENTS AND METHODS:
Blood samples were collected from, and the BMI calculated of 30 morbidly obese patients pre-surgery and at 3 and 6 months post-surgery. Nesfatin-1 hormone levels were measured using enzyme-linked immunosorbent assay (ELISA). Descriptive statistical analysis of the data was performed using Kruskal-Wallis variance analysis, one-way ANOVA, and the Bonferroni-Dunn test. The correlations between continuous variables not displaying normal distribution and those displaying normal distributions were analyzed using the Spearman correlation test and the Pearson correlation test, respectively.

RESULTS:
The mean age of the 30 patients was 41.23 ± 10.37 years. The mean BMI values (kg/m2) were 49.30 ± 7.92, 39,48 ± 7.32, and 34.39 ± 7.56 presurgery, three months post-surgery, and six months post-surgery, respectively (p < 0.001). Mean nesfatin-1 levels (ng/ml) were 22.80 ± 14.16, 60.23 ± 52.92, and 96.99 ± 40.20 presurgery, three months post-surgery, and six months post-surgery, respectively (p < 0.001). The postoperative months 3 and 6 BMI values were significantly lower than the preoperative BMI value and the postoperative month 6 BMI value was significantly lower than the postoperative month 3 BMI value (p < 0.001). The postoperative months 3 and 6 nesfatin-1 levels were significantly higher than the preoperative nesfatin-1 levels. A negative correlation was found between age and preoperative nesfatin-1 values (p = 0.001, r = -0.0557).

CONCLUSIONS:
Observation of significant increases in nesfatin-1 hormone levels in morbidly obese patients who had undergone LSG indicate that nesfatin-1 has important anorexigenic effects post-surgery and may be an important component of future obesity treatments.

Abstract
Gastroesophageal reflux is the most common benign disorder of the esophagus and laparoscopic Nissen fundoplication has become the standard surgical treatment for its treatment. In our area, where the use of bougie calibration is debatable, postoperative dysphagia is encountered often after this surgery although it is usually not permanent. The aim of this study was to investigate the effect of using a soft silicone tube 39 F in diameter for esophageal calibration during laparoscopic Nissen fundoplication on the incidence of postoperative dysphagia. We divided cases scheduled to undergo laparoscopic Nissen fundoplication between January 2009 and November 2010 into two groups, each consisting 25 patients. Esophageal calibration with a 39 F silicone orogastric tube was used for the first group while there was no operative calibration in the second group. The surgical duration was recorded; the presence and severity of the postoperative dysphagia was calculated by using a dysphagia severity scoring system during the 1-year postoperative follow-up. The dysphagia severity scores were significantly lower in group 1 than group 2 on the postoperative second day and at the end of the first week and first month. We did not find a significant difference at the end of the 6-month and first year. There was also no significant difference regarding surgery duration. The use of a soft orogastric tube 39 F in diameter for esophagus calibration during laparoscopic Nissen fundoplication has significantly decreased the incidence of postoperative transient dysphagia without affecting the duration of surgery. Although dysphagia gradually resolves in the majority of patients, a safe and easy calibration method for its prevention is worth developing, and we believe that the use of our method in larger series could be beneficial.

Abstract
OBJECTIVE:
To assess the effect of morbid obesity on retinal nerve fiber layer (RNFL) thickness, central macular thickness (CMT), retinal ganglion cell (RGC), choroidal thickness (CT), central corneal thickness (CCT), and intraocular pressure (IOP).

PATIENTS AND METHODS:
Sixty-seven patients defined as having morbid or class III obesity (BMI ≥ 40; Group 1) scheduled to undergo sleeve gastrectomy surgery and 29 nonobese patients (BMI 18.50-24.99; Group 2) underwent complete ophthalmic examination for measurement of IOP, CT, RNFL thickness, CMT, RGC, and CCT. RNFL thickness, CMT, and RGC were measured using spectral-domain optical coherence tomography (SD-OCT). CT measurement was performed using the enhanced depth imaging technique of the SD-OCT. The group data were analyzed and compared using the Mann-Whitney U test and Student’s t-test. The relationship between the clinical ocular variables and obesity was analyzed using the Spearman’s rank correlation test.

RESULTS:
The mean IOP and CCT of Group 1 were found to be significantly higher (p < 0.001) and the mean RNFL, RGC, and CT significantly lower (p < 0.05) than those of Group 2. While Group 2 was found to have a slightly larger cup-to-disc ratio and Group 1 to have a thinner CMT, the differences between Groups 1 and 2 regarding these variables were not found to be statistically significant (p = 0.322 and p = 0.072, respectively). The results of Spearmen correlation analysis indicated the existence of a moderately positive correlation between IOP and BMI (p < 0.001; r = 0.5-0.6).

CONCLUSIONS:
We have demonstrated by SD-OCT that morbid obesity may have a significant influence on RNFL, RGC, and CT. Morbid obesity may induce inflammatory, hormonal, and metabolic changes.

Abstract
PURPOSE:
Anastomotic leakage in colorectal surgery is a very important issue. Although many studies have shown the positive effects of enteral glutamine (Gln) on anastomotic healing, none has assessed the effects of administering Gln via an enema for anastomotic healing. To fill this study gap, this study investigated the intraluminal effect of administration of Gln enema on the healing of colonic anastomosis in a rat model.

METHODS:
Thirty Wistar albino rats were divided into three groups containing 10 rats each and were subjected to distal left colon transection and anastomosis. Postoperatively, group I (the control group) was administered no treatment, group II was administered daily placebo enemas containing physiological saline, and group III was administered daily 2% L-Gln enemas. After sacrifice on postoperative day 5, anastomotic healing, burst pressure, tissue hydroxyproline levels, and histological parameters were measured, and group values were compared via statistical analysis.

RESULTS:
Group III was found to have the highest mean bursting pressure and tissue hydroxyproline levels and the lowest mean ischemia score. While the values of these parameters were not found to differ significantly among the groups, the lack of significance may have been due to the limited number of subjects examined.

CONCLUSION:
Administration of a Gln enema may have a positive effect on anastomosis in terms of bursting pressure and histopathological parameters. Future research should examine administration of a preoperative Gln enema as a means of decreasing the traumatic effects of the enema and identifying its applicability in surgical practice.

Abstract</br>
The aim of this study was to compare the clinical results and the inflammatory responses against polypropylene and polyester meshes after groin hernia repair. Ninety patients with unilateral inguinal hernia randomly underwent Shouldice herniorrhaphy or Lichtenstein hernioplasty using polypropylene or polyester meshes. Venous blood samples were collected to evaluate serum interleukin-6 (IL-6) and C-reactive protein (CRP) levels. Postoperative acute and chronic pain and time to attain to normal activities were evaluated. IL-6 levels decreased to preoperative levels in all groups at 48th hour. CRP levels of mesh-implanted groups are significantly higher than preoperative level at 48th hour, while it reduced to preoperative level in Shouldice herniorrhaphy group. Patients treated with mesh repair had less postoperative acute pain and recovered more rapidly than those who underwent Shouldice herniorrhaphy. It was concluded that polypropylene and polyester meshes used in hernia repair caused similar inflammatory responses and that clinical results after groin hernia repair with these prostheses were not significantly different.

Abstract</br>
The aim of this study was to compare the clinical results and the inflammatory responses against polypropylene and polyester meshes after groin hernia repair. Ninety patients with unilateral inguinal hernia randomly underwent Shouldice herniorrhaphy or Lichtenstein hernioplasty using polypropylene or polyester meshes. Venous blood samples were collected to evaluate serum interleukin-6 (IL-6) and C-reactive protein (CRP) levels. Postoperative acute and chronic pain and time to attain to normal activities were evaluated. IL-6 levels decreased to preoperative levels in all groups at 48th hour. CRP levels of mesh-implanted groups are significantly higher than preoperative level at 48th hour, while it reduced to preoperative level in Shouldice herniorrhaphy group. Patients treated with mesh repair had less postoperative acute pain and recovered more rapidly than those who underwent Shouldice herniorrhaphy. It was concluded that polypropylene and polyester meshes used in hernia repair caused similar inflammatory responses and that clinical results after groin hernia repair with these prostheses were not significantly different.

Abstract</br>
A 34-year-old male patient who had undergone total colectomy and J-pouch ileanal anastomosis subsequent to diagnosis of familial adenomatous polyposis five years previously was admitted to the emergency room with complaints of severe abdominal pain of a four-day duration. Physical examination revealed widespread tenderness throughout the abdomen, especially in the lower quadrant. Abdominal ultrasonography revealed fluid between intestinal loops and computed tomography revealed free air and fluid in the abdomen. During laparotomy to expand the ileal J-pouch to approximately 12 cm in diameter, a 2-mm perforation was detected in the blind end of the ileal J-pouch. The perforation was repaired primarily and protective ileostomy was performed. During postoperative endoscopy, neither obstruction nor stasis was observed, but pouchitis was observed in the ileal J-pouch. The patient was postoperatively discharged on the 20th day and followed endoscopically. The endoscopic findings were normal in the sixth month postsurgery.

