Bare serratus anterior free flap in the reconstruction of the partial pharyngoesophageal defect

Reconstruction of defects of the cervical esophagus is a challenge in head and neck surgery. Several methods have been used: flaps with local tissues, pharyngogastric anastomosis, deltopectoral skin flaps, skin muscle transplant from the pectoralis major, and microvascularized free skin fascial and small intestine flaps. A 81-year-old patient who has a partial pharyngoesophageal defect after resection of laryngeal carcinoma underwent reconstruction with bare serratus anterior fascial free flap. The subscapular artery and vein were anastomosed to the superior thyroid artery and vein. The patient's postoperative recovery went uneventfully. In the endoscopic examination, the defect was completely covered with native mucosa 8 weeks after surgery, and also, there were no stricture and fistula tract in the reconstructed area.Serratus fascial flap is a thin and pliable flap with good and reliable vascularity; it can be used in the reconstruction of partial cervical esophageal defect with its long pedicle. Serratus fascial flap can provide significant epithelialization that cannot be differentiated from native esophagus. We propose that serratus fascial free flap is an important alternative in esophageal reconstructions because it creates minimal donor-site morbidity and it can easily adapt to the defect.     

Comparison of the protective effects of curcumin and caffeic acid phenethyl ester against doxorubicin-induced testicular toxicity

Whether testicular toxicity is mediated by matrix metalloproteinases (MMPs) is an important question that has not been examined. This study investigated the suppressive effect of curcumin and caffeic acid phenethyl ester (CAPE) on oxidative stress, apoptosis, and whether MMPs mediate doxorubicin (DOX)-induced testicular injury. Male rats were randomly divided into eight groups (n = 8 per group). The groups were as follows: sham, dimethyl sulphoxide (100 µL), DOX (3 mg/kg), CAPE (2.68 mg/kg), curcumin (30 mg/kg), DOX+CAPE (3 mg/kg DOX and 2.68 mg/kg CAPE), DOX+curcumin (3 mg/kg DOX and 30 mg/kg curcumin) and DOX+CAPE+curcumin (3 mg/kg DOX, 2.68 mg/kg CAPE and 30 mg/kg curcumin). Injections were administered daily for 21 days. The oxidative stress, MMPs, proinflammatory cytokines and apoptotic markers in the DOX group were higher than the sham group (p < .05); these measures were lower in the groups treated with CAPE and curcumin together with DOX compared with the DOX group (p < .05). The results showed that MMPs mediated DOX-induced testicular injury, but CAPE and especially curcumin suppressed testis injury and cell apoptosis by suppressing DOX-induced increases in MMPs, oxidative stress and proinflammatory cytokines. However, curcumin exhibited more pronounced effects than CAPE in terms of all studied parameters.     

Pattern electroretinography and visual evoked potentials in optic nerve diseases.

BACKGROUND: To evaluate transient pattern electroretinography (PERG) and pattern visual evoked potential (VEP) for the diagnosis, differential diagnosis and follow-up of optic nerve diseases. METHODS: Twenty-nine consecutive patients (14 female, 15 male) with the diagnosis of ischaemic optic neuropathy (n=14) and optic neuritis (n=15) were included in this study. Mean age of the patients with ischaemic optic neuropathy was 63.3+/-3.3 (60-78) years and the mean age of the patients with optic neuritis was 28.3+/-8.4 (19-43) years. In each patient ophthalmological examination and systemic evaluation were done and VEP and PERG were recorded. As a control group, VEP recordings of 35 healthy subjects were included. RESULTS: In the ischaemic optic neuropathy group (group 1), mean VEP amplitude (+/-SD) (1.96+/-0.95 microV) was found to be decreased significantly in the affected eyes in comparison to the control group and the unaffected eyes. The delay in latency (116.3+/-20.14 msec in the affected eyes compared with 101.31+/-6.19 msec in unaffected eyes) was statistically significant when compared with the healthy subjects. In the optic neuritis group (group 2), VEP amplitude was decreased (4.13+/-4.04 microV vs 6.97+/-3.35 microV and 6.97+/-4.43 microV) and latency was increased (122.59+/-20.09 msec vs 101.31+/-6.19 msec and 108.76+/-13.57 msec) in affected eyes significantly in comparison to the unaffected eyes and control group, respectively. Even though there were no significant differences for P50 latency and N95/P50 ratios between affected and unaffected eyes in both groups, N95 amplitude decreased significantly in the affected eyes of the ischaemic optic neuropathy patients and N95 latency was found to be decreased in optic neuritis patients. There was no correlation between VEP and PERG findings in both groups. CONCLUSION: VEP amplitude decreased significantly in ischaemic optic neuropathies while latency delay was more significant in patients with optic neuritis. PERG findings showed decreased N95 amplitude in ischemic optic neuropathy without associated latency changes.     

