Laparoscopy in Turkish Bariatric Surgery: Initial Experience

Background: The recent application of the laparoscopic method combines minimal invasiveness with reversibility, adjustability and shorter hospital stay. The first laparoscopic bariatric operation in Turkey was performed by us in 1998. Methods: We report the results in 50 consecutive patients who underwent the laparoscopic application of SAGB between April 1998 and April 1999.The operation setting was the same as for the laparoscopic antireflux procedure. After a closed CO pneumoperi2 toneum (16-18 mmHg), in the first 20 cases five and in the remaining 30 cases four trocars were inserted. A 30°laparoscope was placed on the line between the umbilicus and the xiphoid through a 10 mm trocar.We followed and respected the main steps of the operation as well. Pre and postoperative body weight (BW), body mass index (BMI) and percent excess weight (%EW) values were calculated and compared. Results: Our early results were quite satisfactory and promising. After an average follow-up period of 1 year (range 6-18 months), the 50 patients of our laparoscopic series showed a BW of 74 kg (range 56- 112), a BMI of 29 (range 21-40), and an EW of 62% (range 22-86). Conclusion: With its lower morbidity rate, shorter hospital stay and better cosmetic results, the laparoscopic approach may be considered the first choice in bariatric surgery.     

Beta-blocker treatment in heart failure patients with atrial fibrillation: challenges and perspectives

Heart failure (HF) and atrial fibrillation (AF) are common conditions that share similar clinical phenotype and frequently coexist. The classification of HF in patients with preserved ejection fraction (> 50%, HFpEF), mid-range reduced EF (40%−49%, HFmrEF) and reduced EF (< 40%, HFrEF) are crucial for optimising the therapeutic approach, as each subgroup responds differently. Beta-blocker constitute an important component of our pharmacological regimen for chronic HF. Beta-blocker administration is reccomended in patients with HF with reduced ejection fraction in stable sinus rhythm, due to improvement of symptoms, the better long term-outcome and survival. The beneficial role of beta-blocker use in patients with preserved EF still remain unclear, as no treatment showed a positive impact, regarding morbidity or mortality reduction. The presence of AF in HF patients increases as the disease severity evolves and is associated with a higher rate of cardiovascular morbidity and mortality. But more question is the use of betablocker in HF patients irrespective of EF and concomitant AF. There are many conflicting data and publications, regarding the beta blocker benefit in this population. Generally, it is supported an attenuation of beta-blockers beneficial effect in HF patients with AF. A design of more randomised trials/studies with HF patients and concomitant AF may improve our clinical approach of beta-blockers use and identify the patients with HF, who mostly profit from an invasive approach.

Atrial fibrillation (AF) and heart failure (HF) with or without systolic dysfunction constitute common cardiac conditions, that frequently coexist and overlap.^[1] These entities share multiple risk factors such as age, hypertension, diabetes, obesity, as well as cardiac substrates as valvular, ischemic, and non ischemic structural heart disease.^{[1, 2]} Their coexistence can be partially explained by the presence of the common risk factors.^[3]The definition of heart failure revised in 2016, based on the measurement of left ventricular ejection fraction (EF).^[4] Especially, HF can be divided in three groups: heart failure with preserved EF(> 50%, HFpEF), mid-range reduced EF (40%−49%, HFmrEF) and reduced EF (< 40%, HFrEF).^[4] Interestingly, up to 50% of chronic HF patients present normal or only mildly impaired left ventricular EF.^[5] The prevalence of AF in HF patients increases as the disease severity evolves.^[6] Specifically, in patients with New York Heart Association (NYHA) I−II is typically about 5%, NYHA III approximately 26% and NYHA IV is presented up to 50%.^[6] According to the data from randomized clinical trials and registries, the presence of AF in HFpEF patients ranges between 15% and 41%.^[7] Patients with HFpEF are more likely to demonstrate prevalent AF or AF at any time up to twice, compared with those with HFrEF.^[7] Data from the natiowide Swedish heart failure registry reported the prevelance of AF among LVEF ranges, specifically 53% in HFrEF, 60% HFmrEF, and 65% inHFpEF.^[8] The presence of AF in HFrEF patients was 27% in an anaylsis of ESC-HF long term registry.^[9] Notably, AF occurs in 24%−44% of patients in the setting of acute HF and in one third of those with chronic HF.^{[10, 11]} Atrial fibrillation is also found in more than half (57%) of patients with new onset of HF.^[12] Furthermore, HF is present in 33%, 44% and 56% of ambulatory patients with paroxysmal, persistent and permanent AF, respectively and in more than one third (37%) of those with new onset AF.^{[12, 13]}     

Past and present midwifery education in Turkey

Among criteria relating to the level of development in a country are health indicators such as total fertility, maternal mortality, infant mortality, and rates of life expectancy at birth. These have a close relationship with the quality of health-care services, especially those provided by midwives. An improvement in midwifery services can be achieved to a great extent by standardised and high-quality midwifery education. Until recently, midwifery education has not been standardised in Turkey. Although improvements have been made, more needs to be accomplished. In this paper, we report the development of midwifery education in Turkey from a historical perspective, dealing with past and present applications, and make recommendations to overcome existing problems.     