Abstract
OBJECTIVE:
As a bariatric surgery; Laparoscopic Sleeve Gastrectomy (LSG) has gained popularity in recent years. In our study, we aimed to investigate the impact of age on postoperative weight loss at one year after laparoscopic sleeve gastrectomy.

PATIENTS AND METHODS:
In our clinic between May 2011 and July 2013, 55 patients who underwent LSG with the diagnosis of obesity were included in the study. Patients were divided into two groups below and over an age of 40. Preoperative and postoperative first year Body Mass Index (BMI), percent of Body Mass Index Lost (% BMIL) and Excess Body Mass Index Lost (% EBMIL) were recorded.

RESULTS:
A total of 55 patients with a mean age of 37.2 ± 8.6 years were included in the study. 37 were women. Patients divided into the age below 40 years old (group 1, n = 29) and over 40 years old (group 2, n = 26). The average age of the groups was 29.9 ± 4.63 and 45.3 ± 7.02, respectively. Characteristics of patients among groups were similar. The preoperative average BMI of groups were 49.34 ± 5.87 kg/m² and 49.73 ± 5.38 kg/m², postoperative first year mean BMI of groups were 30.05 ± 5.78 kg/m² and 36.15 ± 6.64 kg/m², respectively. Percentage loss in BMI was 19.29 ± 3.14% and 13.58 ± 2.96%, respectively; and % EBMIL was 82.95 ± 21.88% and 56.75 ± 15.90%, respectively.

CONCLUSIONS:
We suggest that age might be as a major determining factor for weight loss and patients over forty years old undergoing LSG for bariatric surgery should be informed about that they will have a lower weight lost.

Abstract
OBJECTIVE:
To analyse outcomes of variable management strategies for the treatment of Acute Cholecystitis in relation to morbidity, mortality and conversion to open surgery.

METHODS:
The retrospective study was conducted at Firat University Hospital, Turkey and comprised records of Acute Cholecystitis patients admitted between 2005 and 2011. Patients were divided into subgroups according to admission time as well as American Society of Anaesthesiologists score. The outcomes of early cholecystectomy, interval cholecystectomy, delayed cholecystectomy, ‚cooling-off‘ therapy and percutaneous cholecystostomy were evaluated. Mortality, morbidity, and conversion to open surgery were calculated as measures of success. Data was analysed using SPSS.

RESULTS:
Of the 1557 patients, 1052(67.6%) were female. The overall mean age was 42.4±14.7 years. Success rates of ‚cooling-off‘ therapy and percutaneous cholecystostomy were 89.3% and 96.3%, respectively. The conversion rate following delayed cholecystectomy was 30%, which was higher than that of both early and interval cholecystectomy (0.2% and 0%, respectively; p<0.001 each). Mortality and morbidity rates of delayed cholecystectomy (57.1% and 7.1%, respectively) were also significantly higher than early and interval cholecystectomy (5% and 0.1%; 5.6 and 0%, respectively).

CONCLUSIONS:
Early laparoscopic cholecystectomy and interval cholecystectomy shared similar outcomes and rates of efficacy. Percutaneous cholecystostomy was a successful treatment option for high-risk patients, while delayed cholecystostomy correlated to the highest rates of conversion to open surgery, mortality and morbidity.

Abstract
As the rise on the prevalence of obesity, it is related with physical impairment of joints, especially in the lumbar spine and knee joints. Losing body weight can reduce or eliminate pain of head, neck, shoulder, lumbar spine and knees. By performing a laparoscopic bariatric surgery we demonstrated a significant improvement on the pain by body weight reduction. In this study we aimed to explore the efficacy and safety of Laparoscopic Sleeve Gastrectomy (LSG) on the relief of pain on head and neck, shoulder, low back and knee among the severely morbid obese female patients. A total of 39 morbidly obese female patients who underwent LSG for morbid obesity were included in this study. Body weight, height, body mass index (BMI), head and neck, shoulder, low back and knee pain intensity were measured with Visual Analog Scale (VAS) before and after LSG at the 6(th) month. 39 morbidly obese female patients were enrolled to this study. The mean age of the patients was 37.69 ± 11.33 years. Preoperative and postoperative body weights were 127.3 kg and 91.21 kg, respectively. Mean height was 165.23 ± 5.78 cm. Preoperative and postoperative BMIs were 46.49 kg/m(2) and 32.33 kg/m(2), respectively. A significant correlation between preoperative and postoperative parameters was found according to BMI. Our data showed that LSG is an efficient and safe procedure on severely obese patients and showed a predictive remission of head and neck, shoulder, low back and knee pain intensity of female patients by analyzing with VAS during the first 6 months.

Abstract
PURPOSE:
Remarkable differences in weight loss have been observed in obese patients undergoing laparoscopic sleeve gastrectomy (LSG). These high variations might be partly explained by genetic factors. The rs9939609 fat mass and obesity-associated gene (FTO) polymorphism has been implicated in the susceptibility of obesity. We aimed to explore the effects of the rs9939609 FTO gene polymorphism on weight loss among severely obese patients applying for LSG.

MATERIALS AND METHODS:
All individuals were analyzed for the FTO rs9939609 gene polymorphism. A total of 74 morbid obese patients (20 male, 54 female) were operated. Body weight and body mass index (BMI) were measured at before LSG and after surgery at the sixth month.

RESULTS:
Twenty-eight patients (37.8%) had genotype TT (wild-type allel), 36 patients (48.6%) had genotype TA, and 10 patients (13.5%) had genotype AA. In both wild-type group and mutant group, BMI and weight levels decreased at the sixth month after surgery. Percent of excess weight loss (EWL) at 6 months of follow-up was similar in both groups. There were no differences between the mutant and wild-type groups percent of EWL at the sixth month after applying LSG.

CONCLUSION:
Our data showed that the rs9939609 FTO gene polymorphism is not a useful genetic test prior to LSG to help clinicians predicting the weight loss for severely obese patients in short-term follow-up.

Abstract
Acute primary hyperparathyroidism and parathyroid crisis are characterized by life-threatening hypercalcemia, a rare disorder. A 69-year-old female patient presented at our hospital’s neurology clinic with weakness, nausea, vomiting, depression, and hypercalcemia. Treatment of hypercalcemia resulted in no improvement in neurological symptoms, indicating resistance to treatment. Thyroid ultrasonography and parathyroid scintigraphy revealed hypoechoic nodules in the right lobe, pieces of nodules in the left lobe, and high serum calcium and parathyroid hormone levels. After provision of intensive medical treatment including hydration, diuresis, and bisphosphonate infusion resulted in only minimal decrease in the calcium level, urgent surgical treatment was performed. Frozen biopsy of the right intrathyroidal giant parathyroid adenoma in the right lobe confirmed initial diagnosis of primary hyperparathyroidism. Based on the biopsy findings, right parathyroidectomy and right total and left subtotal thyroidectomy were performed. Histopathologic examination revealed a parathyroid adenoma localized inside large thyroid nodules. Review of the findings resulted in diagnosis of intrathyroidal parathyroid adenoma. Symptoms of hypercalcemia improved rapidly during the postoperative period.

Abstract
BACKGROUND:
Staple-line leak is a life-threatening complication of laparoscopic sleeve gastrectomy. Reinforcement materials have been reported to lower the risk of staple-line bleeding, but their effects on leak risk have not been elucidated. The aim of this study was to compare the effects of two supportive techniques on burst pressures in sleeved gastrectomy specimens.

MATERIALS AND METHODS:
Thirty patients who underwent laparoscopic sleeve gastrectomy were evaluated. The resected sleeve gastrectomy specimens were categorized into three groups. Group 1 had no extra support in the staple line, Group 2 had oversewing with continuous suture on the staple line, and Group 3 had fibrin sealant (Tisseel(®); Baxter, Deerfield, IL) on the staple line. The end point was the first detectable leakage, at which point leak pressure and the anatomic site of leakage were recorded.

RESULTS:
Thirty sleeved gastrectomy specimens were included (each group included 10 specimens). There were no differences among group in terms of age, sex, and body mass index. The leak pressure was significantly higher (106±10.5 mm Hg) in Group 2 (P<.01). Leaks occurred significantly more frequently in the staple line than in the staple junction points (P=.014).

CONCLUSIONS:
Oversewing the staple line with 3-0 Vicryl(®) (Ethicon, Somerville, NJ) suture significantly increased the strength of the staple line. Increases in intraluminal pressure are known to be one of the significant risks in leak etiology. Thus, we concluded that oversewing the staple line with 3-0 Vicryl suture can be beneficial in the prevention of leaks. However, further work is necessary in this area of research.

Abstract
BACKGROUND:
The aim of this study was to determine whether the lateralization distance causes differences in the flattening ratio of the natal cleft, early complications, or recurrence rates in patients with sacrococcygeal pilonidal sinus disease undergoing the modified Limberg flap.

