Planned second-look laparoscopy in the management of acute mesenteric ischemia

AIM： To investigate the role of second-look laparoscopy in patients with acute mesenteric ischemia （AMI）.
METHODS： Between January 2000 and November 2005, 71 patients were operated for the treatment of AMI. The indications for a second-look were low flow state, bowel resection and anastomosis or mesenteric thromboembolectomy performed during the first operation. Regardless of the clinical course of patients, the second-look laparoscopic examination was performed 72 h post-operatively at the bed side in the ICU or operating room.
RESULTS： The average time of admission to the hospital after the initation of syrnptoms was 3 d （range, 5 h-9 d）. In 14 patients, laparotomy was performed. In 11 patients, small and/or large bowel necrosis was detected and initial resection and anastomosis were conducted. A low flow state was observed in two patients and superior mesenteric artery thromboembolectomy with small bowel resection was performed in one patient. In 13 patients, a second-look laparoscopic examination revealed normal bowel viability, but in one patient, intestinal necrosis was detected. In two of the patients, a third operation was necessary to correct anastomotic leakage. The overall complication rate was 42.8%, and in-hospital mortality rate was 57.1% （n = 6）.
CONCLUSION： Second-look laparoscopy is a minimally invasive, technically simple procedure that is performed for diagnostic as well as therapeutic purposes. The simplicity and ease of this method may encourage wider application to benefit more patients. However, the timing of a second-look procedure is unclear particularly in a patient with anastomosis.     

An infrequent cause of upper gastrointestinal tract bleeding: "Dieulafoy's lesion"

BACKGROUND/AIMS: Dieulafoy's lesions are uncommon sources of upper gastrointestinal tract bleeding. Endoscopists must be aware of these lesions when evaluating patients with upper gastrointestinal tract bleeding. METHODOLOGY: The aim of this study is to analyze the results of active bleeding or recurrently bleeding Dieulafoy's lesions treated either by endoscopic injection therapy (EIT) or endoscopic band ligation (EBL). Fifteen patients who had active bleeding due to Dieulafoy's lesions were evaluated retrospectively with respect to demographic properties, comorbidities, endoscopic therapy procedures, and the success rate of the procedure. RESULTS: The incidence of Dieulafoy's lesions was 4.5% in all cases of upper gastrointestinal tract bleeding. Among the 15 patients there were nine men and six women with a median age of 52 years (25-84 years). Eleven of these lesions were located in the stomach, two were in the duodenum, and two were in the distal esophagus. Eight patients were initially treated by EIT and seven patients had EBL therapy. There was no recurrent bleeding in any of the patients treated with EBL, but five patients (62.5%) treated with EIT bled again and were treated secondarily with EBL. Two of these patients required surgical intervention and one died on the 15th day of surgery due to myocardial infarction. No endoscopy-related complications were detected. CONCLUSIONS: Endoscopic methods should be the first choice in treating bleeding Dieulafoy's lesions. Both EIT and EBL are successful methods for achieving initial hemostasis. However, EIT therapy has a higher re-bleeding rate. EBL is a safe and effective method for the treatment of bleeding Dieulafoy's lesions.     

Serious lower extremity venous injury management with ligation: prospective overview of 63 patients

Management of lower extremity venous trauma using repair or ligation has been an area of controversy during the past decades. However, in unstable patients or if primary repair is technically impossible as a result of extensive disruption of the vein, ligation is recommended. This study investigated the effects of venous ligation on major veins in the lower extremities when primary repair is impossible as a result of extensive laceration of the vein. Between January 2001 and April 2004, 63 patients with Grade III and IV venous injuries were observed prospectively. Compression ultrasonography was performed postoperatively on the fifth day, once before discharge, and at the 3-month visit to assess deep vein thrombosis (DVT) and the patency of arterial repair. If DVT was present, the patient was given an oral anticoagulant (warfarin Na) for 3 months (international normalized ratio, 2.0-3.0), and Class II compression stockings (Sigvaris-212, Ganzoni, Switzerland) were used for 1 year. Follow-up visits occurred at 1, 3, 6, and 12 months and at 6-month intervals thereafter. Combined arterial and venous injuries were present in 50 (79.4%) patients and pure venous injuries were present in 13 (20.6%) patients. DVT developed in 49 patients (77.7%; postoperative n = 37 [58.7%], late n = 12 [19%]). Three arterial restenoses (4.7%) and one pseudoaneurysm (1.6%) of the superficial femoral artery developed. Five early (prophylactic) and two late (compartment syndrome) fasciotomies were performed. Postoperative edema was seen in 56 (88.8%) patients and wound infection was seen in 19 patients (30.1%; n=18 superficial, n=1 deep). Two amputations (3.2%) were performed. One patient (1.7%) died as a result of irreversible shock. After a median of 18 months, 25 patients were classified with Clinical Etiology, Anatomy, Pathology classification: 10 legs C-0, seven legs C-2, and eight legs C-3. No severe postthrombophlebitic syndrome was observed. Early leg swelling after venous ligation was the most common morbidity. We observed no significant sequelae of chronic venous insufficiency, and venous ligation had no detrimental effect on associated arterial repair. In cases of DVT, anticoagulation with low-molecular-weight heparin and oral anticoagulants should begin immediately and continue for 3 months along with compression stocking support for 1 year.     

