The effect of concomitant vascular disruption in patients with iatrogenic biliary injuries

BACKGROUND AND AIMS: To evaluate treatment results in iatrogenic biliary injuries with concomitant vascular injuries. PATIENTS/METHODS: Between January 1998 and May 2002 (inclusive), angiography was performed in 45 of the 105 patients treated for iatrogenic biliary tract injury. The charts of these 45 patients and 5 other patients in whom vascular injury was diagnosed at operation were evaluated retrospectively. Twenty-nine patients had concomitant vascular injury, the biliovascular injury group (BVI), and the remaining 21 patients had isolated biliary tract injury (IBTI). RESULTS: The most frequent initial operation was a cholecystectomy. The frequency of high-level (Bismuth III or IV) strictures was 90% in the BVI group and 62% in the IBTI group ( P<0.05). Perioperative mortality was 7% in the BVI group and 5% in the IBTI group ( P>0.05). The morbidity in the BVI group was significantly higher ( P<0.05). Two patients in each group were lost to follow up. During a median (range) follow up of 31 months (5-51 months), a successful functional outcome was achieved in 96% of the BVI group and 100% of the IBTI group with a multimodal approach ( P>0.05). CONCLUSIONS: The frequency of high-level biliary injury and morbidity were significantly higher in the BVI group. However, concomitant vascular injury had no significant effect on mortality and medium-term outcome of biliary reconstruction. Thus, routine preoperative angiography is not recommended.     

An unusual combination of extremity fractures: floating body injury

Simultaneous quadruple extremity fractures are rare and can be termed as “floating body” injury. A review of the literature produced only one previous report of this rare combination which could not be operated. We presented a 40-year-old female patient with bilateral humerus and femur fractures associated concomitant injuries such as nondisplaced acetabular fracture, rib fractures and traumatic tendon ruptures. She was operated by arthroscopically assisted retrograde intramedullary nailing for femur fractures as well as by external fixators for humerus fractures. She was able to walk with full weight-bearing without any assistance at the end of the first postoperative year. Early fixation of the fractures in floating body injury using retrograde intramedullary nailing and external fixator is successful treatment method.     

p53, p21 and metallothionein immunoreactivities in patients with malignant pleural mesothelioma: correlations with the epidemiological features and prognosis of mesotheliomas with environmental asbestos exposure.

The aim of this study is to investigate immunoreactivity for p53, p21 and metallothionein in diffuse malignant pleural mesothelioma (DMPM) and to determine the relationships between the age, sex, asbestos exposure time, survival of DMPM patients with environmental asbestos exposure and immunoreactivity to p53, p21 and metallothionein. Sixty-seven histopathologically-confirmed DMPMs, 38 of whom had environmental and 29 had occupational asbestos exposure, were included. The tumour tissue samples were immunostained with antibodies against p53, p21 and metallothionein. Epidemiological data and the survival times for the DMPM patients with environmental asbestos exposures were obtained from hospital records. Thirty-three per cent of the DMPMs were positive for p53, 35% for p21 and 52% for metallothionein. There was no statistical difference between the histological subtypes of DMPM in terms of immunoreactivity for p53, p21 and metallothionein. For p21 and metallothionein there was a statistically significant difference between the exposure characteristics: patients with environmental asbestos exposure had shown more immunopositivity. There were statistically significant differences between age groups and between asbestos exposure times for metallothionein, and between asbestos exposure times and p21. The patients with positive immunostaining had longer exposure times and were older than those having negative immunostaining. The differences between survival of the patients were not statistically significant in terms of the immunohistochemical results for p53, p21 and metallothionein.     

A comparison of low-dose and normal-dose gadobutrol in MR renography and renal angiography.

OBJECTIVE: It has been advocated that a reduced injection volume with highly concentrated (1 M) contrast material can produce a sharper bolus peak and an increased intravascular first-pass gadolinium concentration when compared with the use of a lower concentration (0.5 M). A higher concentration would also cause a reduction in dose. The purpose of our study was to test the use of a low dose (0.05 mmol/kg) of gadobutrol in magnetic resonance renography and angiography and compare the findings with a dose of 0.1 mmol/kg. MATERIALS AND METHODS: One-hundred-thirty-four patients referred for magnetic resonance angiography for suspected renovascular disease participated in the study. Contrast enhanced MR renography and angiography were performed after administration of a bolus of 0.1 mmol/kg or 0.05 mmol/kg gadobutrol in randomized patients. The relative signal intensity-time curves of the aorta, peripheral cortex and parenchyma, were obtained. Two radiologists evaluated the angiographic images and evaluated the quality of angiography. RESULTS: The signal intensity with a low dose of gadobutrol was significantly lower in early phases, in the peripheral cortex (for 36, 54, 72 and 90 seconds), the parenchyma (for 36, 54, 72 seconds) and the aorta (for 18, 36, 54, 72 seconds). The decreases in the early phase obtained with a low dose of gadobutrol caused blunter time intensity curves. The difference in the quality scores of the readers for the angiographic images for the use of the two different doses was not statistically significant (p > 0.05). CONCLUSION: A lower dose of gadobutrol can be used for MR renal angiography, but for MR renography the normal dose should be used.     