A complication of brucellosis: epididymoorchitis.

BACKGROUND: Epididymoorchitis is the most frequent genitourinary complication of brucellosis. METHODS: This prospective study was conducted between February 2001 and January 2004, prospectively. Male patients diagnosed with brucellosis were included in this study and evaluated for testicular involvement. RESULTS: Epididymoorchitis was detected in 17 out of 134 (12.7%) male patients with brucellosis. Mean age of the patients was 36.9+/-7.1 years. Twelve patients (70.6%) had acute, four patients (23.5%) had subacute, and one patient (5.9%) had chronic brucellosis. The most common symptoms were scrotal pain (94%) and swelling (82%). Eleven patients had unilateral epididymoorchitis, four had unilateral orchitis and two had unilateral epididymitis. A testicular abscess was detected in one patient. Sperm analysis was performed on 14 patients. Five patients had aspermia and eight had oligospermia. Combined antibiotic therapy was started and continued for 6-8 weeks. Orchiectomy was required for two patients and granulomatous orchitis was detected in the resected specimens. Relapse occurred in only one patient. Three patients had permanent oligospermia and one patient had permanent aspermia after the antibiotic therapy. Younger age, high C-reactive protein level and blood culture positivity were statistically significant differences between the patients with and without epididymoorchitis. CONCLUSIONS: Brucellosis should be considered in the diagnosis of scrotal diseases in endemic areas. A conservative approach is usually adequate for managing brucellar epididymoorchitis. However, infertility problems may develop in these patients. Well-designed further investigations are needed to explain the relationship between brucellar epididymoorchitis and infertility in man.     

Predictors for treatment failure after laparoscopic electrocautery of the ovaries in women with clomiphene citrate resistant polycystic ovary syndrome

BACKGROUND: Laparoscopic electrocautery has been put forward as the treatment of choice in women with clomiphene citrate (CC)-resistant polycystic ovary syndrome (PCOS). In order to make an informed treatment decision it would be helpful if we could identify women with PCOS with a high probability of treatment failure following electrocautery of the ovaries. METHODS: Eighty-three women with CC-resistant PCOS were allocated to receive laparoscopic electrocautery followed by CC when anovulation persisted as part of a randomized controlled trial. Multivariable logistic regression analyses using clinical, ultrasonographic and endocrinological parameters were performed to predict (i) failure to ovulate within 8 weeks after electrocautery, and (ii) failure to reach an ongoing pregnancy after electrocautery with or without CC. RESULTS: Of the 83 women, 56 (67%) ovulated within 8 weeks after electrocautery. The model for predicting anovulation after electrocautery included LH/FSH rate, year of menarche and glucose level. Women who were younger at menarche, had a lower LH/FSH ratio and a lower glucose level were more likely to have persistent anovulation. The area under the curve was 0.74. After electrocautery and CC, 41 women reached an ongoing pregnancy. No prognostic parameters could be identified to predict failure to reach an ongoing pregnancy after electrocautery followed by CC. CONCLUSIONS: Persistence of anovulation after electrocautery could be predicted and women with a high risk of persisting anovulation could be distinguished. We were, however, not able to predict treatment failure after electrocautery followed by CC.     

Serum leptin levels of premature and full-term newborns in early infancy: metabolic catch-up of premature babies

Leptin is secreted from the edipose tissue and has an important role in the regulation of energy metabolism. This study aimed to compare serum leptin levels of preterm and full-term infants during the first three months of their life and to define the roles of sex, weight, thickness of subcutaneous adipose tissue, gestational age and maternal leptin in the determination of serum leptin levels. Forty-four full-term and 32 preterm infants were included in the study. Weight, thickness of subcutaneous adipose tissue, serum glucose, cortisol, insulin and leptin levels were compared between preterm and full-term infants at 7th, 30th and 90th days. ELISA method was used in determining serum leptin levels. Weight, thickness of subcutaneous adipose tissue and serum leptin levels were significantly increased in full-term infants compared to preterm infants at days 7 and 30. At 90th day weight and thickness of subcutaneous adipose tissue were significantly increased in full-term infants, but the difference in serum leptin levels did not reach statistical significance (p=0.56). Weight was the most important factor predicting serum leptin levels at the 7th day. On the other hand, the thickness of subcutaneous adipose tissue was the most important determinant at days 30 and 90. Maternal serum leptin level was a determinant of serum leptin level at day 7. Sex was a determinant of serum leptin level of the infant at days 7 and 30. The differences in weight gain, increase in thickness of subcutaneous adipose tissue and increase of serum leptin levels were not significant between groups. But the increase in serum leptin levels was correlated in both preterm and full-term infants with weight gain and increase in thickness of subcutaneous adipose tissue. At three months of age, in the catch-up growth period, preterm infants reach serum leptin levels near those of full-term infants. The thickness of subcutaneous adipose tissue has a role in the determination of serum leptin levels after 30 days of life.     