METHODS:
This clinical study was conducted from March 2012 to April 2013. Forty patients with sacrococcygeal pilonidal sinus disease were divided into two groups of 20 patients, each according to the lateralization distance of the lower part of the Limberg flap incision (Group I, 1 cm lateralized; Group II, 2 cm lateralized). Early wound complications, recurrence rates, and the flattening ratio of the natal cleft were evaluated.

RESULTS:
No statistically significant differences in operating time (mean 42.2 ± 5.7 and 42.3 ± 6.4 min, respectively; p = 0.855), drain removal time [median 3 (range 2-10) and 4 (range 2-14) days, respectively; p = 0.1], or length of hospitalization [median 1 (range 1-3) and 1 (range 1-4) days, respectively; p = 0.775] were found between the groups. The mean follow-up period was 12.8 ± 3.7 months. Recurrence was observed in only one patient of Group II. There were no statistically significant differences in the flattening ratio of the natal cleft, overall wound complications, or recurrence between the two groups.

CONCLUSIONS:
No statistically significant differences in early complications or recurrence rates were found between the two different lateralization distances in the modified Limberg flap procedure. Therefore, we conclude that 1-cm lateralization of the lower part of the incision is sufficient.

Abstract
Dieulafoy lesion is rarely seen, yet it can be life-threatening. This lesion makes up to 1-2% of gastrointestinal bleedings and must definitely be considered in gastrointestinal bleedings whose source cannot be identified. In this case study, the 75-year-old woman was suffering from active, fresh, and massive rectal bleeding. Colonoscopy was applied in order to find out the source of bleeding. In the typical endoscopic appearance of the lesion a single round mucosal defect in the rectum and arterial bleeding were observed. To procure hemostasis, epinephrine was injected into the lesion and the bleeding vein was sutured.

Abstract
PURPOSE:
Aurora kinase family plays an important role in mitosis and cell cycle organization. Aurora-A is an important member of the aurora kinase family and its expression increases the genomic instability and contributes to carcinogenesis. In this study, the prognostic role of Aurora-A expression in colorectal cancer (CRC) was assessed.

METHODS:
Metastatic CRC patients, whose diagnoses were histopathologically confirmed and who were followed up at the Antalya Education and Research Hospital between 2008 and 2010, were included in the study. Aurora-A expression was assessed with immunohistochemistry.

RESULTS:
A total of 40 patients were included in the study. Aurora-A expression was determined as positive in 33 (82.5%) patients and as negative in 7 (17.5%). No significant correlation was determined between Aurora-A expression and tumor location, metastatic location and histological subtype (p=0.549, 0.511, and 0.709, respectively). Also, no significant correlation was determined between Aurora-A expression and overall survival (p=0.202). Median survival was 8.7 months (95) confidence interval/CI 6.9-10.4) in patients with negative Aurora-A expression, whereas it was 22.6 months (95% CI 12-33.3) in patients with positive Aurora-A expression (p=0.202).

CONCLUSION:
Despite the lack of statistical significance, we speculate that Aurora-A overexpression may have a positive effect on the survival of patients. With this regard, there is a need for further comprehensive studies examining the relation and effect of Aurora-A expression on survival and response to treatment.

Abstract
BACKGROUND:
Tight junction proteins in the cell organize paracellular permeability and they play a critical role in apical cell-to-cell adhesion and epithelial polarity. Claudins are major integral membrane proteins of tight junctions, especially Claudin 1, 4, and 7, which are known as the impermeability Claudins. In this study, we investigated the importance of loss of Claudin 1, 4, and 7 expression, and their relation to tumor progression in colorectal cancer patients.

MATERIAL/METHODS:
Loss of Claudin 1, 4, and 7 expression was examined by immunohistochemical method in 70 patients diagnosed with colorectal cancer. Cases with loss of Claudin expression in <1/3 of tumor cells were classified as mild loss, whereas cases with loss of Claudin expression ³1/3 of tumor cells were classified as moderate-to-marked loss in order to evaluate the relation between loss of Claudin 1, 4, and 7 expression and clinicopathologic data.

RESULTS:
The severe suppression of Claudin 1, 4, and 7 expression was found to be significantly related to the depth of tumor invasion, positive regional lymph nodes, histological grade, lymphovascular invasion, perineural invasion, and lymphocytic response. Additionally, severity of loss in Claudin 4 expression was found to have a relation with distant metastasis.

CONCLUSIONS:
Claudin 1, 4, and 7 are important building blocks of paracellular adhesion molecules. Their decreased expression in colorectal cancer seems to have critical effects on cell proliferation, motility, invasion, and immune response against the tumor.

Abstract
The aim of this study was to compare mesh placement in front of the fascia transversalis and behid the fascia transversalis via inguinal incision. We evaluated the results of 106 inguinal hernia cases treated with polypropylene mesh applied via the anterior approach between December 2004 and January 2010. Using the anterior approach, the mesh was placed preperitoneally behind the fascia transversalis in 51 of the patients, whereas in the other 55 patients the mesh was placed in front of the fascia transversalis. Mean duration of surgery was shorter in the patients in which the mesh was placed behind the fascia transversalis (60 min vs. 75 min) (P < 0.05). In all, 8 patients (7.5%) had postoperative complications, including hematoma (n = 4), seroma (n = 2), scrotal edema (n = 1), and orchitis (n = 1). There weren’t any significant differences in the complication rate between the 2 groups of patients (P > 0.05). During a mean 44-month follow-up period (range: 12-72 months), no recurrence was observed. In conclusion, there weren’t any significant differences between the 2 methods of inguinal hernia repair, other than the duration of surgery.

Abstract
PURPOSE:
Staple-line leak is a life-threatening complication of laparoscopic sleeve gastrectomy. Reinforcement materials have been reported to lower the risk of staple-line bleeding, but their effects on leak risk have not been elucidated. The aim of this study was to compare the effects of 2 supportive techniques on burst pressures in sleeved gastrectomy specimens.

METHODS:
A total of 30 patients who underwent laparoscopic sleeve gastrectomy were evaluated. The resected sleeve gastrectomy specimens were categorized into 3 groups: group 1 had no extra support in the staple-line, group 2 had interrupted serosal suture on the staple-line, and group 3 had serosal suture on staple-line junction points. The endpoint was the first detectable leakage, at which point the leak pressure and anatomic site of the leakage were recorded.

RESULTS:
A total of 30 sleeved gastrectomy specimens were included (each group included 10 specimens). There were no differences between groups in terms of age, sex, and body mass index. The leak pressure was significantly higher (56.2±6.4 mm Hg) in group 2 (P<0.01). Leaks occurred significantly more frequently in the staple-line than in the staple-line junction points (P<0.01).

CONCLUSIONS:
Interrupted serosal suture significantly increased the burst pressure. Increases in intraluminal pressure are known to be significant in leak etiology. Thus, we concluded that interrupted serosal suture may be beneficial in the prevention of leaks.

Abstract
BACKGROUND:
HMGB1, the most important member of the high mobility group box protein family, is a nuclear protein with different functions in the cell; it has a role in cancer progression, angiogenesis, invasion, and metastasis development. We studied the expression of HMGB1 and whether it is a prognostic factor in colorectal carcinoma.

MATERIAL AND METHODS:
The study included 110 cases that were histopathologically diagnosed with colorectal carcinoma from the tissue samples acquired by surgical resection and biopsy in Antalya Education and Research Hospital between 2008 and 2012. HMGB1 expression was examined via immunohistochemical method.

RESULTS:
HMGB1 expression was evaluated as negative in 32 (44.4%) of the patients and as positive in 40 (55.6%) patients. There was no relation between the HMGB1 expression and sex, age, tumor invasion depth, and histological type. However, a significant relation was detected between the HMGB1 expression and lymph node status, metastasis status, and stage (p:<0.001, p:<0.001, p:<0.001, respectively). Similar results were obtained for the relations between the HMGB1 and histological grade, perineural invasion, lymphovascular invasion, and lymphocytic response (p<0.001, p<0.001, p<0.001, and p<0.001, respectively).

CONCLUSIONS:
The results of our study demonstrate that HMGB1 overexpression has a significant role in tumor progression (especially migration of tumor cells) and tumor ability to metastasize in colorectal cancers; thus, it corroborates the idea that it might be an important prognostic factor.

Abstract
BACKGROUND:
Long-term occupational exposure to trace concentrations of volatile anesthetics is known to have adverse effects on the health of exposed personnel.

OBJECTIVES:
We investigated paraoxonase-1 (PON1) and arylesterase (ARE), as well as antioxidant status (TAS) and total oxidant status (TOS) levels in anesthesia personnel (AP) who were chronically exposed to inhalation anesthetics, and compared them with levels in a control group.

MATERIAL AND METHODS:
We designed a comparative prospective study with 50 female subjects. The first cohort included 25 full-time female workers in operating rooms in two locations in the Antalya Education and Research Hospital in Antalya, Turkey. The control group was comprised of 25 female individuals working in the same hospitals without any work-related exposure to hazardous agents.