Bioassay-guided isolation of anti-inflammatory, antinociceptive and wound healer glycosides from the flowers of Verbascum mucronatum Lam.

Ethnopharmacological relevance

The leaves, flowers and whole aerial parts of Verbascum L. species have been used to treat respiratory problems, haemorrhoids and other types of inflammatory conditions in traditional Turkish medicine.

Aim of the study

In order to evaluate this traditional information, the anti-inflammatory, antinociceptive and wound healing activities of Verbascum mucronatum Lam. which is used as haemostatic in Turkish folk medicine were investigated.

Materials and methods

In vivo inhibitory effect of the extracts on the carrageenan-induced hind paw edema model in mice was studied for the assessment of anti-inflammatory activity. Moreover, the wound healing potential of the plant were evaluated by using in vivo wound healing experimental models, i.e. incision and excision models on mice and rats, were comparatively assessed with a reference ointment Madecassol^®. Skin samples were also evaluated histopathologically.

Results

The results of these experimental studies exhibited that Verbascum mucronatum displays anti-inflammatory, antinociceptive and wound healing activities. Through bioassay-guided fractionation and isolation procedures four iridoid glucosides, ajugol (1), aucubin (2), lasianthoside I (3), catalpol (4), two saponins, ilwensisaponin A (5) and C (6) and a phenylethanoid glycoside, verbascoside (7) were isolated and their structures were elucidated by spectral techniques. Verbascoside (7) was found to possess significant wound healing activity as well as antinociceptive and anti-inflammatory potentials, per os without inducing any apparent acute toxicity or gastric damage.

Conclusion

The experimental study revealed that Verbascum mucronatum displays remarkable antinociceptive, anti-inflammatory and wound healing activities.     

Gravin gene expression in acute leukaemias: clinical importance and review of the literature

The aim of this study was to determine the expression of Gravin (a tumor suppressor gene belonging to the A kinase anchoring protein family) in samples of acute leukaemia and to explore its association with the prognosis. The study group consisted of 162 people (137 patients with acute leukaemia and 25 volunteers as control). Real-time quantitative PCR was used to determine the gene expression and beta Actin used as a control gene. The results were evaluated with Comparative Ct method. Gravin beta-Actin DeltaCt was statistically different between patients and controls (p value < 0.001). The Gravin expression was found to be decreased 11-fold when compared with controls and was found to be decreased in 106 cases (77.5%). There was an inverse correlation between gravin expression and overall survival. The Gravin expression was found to be decreased in samples of acute leukaemia and was associated with an inferior overall survival. Because of paradoxical results, there is a need for more studies exploring gravin isoforms and other related gene expressions.     

The versatile reverse-flow digital artery cross-finger flap

Various flaps have been described for the reconstruction of the soft tissue defects of the digits, but these are not applicable to all kinds of defects. Moreover, these techniques are mostly 2-staged operations that require long-term immobilization. In this study, reverse-flow digital artery cross-finger flap was used to cover various volar and dorsal digital defects in 9 cases. Seven of 9 cases that had follow-up period longer than 2 years were evaluated, and all had good results. We recommend that reverse-flow digital artery cross-finger flap is a universal flap that can be used for almost all types of soft tissue defects of the digits.     

Survivin and EPR-1 expression in acute leukemias: prognostic significance and review of the literature

The aim of this study is to detect the biologic and/or prognostic significance of survivin (S) and effector protease receptor 1: EPR-1 (E) expression in acute leukemias (34 ALL and 40 AML) by using RT-PCR. S and E expressions were found in 83.8 and 20.3% of the cases, respectively. S was detected in 90%, 76.5% and E was detected in 17.5%, 23.5% of the cases with AML and ALL, respectively. There was a significant correlation between S and E (r=0.30 p=0.01). Mortality rate was higher in E(-) cases than E(+) cases (83.1 % versus 66.7%) (p=0.04). The median DFS and OS rates were shorter in S(+) and E(-) cases. In subgroup analysis, there was not a significant difference for OS between S(-) and S(+) cases and E(-) and E(+) cases in ALL group. The median OS rate was significantly longer in S(-) cases than S(+) cases, and longer in E(+) cases than E(-) in AML groups (p=0.04, 0.001, respectively). OS and DFS rates were longest in S(-) E(+) cases and shortest in S(+) E(-) cases (p=0.04 and 0.03, respectively). In multivariate analyses EPR1 negativity was found to be an independent poor risk factor for survival (OR: 2.4, p=0.02). In conclusion S expression is a bad prognostic indicator in cases with acute leukemia especially in AML. S negativity and E positivity show good clinical outcome in acute leukemias. E expression is important due to its property of the possible natural anti-sense of the S.