Comparison between HELLP syndrome, chronic hypertension, and superimposed preeclampsia on chronic hypertension without HELLP syndrome

AIM: To compare perinatal outcome of patients with HELLP syndrome to that of patients with chronic hypertension and superimposed preeclampsia on chronic hypertension without HELLP syndrome. METHODS: We retrospectively evaluated the perinatal outcome of 147 pregnancies complicated by the HELLP syndrome, chronic hypertension, and superimposed preeclampsia on chronic hypertension without HELLP syndrome. RESULTS: Gestational age at delivery and birthweights were lower among women with HELLP syndrome than among women with superimposed preeclampsia and chronic hypertension (P < 0.05). There were no statistically significant differences among the three groups with respect to intrauterine growth retardation, respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, Apgar score, admission to neonatal intensive care unit, overall rate of cesarean delivery and cesarean delivery rate for fetal distress. The total perinatal mortality rate was 17% (28/147) and was more frequent in the HELLP group (27%). Multivariate logistic regression analysis showed that gestational age at delivery (RR 0.45) and birthweight (RR 0.99) were risk factors for adverse outcome. CONCLUSIONS: Perinatal outcome is primarily influenced by gestational age at delivery and birthweight independent of the severity of the hypertensive status of pregnant women.     

A new instrument,the "Perfore-Aspirator" for laparoscopic treatment of hydatid cysts of the liver

The authors introduce a new instrument functioning as both perforator and aspirator in the laparoscopic management of hepatic hydatid cysts. Between January 1998 and January 2002, 11 laparoscopic cystotomy + partial cystectomy + drainage procedures were performed for eight consecutive patients. Eight of the cysts were located in the right lobe, and the remaining three in the left. The average diameter (+/-SD) of the cysts was 9.6 +/- 3.66 cm, and the mean age of the patients was 31.3 +/- 7.24 years. The diagnosis was confirmed by ultrasonography and/or computerized tomography. The procedure was performed with the help of three ports. The "perfore-aspirator" instrument (Bahadir Tibbi Aletler A. S., Samsun, Turkey) was introduced through the 10-mm trocar at the subcostal area, and the cystotomy procedure was done with success. Then, a partial cystectomy procedure was performed with the use of a grasper and scissors attached to an electrocautery device. The average hospitalization period was 5 +/- 1.69 days. No major morbidity or mortality was seen. All patients were treated with albendazole preoperatively and postoperatively.     

Disclosure of cancer diagnosis to patients and their relatives in Turkey: views of accompanying persons and influential factors in reaching those views

AIMS AND BACKGROUND: In Turkey, it is a common belief that most family members of patients with cancer would not want them to be informed of a diagnosis of cancer. Our aim was to evaluate the attitudes and opinions of people accompanying cancer patients, regarding cancer diagnosis disclosure. METHODS: In a cross-sectional study 270 caregivers accompanying cancer patients during outpatient chemotherapy sessions were asked to fill in a questionnaire to determine their opinions regarding whether the diagnosis of cancer should be disclosed to the patients and their relatives or not. Timing of telling the diagnosis and from whom it should be learned were queried as well. Possible influential factors for the answers were analyzed with the chi-square test. RESULTS: Of the 270 accompanying persons, 130 (48.2%) said that the patients should be informed of the diagnosis, whereas a greater number (236, 87.4%) believed that the patient's relatives should be informed. Being younger than 40 years old (P = 0.0005), being unmarried (P = 0.002), having a higher educational status (P = 0.0001) and having passed less than four months since the diagnosis (P = 0.005) positively affected opinions regarding telling the truth to the patient. Higher education (P = 0.012) and high monthly income (P = 0.002) positively affected opinions regarding disclosing a diagnosis of cancer to the patient's relatives. CONCLUSION: As a result, in a survey of caregivers' points of view, more than half of the accompanying persons did not agree with disclosing a cancer diagnosis to patients, whereas the majority agreed with disclosing it to the relatives, and educational level seemed to be the major influential factor.