RESULTS:
Serum ARE activity and TAS levels were significantly reduced (p = 0.04 and p < 0.0001, respectively), whereas TOS and OSI levels were found to be significantly higher (p = 0.01 and p < 0.0001, respectively) in AP. However, there were no significant differences in PON1 activity, PON1/HDL-C, ARE/HDL-C, and PON1/ARE (p = 0.30, p = 0.5, p = 0.1 and p = 0.7, respectively) when the two groups were contrasted.

CONCLUSIONS:
According to the results of this study, depending on the putative role of PON/ARE in oxidant stress-related diseases, particularly atherosclerosis and cancer, AP might be considered a risk group for the development of atherosclerosis and many other diseases.

Abstract
The purpose of this study is to investigate the potential protective effect of the flavonoid Luteolin on ischemia-reperfusion (IR) injury in mouse intestine, which has not previously been studied. Twenty-four female C57BL/6 mice were randomly assigned to four groups, each consisting of 6 mice: a sham group (laparotomy, but no IR injury), a sham + Luteolin group (no IR, and Luteolin was administered intraperitoneally 30 min after laparotomy), IR group (30 min occlusion of the superior mesenteric artery (SMA) then 2 hr‘ reperfusion), IR + Luteolin (30 min occlusion of the SMA then 2 hr‘ reperfusion; Luteolin was administered intraperitoneally before reperfusion). Intestine tissues were harvested from the mice for histopathological and biochemical analysis. Total oxidant status (TOS) and total antioxidant capacity (TAC) of the intestinal tissues were measured using Erel’s method. Oxidative stress index (OSI) was calculated using the TOS/TAC ratio. Intestinal histological changes were significantly decreased in the IR + Luteolin group compared with the IR group (p = .037). TOS tissue levels were also significantly decreased in the IR + Luteolin group compared with the IR group (p = .005). TAC levels did not increase significantly in the IR treatment group and were not affected by Luteolin treatment (p > .05). The results of this study show that Luteolin administration provides considerable protection against IR injury in the mouse intestine.

Abstract
BACKGROUND/AIMS:
An impaired oxidative/antioxidative status plays an important role in the pathogenesis of many diseases, including cancer. The aim of this study was to evaluate the levels of the novel marker ischemia-modified albumin (IMA) and albumin-adjusted IMA (Adj-IMA) in patients with colorectal cancer (CRC) and look for the associations of these with the total antioxidant status (TAS), total oxidant status (TOS), and oxidative stress index (OSI).

METHODS:
Forty patients with CRC (19 females and 21 males; mean age, 56.5±2.1 years) and 39 age- and sex-matched healthy people (22 females and 17 males; mean age, 56.0±1.7 years) were included in this study. Serum levels of IMA, TAS, and TOS were analyzed, and the OSI was calculated.

RESULTS:
Serum IMA, TOS, and OSI levels were significantly higher in patients with CRC than in controls (p<0.0001), whereas TAS levels were significantly lower in CRC patients (p=0.03). There was no significant difference in serum Adj-IMA levels between groups (p=0.32).

CONCLUSIONS:
In this study, the oxidative/antioxidant status was impaired in favor of oxidative stress in CRC patients. This observation was not confirmed by IMA measurement. Further studies are needed to establish the relationship between IMA and oxidative stress parameters in CRC and other cancers.

Abstract
The main early complications of Laparascopic Sleeve Gastrectomy are bleeding and gastric leakage. Many reinforcement methods are performed in order to reduce these complications. In this prospective, randomized study, we compared four different techniques to evaluate staple line reinforcement in Laparascopic Sleeve Gastrectomy. Between January 2012 and May 2013, 65 patients were prospectively randomized into four groups in which different techniques were used in handling the staple line during Laparascopic Sleeve Gastrectomy. Of the four groups, there wasn’t any reinforcement used on 15 patients during LSG (group 1), continuous serosal 3-0 prolene sutures were used on 16 patients for staple line reinforcement (group 2), staple line was supported with v-loc suture in 16 patients (group 3), and 18 patients had Tisseel fibrin sealant applied throughout the staple line (group 4). 40 of 65 patients were females, the mean age was 36.8 years (20-58 years), and the mean BMI was 49.2 (41-60 kg/m²). Characteristics of patients among groups were similar. There wasn’t any significant difference found between groups for BMI. Gastric leakage was detected from the staple line in 2 patients of the v-loc group. According to our results, we demonstrated that good results can be obtained without any reinforcement. Reinforcement with propylene suture only prolongs the operation time, and tissue fibrin sealent increases the cost. In conclusion, we should be more careful using v-loc sutures, and further series with larger numbers are needed to test v-loc.
Abstract
Selection of multinodular goiter (MNG) surgery procedure is stilll under discussion. Subtotal thyroidectomy (STT) and neartotal thyroidectomy (NTT) are preferred surgical procedures. However, it is uncertain whether the remnant tissue contains pathological findings or not after these procedures. We aimed to evaluate and comparison the pathologic findings in remnant tissue after NTT and STT. Thyroid tissue samples of 50 patients who underwent TT for MNG disease between January 2010 and August 2011 in our clinic were evaluated. Before the dissection of the thyroid tissue subtotal and neartotal margins were marked in both right and left lobes. After the resection of the specimen, the tissue was excised from the subtotal and neartotal margin marked during the surgery. The pathologic findings of the main tissue, the residual subtotal and neartotal tissues were evaluated and compared. All patients were followed-up 1 year. 43 (86%) females and 7 (14%) males with an average age of 50.5 (23-77) were included in the study. Incidental papillary thyroid cancer was detected in 5 patients (10%). Pathologic findings were present in 31 patients (62%) of subtotal residual tissue and 28 of the patients (56%) of neartotal residual tissue. Papillary microcarcinoma was detected in 3 (9.7%) of subtotal residual tissues and 2 (7.1%) of neartotal residual tissues. There is no significant difference between subtotal and neartotal tissues in terms of existence of pathological findings (p>0.05). There is no significant difference between the neartotal and subtotal residual tissues contralateral of dominant nodule (p>0.05). 2 of the patients (4%) had temporary hypocalcemia, 1 patient (2%) had seroma and 1 patient (2%) had recurrent laryngeal nerve injury. There are high rates of microscopic pathological findings on residual tissues both after STT and NTT. The neartotal and subtotal residual tissues contralateral to the large nodule also had high levels of pathologic findings.
Abstract
Pseudomonas aeruginosa is an important nosocomial pathogen that causes opportunistic infections and hospital outbreaks. During October 2012, carbapenem-resistant P.aeruginosa strains with similar antibiotic resistance patterns, were isolated from specimens sent from the intensive care and plastic surgery units in our hospital. Thus a hospital outbreak was suspected. The microbiology laboratory database was retrospectively searched and all strains of P.aeruginosa isolated during the four month period, starting with the initial carbapenem-resistant strain in August 2012, was evaluated as a hospital outbreak. The aim of this study was to define the outbreak by investigating the clonal relationship between the strains, to detect the potential environmental sources and to evaluate the period of the outbreak, risk factors and the efficiency of infection control measures. The study was conducted between August-November 2012. Twenty patients with carbapenem-resistant P.aeruginosa (CRPA) positive cultures were included in the study. The control group consisted of 22 patients with carbapenem-susceptible P.aeruginosa (CSPA) positive cultures. The clonal relationship between 26 CRPA strains was studied by pulsed-field gel electrophoresis (PFGE). The PFGE results indicated that CRPA strains in our hospital were not related to a single clone, however, there were four major clones composed of four to eight strains. Logistic regression analysis indicated that the risk increased 15.7 fold (95% CI: 1.19-207.76) by the use of carbapenem, 76.8 fold (95% CI: 2.03-2901.30) by surgical procedures and 0.787 fold (95% CI: 0.63-0.97) by the duration of hospital stay. Surveillance cultures from health-care personel and the environment performed in course of the outbreak, yielded no growth of a strain with the similar antibiotic resistance pattern. The spread of CRPA has been controlled by the use of effective precautionary measures, regressing the isolate number to 0-1 strain/month. Since CRPA infections have high mortality and lack therapeutic alternatives, they should be regarded among the priorities of the infection control programmes. This study has enabled to test the effectiveness of the infection control program, to make plans for the possible future outbreaks and to train the staff.

Abstract
PURPOSE:
Colorectal cancer (CRC) is a common and potentially lethal disease. A number of genetic aberrations is known to take place in colorectal carcinogenesis, which leads to progressive alteration of normal mechanisms controlling cell growth. A-kinase-anchoring protein 12 (AKAP12) plays a role in cell proliferation, angiogenesis and cytoskeletal remodeling. The purpose of this study was to demonstrate the role of the AKAP12 gene expression in CRC patients and to determine its relationship (if any) with prognosis.

METHODS:
AKAP12 gene expression was investigated by immunohistochemistry.

RESULTS:
A total of 55 patients (63.6% males, 36.4% females) with histologically confirmed CRC were studied. Normal intestinal epithelium showed weak basal staining, dysplastic areas were stained mildly, whereas all of the cancer cells were stained completely with AKAP12.