"Portal double ductopathy sign" in patients with portal vein cavernous transformation

BACKGROUND/AIMS: The aim of this study was to determine to what extent portal vein cavernous transformation affects the biliary tract and pancreatic duct system concurrently. METHODOLOGY: Patients who had liver cirrhosis, liver malignancy, history of chronic alcohol use, chronic pancreatitis, pancreatic cancer, or surgery of upper abdomen were excluded. Endoscopic retrograde cholangiopancreatography was performed on all patients. The radiographic images from the biliary and pancreatic systems obtained at the same session were evaluated. RESULTS: In 36 patients, both systems were evaluated. In 2 out of 36 patients, the biliary system was normal, while in 5 patients (13.9%) the pancreatic duct was found to be normal. Thus, 31 patients (12 men, 19 women) had successful visualization. Additionally, 31 out of 36 patients had luminal narrowing throughout the pancreatic duct, local atrophy at head of the pancreas with moderate dilatation behind the narrowed segment. These findings were not found in control patients. In 4 patients who underwent splenectomy for severe hypersplenism, radiological findings were consistent with surgical findings. CONCLUSIONS: The above mentioned morphological findings which are demonstrated in biliary and pancreatic duct are novel findings which the authors propose to call "portal double ductopathy sign" when both ducts are affected concurrently.     

A comparison of conventional and pulsed radiofrequency denervation in the treatment of chronic facet joint pain

OBJECTIVES: The goal of this study was to compare the effects of conventional radiofrequency (CRF) and pulsed RF (PRF) denervation to medial branches of dorsal rami in the treatment of facet joint pain. METHODS: The patients greater than 17-year old, with continuous low back pain with or without radiating pain with focal tenderness over the facet joints, pain on hyperextension, absence of neurologic defect, unresponsiveness to conservative treatment, no radicular syndrome, and no indication for low back surgery were included in the study. Local anesthetic was applied in the control group (n=20), whereas 80 degrees C CRF were applied in the CRF (n=20) and 2 Hz PRF were applied in the PRF group (n=20). Pain relief was evaluated by visual analog scale (VAS) and Oswestry Disability Index (ODI) at preprocedure, at procedure, at 6 months and 1 year after the procedure. Reduction in analgesic usage, patients' satisfaction, and complications were assessed. RESULTS: Mean preprocedural VAS and ODI scores were higher than postprocedural scores in all groups. Both VAS and ODI scores of PRF and CRF groups were lower than the score of the control group at the postprocedural evaluation. Although decrease the pain score was maintained in the CRF group at 6 months and 1-year period, this decrease discontinued in the PRF group at the follow-up periods. The number of patients not using analgesics and patient satisfaction were highest in CRF group. DISCUSSION: PRF and CRF are effective and safe alternatives in the treatment of facet joint pain but PRF is not as long lasting as CRF.     

Controversies in the laparoscopic treatment of hepatic hydatid disease

BackgroundLaparoscopic treatment of hydatid disease of the liver can be performed safely in selected patients.MethodsSix hundred and fifty patients were treated for hydatid disease of the liver between 1980 and 2003 at the Hepatopancreatobiliary Surgery Unit of Istanbul Medical Faculty, Istanbul University. Of these, 60 were treated laparoscopically between 1992 and 2000. A special aspirator-grinder apparatus was used for the evacuation of cyst contents. Ninety-two percent of the cysts were at stages I, II or III according to the ultrasonographic classification of Gharbi.ResultsConversion to open surgery was necessary in eight patients due to intra-abdominal adhesions or cysts in difficult locations. There was no disease- or procedure-related mortality. Most of the complications were related to cavity infections (13.5%) and external biliary fistulas (11.5%) resulting from communications between the cysts and the biliary tree. There were two recurrences in a follow-up period ranging between 3.5 and 11 years.DiscussionLaparoscopic treatment of hydatid disease of the liver is an alternative to open surgery in well-selected patients. Important steps are the evacuation of the cyst contents without spillage, sterilization of the cyst cavity with scolicidal agents and cavity management using classical surgical techniques. Our specially designed aspirator-grinder apparatus was safely used to evacuate the cyst contents without causing any spillage. Knowledge of the relationship of the cyst with the biliary tree is essential in choosing the appropriate patients for the laparoscopic technique. In our experience of 650 cases, the biliary communication rate was as high as 18%; half of these can be detected preoperatively. In the remaining, biliary communications are usually detected during or after surgery. Endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy are helpful to overcome this problem. As hydatid disease of the liver is a benign and potentially recurrent disease, we advocate the use of conservative techniques in both laparoscopic and open operations.