CONCLUSION:
AKAP12 gene seems to play a role in colorectal carcinogenesis.

Abstract
Bidirectional endoscopy (BE) is often used to assess patients for the reason of anemia or to screen asymptomatic population for malignancy. Limited clinical data favors to perform first the upper gastrointestinal system endoscopy, but its effect to the duration of colonoscopy is yet to be determined. The aim of this retrospective study is to evaluate the effect of upper gastrointestinal system endoscopy on the time to achieve cecal intubation during colonoscopy in patients undergoing BE. Patients of four endoscopists at similar experience levels were retrospectively identified and categorized into the upper gastrointestinal system endoscopy before colonoscopy group (group 1) or the colonoscopy only group (group 2). The demographics, clinical data and the time to achieve cecal intubation for each patient were analyzed. The mean time to achieve cecal intubation in the first group that included 319 cases was 8.4 ± 0.93 minutes and the mean time in the second group that included 1672 cases was 8.56 ± 1.16 minutes. There was no statistically significant difference between the groups. There was also no significant difference between the Group 1 and Group 2 when compared according to which of the four endoscopists performed the procedures. Performing the upper gastrointestinal system endoscopy prior to colonoscopy did not affect the time to achieve cecal intubation. Considering that performing the upper gastrointestinal system endoscopy prior to the colonoscopy is more advantageous in terms of patient comfort and analgesic requirement, beginning to BE with it seems more favorable.

Abstract
PURPOSE:
The aim of this study was to investigate the diagnostic performance of lesion echogenicity ratios (LER) calculated by image histogram analysis for distinction of malignant and benign breast lesions.

MATERIAL AND METHODS:
A total of 55 patients (mean age, 44 years) with 59 lesions were included. Ultrasound images were analyzed retrospectively.

RESULTS:
Mean LER values in benign and malignant lesions were 1.63±0.41 and 3.1±0.87, respectively. The difference between LER values of benign and malignant breast lesions was statistically significant (P<.001).

CONCLUSION:
LER can be used as an adjunct ultrasound parameter to differentiate between benign and malignant breast lesions.

Abstract
PURPOSE:
Gastric cancer is a biologically heterogeneous disease containing many genetic and epigenetic alterations. In our study, the expression status of apoptosis-inducing p53 and apoptosis-inhibiting Bcl-2 in gastric cancer and their relation with prognosis, if any, was investigated.

METHODS:
Patients that were being followed in our clinic and had histopathologically diagnosed gastric adenocarcinoma were included in this study. The p53 and bcl-2 expressions were investigated immunohistochemically and patients were grouped according to p53 and Bcl-2 expression as follows: group A: both p53 and Bcl-2 negative; group B: p53 positive and Bcl-2 negative; group C: p53 negative and Bcl-2 positive; group D: both p53 and Bcl-2 positive.

RESULTS:
In 19 (51.4%) patients positive immunostaining with p53 was observed, while negative in 18 (48.6%). A significant relationship between the metastatic ability of the tumor and p53 expression was determined (p=0.004). In 78.6% of the metastatic tumors no p53 expression was observed, while in 69.6% of the non-metastatic tumors p53 expression was positive. No significant relationship was detected between p53 expression and survival. Positive immunostaining with Bcl-2 was observed in 9 (16.7%) patients, and negative in 45 (83.3%). No significant relationship was determined between the Bcl-2 expression and the depth of invasion, dissemination to lymph nodes and metastatic ability of the tumor. A borderline statistically significant relationship was determined between the Bcl-2 expression and survival (p=0.051). Group B patients showed a statistically significant survival difference compared with the other groups (p=0.022).

CONCLUSION:
The results of this study suggest that concurrent evaluation of p53 and Bcl-2 in patients with gastric adenocarcinoma may have prognostic importance.

Abstract
BACKGROUND:
Unnecessary hospital admissions and negative appendectomies increase healthcare costs of patients with right lower quadrant (RLQ) pain. This study aimed to evaluate the impact on the cost of treatment of appendicitis scoring systems.

METHODS:
Charts were reviewed of patients admitted to the general surgery ward of our hospital with RLQ pain within a year. Alvarado and Lintula scores were calculated, and a simulation was performed to determine the treatment charges that would have been generated had the scoring recommendations been used for admission and surgical decision-making.

RESULTS:
Of the 114 admitted patients, 64 (56%) underwent appendectomy. The rate of negative appendectomy was 17.2%. The overall accuracy rates of the Alvarado and Lintula scores for both ‚admit‘ and ‚operate‘ decision-making were 82.7% and 91.9%, respectively (p=0.102). Total charges for the 114 patients were $39,655. If the Alvarado or Lintula score had been used, the total treatment charges would have been $34,087 and $25,772 (p=0.015 and p=0.000), with negative appendectomy rates of 18.5% and 3.6%, respectively.

CONCLUSION:
The implementation of Alvarado and Lintula scores for the decision of hospital admission and appendectomy would have reduced overall treatment charges for acute RLQ pain.

Abstract
Oxidative stress has been shown to play an important role in carcinogenesis. We hypothesize that serum oxidative and anti-oxidative factors work together to influence colon and rectal cancer through an oxidative balance mechanism. Total thiol (Ttl) is considered a plasma antioxidant and high density lipoprotein (HDL)- dependent paraoxonase l (PON1) is known as a free radical scavenger. This study was undertaken to determine the activity of PON1, arylesterase (ARE) and Ttl levels and oxidative balance in colorectal cancer (CRC) patients and healthy subjects.Paraoxonase and arylesterase activities of the HDL-dependent PON1 enzyme and the level of Ttl, total oxidant status (TOS) ,total antioxidant status (TAS) in forty patients with CRC (19 female, 21 male; mean age, 56.5 ± 2.1) and thirty-nine age and sex matched healthy persons (22 female, 17 male; mean age 56 ± 1.7) were studied.PON1 and ARE activities were significantly lower in patients with CRC compared to controls (p<0.001 for each), whereas oxidant parameters (TOS and OSI) were significantly higher in CRC patients (p<0.001 for each). However, TAS and Ttl significantly decreased in patients with CRC (p=0.03 and p<0.0001, respectively). According to the ROC curve analysis, Ttl was superior to other parameters in terms of diagnostic sensitivity and specificity which were 97.5% and 92.3%, respectively, and the AUC 0.97 in CRC patients. Decreased Ttl and HDL-dependent PON 1 enzyme activities and high TOS levels imply an imbalance of the free radical system which enhances the support the hypothesis that CRC is associated with excess reactive oxygen species.These findings show that of serum oxidative imbalance was associated with an increased risk of CRC. To our knowledge, this is the first report demonstrating lower serum PON1, ARE activities in CRC patients. The mechanism behind this association needs further elucidation.

Abstract
BACKGROUND/AIMS:
Malnutrition adversely affects the postoperative outcome of patients with gastrointestinal cancer. Therefore, the malnourished cancer patients are supported by enteral or parenteral nutrition. In this study, we aimed to investigate the effects of preoperative nutritional supports on total antioxidant capacity (TAC) in malnourished patients with gastrointestinal (GI) cancers.

METHODOLOGY:
Seventy-five malnourished patients with GI cancers and 25 patients with non-cancer surgical problems were included in the study. The dietary of cancer patients were supported with immune-enhancing enteral solution in group II or standard enteral solution in group III and with parenteral solution in group IV. Plasma TAC levels were measured prior and after nutritional support. Data were expressed as mmol Trolox eq./L.

RESULTS:
The mean TAC levels of groups before treatment were 1.10±0.17, 0.92±0.19, 0.89±0.17 and 0.92±0.18, respectively. It was significantly higher in group I than others. The mean TAC levels of supported groups after treatment were 1.11±0.20, 1.08±0.21 and 1.09±0.27, respectively. Although there was a statistically significant increase in TAC after treatment in group II and III, it was not statistically significant in group IV.

CONCLUSIONS:
It was concluded that preoperative nutritional support with standard or immune-enhancing enteral solutions significantly increased TAC levels of malnourished patients with GI cancers.

Abstract
BACKGROUND:
Cavity drainage has been used routinely in Limberg flap repair for pilonidal disease but there have been few controlled studies on the rationale for routine usage of drains. The aim of this study was to determine whether routine cavity drainage affects the rates of early wound complications and recurrences after rhomboid excision with Limberg flap repair for pilonidal disease.
METHODS:
Sixty patients with pilonidal disease in the sacrococcygeal region were randomized sequentially into 2 groups as drained or non-drained. All of them underwent rhomboid excision and Limberg flap reconstruction. The patients were followed up by physical examination at 2 and 4 weeks after the operation and every 6 months thereafter.
RESULTS:
Two patients in the drained group and 3 patients in the non-drained group were excluded from the study because of non-attendance at the follow-up physical examinations. The average length of hospital stay was 3.1 ± 0.9 and 3.3 ± 0.8 days in the drained and non-drained groups, respectively. There were 5 seromas, 2 wound dehiscences and 1 hematoma in the non-drained group, while 3 seromas and 2 wound dehiscences developed in the drained group. The complication rates of groups were similar (29.6% in the non-drained group vs. 17.8% in the drained group). Pilonidal disease recurred in 2 patients in the drained group who had wound dehiscence and in 3 patients in the non-drained group who had wound dehiscence or seroma.
CONCLUSIONS:
Routine usage of drains for Limberg flap reconstruction in the sacrococcygeal region did not affect wound-related complications and recurrence rates.

Abstract
AIMS:
This study determined the effects of a single dose of bevacizumab, an antiangiogenic recombinant monoclonal antibody that specifically targets vascular endothelial growth factor (VEGF), on adhesion formation in the rat cecal abrasion model.

METHODOLOGY:
Thirty female Wistar albino rats (200-224 g) were divided into three groups. All rats underwent laparotomy at which time cecal wall abrasion and abdominal wall injuries were induced. Group I (control) underwent only the abrasion procedure; Groups II and III received saline or bevacizumab intraperitoneally, respectively, following the abrasion. The rats were killed on postoperative day 7, and the severity of adhesions was evaluated, together with histopathological fibrosis parameters and immunohistochemical staining to identify the VEGF receptor.

RESULTS:
The mean adhesion severity score in Groups I-III was 2.5 ± 0.52, 2.4 ± 0.69, and 0.7 ± 0.82, respectively; the score in Group III was significantly lower than that in Groups I (P < 0.001) and II (P < 0.001). In the histopathological evaluation, the mean fibrosis score in Group III was significantly lower that the scores in Groups I (P < 0.001) and II (P < 0.001). VEGF staining of the adhesion areas in Group III was significantly lower than that in Groups I (P < 0.001) and II (P < 0.001).

CONCLUSION:
Bevacizumab decreases adhesion formation following laparotomy in rats by blocking VEGF receptor occupancy.

Abstract
AIMS:
This study evaluated the prognostic value of the preoperative CEA and CA 19-9 levels on the survival time and TNM staging in patients with colorectal cancer.

METHODOLOGY:
We retrospectively analyzed 172 patients who underwent potentially curative resection of colorectal cancer (TNM I-III) between 2002 and 2007. Clinical data were obtained from medical charts, including age, gender, tumor location, TNM stage, mortality, follow-up duration, and preoperative CEA and CA 19-9 levels. A CEA > or = 5ng/mL was defined as abnormal (CEA+), while the cutoff for the CA19-9 was set at 37U/mL (CA19-9+). Patients were categorized into Groups I-IV according to the preoperative serum CEA and CA 19-9 levels [CEA/ CA 19-9: (-/-), (+/-), (-/+), and (+/+)].

RESULTS:
Follow-up was longest for Group I (p<0.001). Mortality rates were higher in Groups V (p<0.001) and II (p<0.008). On comparing patients according to CEA levels, survival was longer in the CEA-negative group (p=0.0001). On comparison according to CA 19-9 levels, survival was greater in the CA 19-9-negative group (p=0.0001). While CEA (p<0.016) and CA 19-9 (p<0.001) were independent prognostic factors according to the logistic regression analysis, TNM (p=0.002), CEA (p<0.001), and CA 19-9 (p<0.001) were prognostic factors in the ROC curve analysis.

CONCLUSIONS:
Colorectal cancer patients with elevated levels of both CEA and CA 19-9 have a significantly poorer prognosis than those with normal levels of these tumor markers.

Abstract
OBJECTIVE:
It was previously described that endothelins may contribute to the pathogenesis of Crohn’s disease. In this study, it was aimed to investigate the effects of endothelin receptor blockade by bosentan on the healing of a bowel anastomosis in an experimental Crohn’s disease model.

MATERIAL AND METHODS:
Twenty-eight Sprague-Dawley rats were divided into four groups. Groups I and II were used as sham-operated and control groups, respectively. Bowel inflammation induced by intrajejunal injection of iodoacetamide in groups III and IV. Rats in group IV were treated with oral preparation of bosentan 60 mg/kg/day. Three days after induction of the inflammation, partial resection of test loop and anastomosis was performed. Re-laparotomy was performed, anastomosis bursting pressures and peritonitis scores were measured, and tissue samples were obtained for the measurements of tissue hydroxylproline level and mucosal damage index 4 days later.

RESULTS:
The mean mucosal damage index and peritonitis score of group IV were significantly lower, and the mean tissue hydroxyproline level and anastomotic bursting pressure of group IV were significantly higher than those of group III.

CONCLUSION:
The blockade of endothelin receptors by bosentan decreases the severity of iodoacetamide induced intestinal inflammation, increases the wound healing in the inflamed intestinal tissue, and decreases the severity of peritonitis.

Abstract
BACKGROUND/AIMS:
Hydatid cyst remains an important public health problem in endemic areas.

METHODS:
This study retrospectively reviewed medical records of 63 patients treated for hepatic cyst hydatidosis in Frat University, Medical School, Department of General Surgery between January 1994 and December 2002.

RESULTS:
There were 96 cysts in total in 63 patients, with 67 (69%) of them located in the right lobe of the liver. Of 96 hepatic cysts, 41 (45%) were treated with partial cystectomy and drainage, 25 (26%) with partial cystectomy and capitonnage and 15 (15%) with partial cystectomy and omentoplasty. Thirty-two patients (51%) received treatment with albendazole while 31 (49%) received no medical therapy. The postoperative complication rate was 19% and there was no significant difference in the early post-operative complications between surgical procedures (p>0.05). Cysts recurred in 6 patients (11%) and no correlation was found between recurrence of cysts and albendazole use, type of surgical procedure, number and size of the cysts, Gharbi classification as determined by ultrasound examination or the relation of the cyst with the biliary tract (p>0.05).

CONCLUSION:
It was concluded that there was no significant difference in the rates of complications and recurrences among different surgical procedures when performed with basic rules of the surgical principles.

Abstract
BACKGROUND:
Early identification of patients who develop severe acute pancreatitis and those who can benefit from intensive care is important. We studied whether procalcitonin, a marker of systemic inflammation, is important in the differential diagnosis of patients with mild and severe acute pancreatitis.

METHODS:
Patients were divided into two groups (mild and severe form) prospectively. Procalcitonin levels and the Ranson’s and Acute Physiology and Chronic Health Evaluation II scores were determined both at admission and during the follow-up.

RESULTS:
Of the 65 patients with acute pancreatitis, 46 had mild and 19 had severe pancreatitis. Sensitivity and specificity values for patients calculated using procalcitonin level at 0.5 ng/ml, Ranson’s score at 3 and APACHE II score at 8 cut-off levels, were 100%, 84% and 89%; and 84%, 63% and 89% respectively.

CONCLUSION:
Procalcitonin is a practical, simple parameter that can be used in order to diagnose severe acute pancreatitis earlier and to monitor the clinical prognosis of the disease.

Abstract
INTRODUCTION:
The aim of this prospective randomized clinical study was to compare the Lichtenstein hernia repair with Kugel’s patch hernia repair.

METHODS:
From September 1999 to August 2002, adult patients with inguinal hernia were randomized into two groups. Group I included patients with the Lichtenstein hernioplasty, and group II included patients with the Kugel hernioplasty. The duration of the operation, surgical findings, and postoperative complications were recorded for the patients in both groups.

RESULTS:
A total of 139 patients (134 men, 5 women) were randomized to either group I or group II. No significant differences were observed for the duration of the operation or the complication rates between the groups during the same follow-up time (53.06 +/- 5.6 months vs. 53.41 +/- 7.11 months in groups I and II, respectively).

CONCLUSIONS:
Kugel herniorraphy is a minimally invasive method and as safe as the Lichtenstein hernia repair technique, with similar complication rates.

Abstract
PURPOSE:
Laparoscopic cholecystectomy (LC) is the treatment of choice for symptomatic cholelithiasis, but sometimes conversion to open cholecystectomy (OC) is necessary. The difficulty of LC or the risk of conversion to OC can be predicted by assessing some preoperative variables. We evaluated the efficacy of the „risk score for conversion from laparoscopic to open cholecystectomy“ (RSCLO), which was recently developed by Kama et al. (Am J Surg 2001; 181:520), in a single center.

METHODS:
We recorded the RSCLO values of 571 patients admitted to undergo LC in the Department of General Surgery, Firat University Hospital, between June 2001 and June 2004.

RESULTS:
The mean RSCLO score of 19 patients who needed conversion to OC was significantly higher than that of the patients who underwent successful LC, at 16.2 (range, -9 to 41) vs -5.7 (range, -20 to 25) (P < 0.001). The RSCLO was well correlated with conversion to OC. The sensitivity and specificity rates for RSCLO determining the risk of conversion to OC were 100% and 96%, respectively, and its positive and negative predictive values were 43% and 100%, respectively.

CONCLUSION:
We think that RSCLO could be used to define the term „difficult LC“ more accurately and assist in selecting the most appropriate operation.

Abstract
BACKGROUND:
It has been showed that free oxygen radicals and cytokines contribute to tissue damage and impairment of pancreatic microcirculation in acute pancreatitis. In this study, the effects of melatonin and pentoxiphylline were investigated in rabbits with L-arginine induced acute pancreatitis.

METHODS:
Rabbits were divided into 5 groups (n=10). Any procedure was not applied for the control group (G1). Acute pancreatitis was induced in one group (G2). Melatonin (G3), pentoxiphylline (G4) and melatonin + pentoxiphylline (G5) were given to other groups after induction of acute pancreatitis. Plasma levels of MDA, amylase, LDH, SGOT, IL-6 and TNF-a were measured at 0, 6, 12, 24 and 48 hours and pancreatic tissue was assessed histopathologically.

RESULTS:
Melatonin significantly reduced amylase activities at 6, 12, 24, and 48 hours (p<0.025), and all biochemical parameters, (excl. MDA) and edema and necrosis of acinar cells after 48 hours. Although pentoxiphylline reduced abnormally increased parameters in acute pancreatitis (significant for SGOT at 6, 12, 24 and IL-6 at 12, 48 hours), it did not normalized pancreatic abnormalities.

CONCLUSION:
Melatonin in contrast to pentoxiphylline significantly improved biochemical and histopathological abnormalities due to its powerful antioxidant and free oxygen scavenger properties in acute pancreatitis, and it can be used for patients with pancreatitis.

Abstract
BACKGROUND:
Dehiscence of intestinal anastomosis is associated with high mortality and morbidity rates. Angiotensin II is a potent agent in the acceleration of wound repair. Angiotensin converting enzyme (ACE) inhibitors have antifibrogenic effects.

AIM:
This study was performed to investigate the effect of ACE inhibitors on healing of intestinal anastomosis.

MATERIALS AND METHODS:
Forty-five male Wistar albino rats were divided into three groups. Ileum was divided above 10 cm from ileocecal valve after laparotomy and a single-layer ileoileal anastomosis was performed. While no treatment was given to rats in group 1, Lisinopril (an ACE inhibitor) was given to rats in group 2 and group 3 for post-operative 7 days in drinking water at 50 and 5 mg/l concentrations, respectively. Estimated amounts of supplied lisinopril were 6.5 and 0.65 mg/kg/day in groups. On post-operative 8th day, relaparotomy was performed and anastomosis-bursting pressures were measured. Then blood and tissue samples were taken for serum transforming growth factor beta-1 and tissue hydroxyproline measurements and histopathological examinations.

RESULTS:
High dose of lisinopril impaired the all parameters of anastomotic wound healing including bursting pressure, tissue hydoxyproline level, collagen deposition and epithelization (P < 0.001, group 2 versus groups 1 and 3). But low dose of lisinopril had no effect on those parameters (P > 0.05, group 1 versus group 3).

CONCLUSION:
It was concluded that lisinopril has impaired intestinal wound healing in a dose dependent manner and low doses of lisinopril can be safely used on patients with intestinal anastomosis.

Abstract
BACKGROUND:
Peritoneal adhesions are pathological fibrotic bands developing after mesothelial damage. Transforming growth factor beta-1 (TGF-beta1) has mitogenic activities for macrophages and fibroblasts. Over-expression of TGF-beta1 has been implicated in the pathogenesis of several fibrotic disorders. Angiotensin II increases the expression of the TGF-beta1 in fibroblasts. The aim of the study was to investigate the effect of angiotensin converting enzyme inhibitor (ACE) on intraperitoneal adhesions.

MATERIALS AND METHODS:
Thirty male Wistar albino rats were divided into two groups. In the first procedure, laparotomy was performed through a 3-cm midline incision. Ileum was divided above 10 cm from ileocecal valve and a single-layer ileoileal anastomosis was performed. Although no treatment was given to rats in group 1, lisinopril (an ACE inhibitor) was given to rats in group 2 for postoperative 7 days in drinking water. Estimated amount of supplied lisinopril was 6.5 mg/kg/day. On postoperative 8th day, relaparotomy was performed and adhesions were evaluated. At the same time, blood samples were taken for TGF-beta1 measurements.

RESULTS:
Adhesion severity was significantly less in the ACE inhibitor group (P < 0.001). While mean TGF-beta1 level was 860.3 +/- 108.1 pg/dl (mean +/- SD) in control group, it was 335.8 +/- 52.4 pg/dl in ACE inhibitor group (P < 0.001). There was a significant correlation between serum TGF-beta1 levels and grade of adhesions (r = 0.948).

CONCLUSION:
It was concluded that ACE inhibitors might be useful for preventing peritoneal adhesions.

Abstract
Hemorrhagic shock causes mucosal damage in intestine and it results in translocation of bacteria to distant organs. In this study, effects of various doses of L-Tryptophan on the prevention of bacterial translocation in hemorrhagic shock induced rabbits were investigated. This study was carried out on six groups, each was consisting of 10 rabbits. While any procedure was conducted on the rabbits in group 1 (as a control group), 1 x 10(10)Escherichia coli isolate were administered rabbits in the other groups by gavage. In groups 3, 4, 5, and 6, hemorrhagic shock was induced. After induction of hemorrhagic shock, 10, 50, and 200 mg/kg L-Tryptophan were intragastrically administered to animals in groups 4, 5, and 6, respectively. Blood and terminal ileum samples were taken to detect bacterial translocation by polymerase chain reaction and mucosal damage by histopathological examination at 24 h after hemorrhagic shock. The occurrence of bacterial translocation increased as well when intestinal bacterial intensity was increased (P < 0.05). The most intensive bacterial translocation was formed in group 3 as a result of the additive effect of hemorrhagic shock to bacterial augmentation. It was observed that bacterial translocation was significantly reduced in groups 5 and 6 that are 50 and 200 mg/kg L-Tryptophan were administered (P < 0.01). Histopathological changes on mucosa and submucosa support these results. As a result, we concluded that augmentation of intestinal bacterial intensity induces bacterial translocation, the addition of hemorrhagic shock to bacterial augmentation makes more excessive translocation and mucosal changes have effective roles in these events. L-Tryptophan decreased the intestinal mucosal damage and bacterial translocation induced by hemorrhagic shock, in a dose-dependent manner.
Abstract
Melatonin usage is increasing gradually, but reports of its effects on wound healing are inconsistent. It has been shown that the hormone is synthesized in and secreted from the gastrointestinal system independently of the pineal gland. We have investigated, by means of a comparative study on the healing of incision and anastomotic wounds, whether melatonin has an effect on wound healing independent of the pineal gland. Rats were divided in five groups (n = 10), all of which were subjected to small intestine anastomosis. The first group (control) was otherwise untreated. Exogenous melatonin was given to the rats in second group. The calvaria was opened then closed in the third group (sham operated), whereas the fourth group was pinealectomized and the fifth group were pinealectomized and then treated with melatonin. After anastomosis bursting pressures and incision wound breaking strength were measured on the 7th postoperative day, tissue hydroxyproline levels were determined, and histopathological investigation was performed. It was found that while collagen deposition and epithelization increased concurrently in incision wounds after pinealectomy, only collagen deposition increased at the anastomosis line. Exogenous melatonin decreased collagen synthesis and epithelium proliferation and had negative effects on wound healing in both normal and pinealectomized rats.
Abstract
In this study we investigated TNF-alpha and leptin levels in two different liver fibrosis models induced by carbon tetrachloride (CCl(4)) and common bile duct ligation (CBDL). A total of 36 male rats of Albino-Wistar strain were allocated to three groups. One of the groups was the control. The second group received 0.15 ml 100 g(-1) CCl(4) subcutaneously for 6 weeks, 3 days per week. The third group underwent common bile duct ligation (CBDL) and was monitored for 4 weeks. Histopathological investigation included fibrosis, steatosis and inflammation. Serum IL-6 and TNF-alpha levels were analysed by ELISA methods and leptin was analysed by RIA. Fibrosis and steatosis increased significantly in the CCl(4) group in comparison with the CBDL group (p < 0.01; p < 0.001). Leptin and TNF-alpha levels in CCl(4) group were higher than those in the CBDL and control groups (p < 0.05). TNF-alpha and leptin levels were not related to each another in either the CCl(4) group or the CBDL group (r=0.22, p > 0.05; r=0.19, p > 0.05). The IL-6 level was higher in the CCl(4) group in relation to severity of inflammation (p < 0.05). TNF-alpha and leptin levels were higher in animals with liver fibrosis induced by CCl(4), than they were in those whose liver fibrosis was induced by common bile duct ligation. Leptin and TNF-alpha may be less effective on the development of liver fibrosis in the group which underwent common bile duct ligation.
Abstract
The effects of antioxidant melatonin and a prostaglandin E1 analogue (PGE1) on hepatic ischaemia reperfusion damage were investigated. Fifty rats were divided into five equal groups: sham, control, melatonin, PGE1 and combined treatment. No procedures were applied to the sham group. In the control and treatment groups, the hepatic hilus was clamped at the level of the hepatic artery and portal vein for 60 min and reperfusion was provided for two hours. In the treatment and combined treatment groups, melatonin was administered intramuscularly at a dose of 20 mg/kg 15 mins before reperfusion, and PGE1 was administered intravenously at a dose of 25 mg/kg 1 min before reperfusion. Blood samples for SGOT, SGPT, GSH-Px, SOD and MDA measurements and hepatic tissue samples were taken. The decrease in the plasma MDA levels was statistically significant in the melatonin and combined treatment groups, but not in the PGE1 group (p > 0.025). A significant decrease was found in the tissue MDA levels of the treatment groups (p < 0.025). The decrease in SGOT and SGPT levels in the PGE1 group was significant (p < 0.025), but the decreases in the melatonin and combined treatment groups were not significant (p>0.025). Melatonin and PGE1 were found to be effective in reducing the hepatic ischaemia reperfusion damage in rats. However, the damage could not be reversed. Combined treatment was found not to be superior to melatonin or PGE1 alone.

Abstract
OBJECTIVE:
To study the effect of Seprafilm (Genzym Corporation, Cambridge, Massachusetts), a biosorbable membrane, on adhesion formation and injury recovery.

STUDY DESIGN:
Twenty female Wistar-albino rats were divided into two groups of 10 each. The right uterine horns of all rats were incised longitudinally and then stitched. While no procedure was conducted in group I (control group), in group II (Seprafilm group) this incision line was wrapped with Seprafilm. The rats were reoperated on day 7 after the first operation. The results were assessed using the Mann-Whitney U (MWU) test, and P < .05 was considered significant.

RESULTS:
The adhesion score in group I was higher than in group II (3.6 +/- 0.1 vs. 0.3 +/- 0.1; P = .000, MWU test). In the histopathologic examination performed to examine injury recovery, the measured bursting pressures and hydroxyproline levels were similar in the two groups.

CONCLUSION:
Seprafilm prevented postoperative adhesions without affecting injury recovery and thus can be used reliably.

Abstract
BACKGROUND:
It is well known that stress leads to the formation of gastric mucosal lesions. Free oxygen radicals play an important role in the pathogenesis of inflammation and tissue damage. It was observed that L-tryptophan has a positive effect on gastric mucosal damage in ischemia-reperfusion injury by inhibition of free oxygen radicals. The protective effect of pentoxifylline was shown in gastric mucosal damage induced by ischemia – reperfusion or the application of some topical agents. We performed an experimental study to determine whether intragastric L-tryprophan and intramuscular pentoxifylline protect gastric mucosal damage that is induced by immobility stress.

METHODS:
Forty rats were immobilized and divided into four groups. No treatment was made in the first group; in group 2,3 and 4, L-tryptophan, pentoxifylline and L-tryptophan + pentoxifylline were administered, respectively. The gastric lesions were assessed macroscopically and microscopically two hours following treatment.

RESULTS:
In the second and fourth groups, the lesion surface area and average mucosal damage were fewer in comparison to the control group (p<0,03). Moreover, an histopatologically improvement in the surface epithelium was observed in these groups. The average lesion score also reduced significantly (p<0,03) only in the L-tryptophan group. On the other hand, no statistically significant improvement was observed in the pentoxifylline group.

CONCLUSION:
As a result, it was concluded that L-tryptophan could play a protective role in the gastric mucosal damage associated with stress.

Abstract
BACKGROUND:
Laparoscopic procedures are safe and effective treatment methods in experienced hands. However, complications have been reported for laparoscopic procedures. One of the complications of laparoscopic cholecystectomy is vascular injuries. Hepatic and cystic artery injuries may occur alone or in association with bile duct injury. Bleeding from arterial injury may be seen during operation or in the late postoperative period. One of the most significant pathologies leading to this rare phenomenon is hemobilia.

METHODS:
We present a case of a 62-year-old woman who underwent routine laparoscopic cholecystectomy for cholelithiasis at another hospital. She presented 6 months later with the clinical feature of upper gastrointestinal bleeding.

RESULTS:
There was a 42 x 40 x 11 mm anechoic lesion and an echoic pattern compatible with a metallic object was found in the subhepatic region using abdominal ultrasonography. In the endoscopic examination, fresh blood was found in the stomach. The source of hemorrhage could not be identified. Bulbus duodeni was normal but a fresh clot on the papilla of Vateri was seen on gastroduodenoscopic examination. Laparotomy was performed and the provisional diagnosis of hemobilia was reached. The injured hepatic artery and pseudoaneurysmatic structure were repaired.

CONCLUSION:
Hemobilia is a late complication of laparoscopic cholecystectomy. We believe that it is important to take into consideration that bile duct injuries may be accompanied by arterial pathology.

Abstract
The negative effects of obstructive jaundice (OJ) on the liver and kidneys cause high morbidity and mortality. In this study, the effects of melatonin (M) and lactulose (L) on the liver and kidneys were investigated by inducing OJ in 30 rats in five groups (n = 6): controls, sham, M, L, and M + L. In the treatment group, after the rats‘ biliary canals were tied and cut, 10 mg/kg M IM and 2 ml/day L p.o. was administered for 7 days. The histopathologic findings in the liver and kidneys, tissue malonyl dialdehyde (MDA) levels, and serum biochemistry were evaluated. In the M group, pathological histologic findings were less marked than in the other groups; investigation of kidney cross-sections revealed no significant differences among groups. In the jaundiced rats liver MDA levels were significantly higher compared to the control group ( P < 0.001), but no such difference was observed in kidney MDA levels ( P > 0.05). L did not cause any significant changes in tissue MDA levels. There were no differences among groups with regard to serum levels of liver enzymes and bilirubin. Serum urea was significantly less in the group that received L ( P < 0.001), but the groups showed no significant differences with respect to creatinine values ( P > 0.05). The increase in serum total cholesterol was significantly less in the M + L group than in the other groups ( P < 0.001). We conclude that in the rats in which obstructive jaundice was induced, M administration reduced liver and kidney injury, but L and M + L did not lead to significant improvement.
Abstract
We describe herein the case of a 65-year-old man in whom a lower gastrointestinal hemorrhage developed a few days after he underwent an elective laparoscopic cholecystectomy. A laparotomy was performed on postoperative day 16 and a jejunal segment containing mucosal changes and oozing ulcers was resected. Pathologic examination of the specimen revealed „nonspecific ulcerated jejunitis.“ There is no explanation for the etiopathogenesis of this pathology; however, we concluded that this clinical picture may be attributed to ischemia-reperfusion injury that occurred following an ischemic period caused by the pneumoperitoneum during laparoscopic surgery.
Abstract
In this experimental study, the effects of an antihelminthic and immunostimulating agent (levamisole) on anastomosis recovery in transfused and normal guinea pigs were investigated. A total of 56 animals were divided into four groups of 14 each; an additional 10 were employed for blood transfusion (BT). Intestinal anastomoses were performed on all animals; the following postoperative treatments were administered: none (control group); BT; intra-abdominal (IA) levamisole; and BT + levamisole. After recording the mortality of each group, a relaparotomy was performed on one-half of the animals on the 3rd postoperative day and on the remaining half on the 7th postoperative day. Findings of IA sepsis, resistance of the anastomosis, bursting pressure, and hydroxyproline values were evaluated. Statistical comparison of the groups was accomplished by analysis of variance. In the transfused group an increase in sepsis was determined and the bursting pressure was significantly lower than in the control group. IA levamisole application following BT reduced the mortality by diminishing IA sepsis and anastomotic abscess formation and increased anastomotic pressure and recovery (P < 0.01). Histopathologic recovery in levamisole groups was better than in the group that received BT only. Levamisole application without BT resulted in equal mortality and morbidity to that of the control group. We conclude that clinical use of levamisole should be considered only in intestinal anastomoses in which BT is inevitable.
Abstract
Reconstruction of choledochal wall defects in an experimental dog model by T-tube plus fascioperitoneal graft and an evaluation of the short-term results were the aims of this study. Twelve randomly selected mongrel dogs of both sexes, having an average weight of 22.15 +/- 1.85 kg, were anaesthetized with ketamine HCI and xylazine and underwent laparatomy. The front wall of choledoch canal were excised with its all layers 0.5 cm in diameter at the distal part of the cystic duct junctions. These defects were repaired by using grafts prepared of the same diameter from the dorsal fascias of rectus muscles and peritoneum. T-tubes were introduced into the common ducts on the proximal part of the grafts. One of the animals died in the postoperative period due to evantration. T-tube cholangiograms on the twelfth day did not indicate any extravasation or stricture. Histopathological examination of the graft regions on the sixtieth day revealed that the epithelialization had commenced on the border between the bile epithelium and grafts. Based on these early findings, it was suggested that if supported by further studies it may be thought of as a clinical method.

Seit 2007 hat Dr. Bülbüller mehr als 10.000 Operationen auf dem Gebiet der Adipositas- und Stoffwechselchirurgie durchgeführt. Sleeve-Gastrektomie, Roux-en-y-Magenbypass, Mini-Gastric-Bypass und Transit-Bipartition sind chirurgische Verfahren, die häufig von ihm durchgeführt werden.

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