Lateral internal sphincterotomy versus 0.25 % isosorbide dinitrate ointment for chronic anal fissures: a prospective randomized controlled trial

Purpose

To compare the healing properties of lateral internal sphincterotomy (LIS) and isosorbide dinitrate (ISDN) ointment for chronic anal fissure.

Methods

Patients with a chronic anal fissure were randomly assigned to a group treated with ISDN ointment (n = 105) or a group treated with LIS (n = 102). The same investigators examined the patients in a blinded manner, 1, 2, 3, 6, and 12 months after the treatments.

Results

The anal fissure had healed completely by 4 weeks in 64.7 versus 92.2 %, and by 6 months in 77.1 versus 97.1 % of the ISDN and LIS group patients, respectively. At 12 months, the recurrence rates were 4.8 versus 1 % for the ISDN and LIS groups, respectively, and the success rates of the treatments were 72.4 versus 96.1 %, respectively. Six patients in the LIS group experienced minor fecal incontinence, and seven (6.7 %) patients in the ISDN group experienced headaches that responded well to paracetamol.

Conclusion

ISDN ointment was reported by all patients to be easy to use. Although its success rate was lower than that of surgery, ISDN can be offered to selected patients with a chronic anal fissure, as it has a low recurrence rate and rare side effects are rare.     

Reduction of the sinotubular junction in patients undergoing ascending aortic replacement with coexisting aortic insufficiency

Abstract Background and Aim of the Study: Dilatation of the STJ may cause consequent aortic insufficiency (AI) in patients with normal aortic valve, in patients with ascending aortic aneurysm. In this study, we analyzed the results of ascending aorta replacement with STJ diameter reduction to correct consequent AI in patients with ascending aortic aneurysm. Methods: Forty‐five consecutive patients who had ascending aortic aneurysm underwent replacement of ascending aorta with reduction of the STJ diameter to correct AI. Mean age of the patients was 61.3 ± 5.2. Twenty‐six (57.8%) were female. Six patients had arch aneurysm. Postoperative echocardiographic studies were performed at discharge and annually thereafter. The mean duration of follow‐up was 4.6 ± 2.9 years. Results: Hospital mortality rate was 4.9% (n = 2). Three patients died during follow‐up. Three patients had late recurrence of AI that was caused by aortic root dilatation. One of these patients required aortic valve replacement because of severe aortic insufficiency. The five‐year survival and survival free from aortic insufficiency were 91.4%± 5.0% and 91.2%± 5.1%, respectively. Conclusions: Reduction of the diameter of STJ can be used to treat AI in patients with ascending aortic aneurysm with nearly normal aortic cusps. Midterm results of this procedure are encouraging. (J Card Surg 2011;26:88‐91)     

Metalloproteinases and Their Inhibitors in Patients with Inguinal Hernia

Aim

The aim of this prospective study is to investigate if there is a relationship between inguinal hernia, matrix metalloproteinases (MMPs), and tissue inhibitors of metalloproteinases (TIMPs).

Materials and methods

This case control study was performed on patients admitted to the general surgery department of Erzincan University Hospital. Four groups were created: control, indirect hernia, direct hernia, and bilateral hernia. All groups were comprised of 11 patients. Serum and tissue levels of MMP-1, MMP-2, MMP-9, MMP-13, TIMP-1, TIMP-2, TIMP-3, and hydroxyproline were evaluated.

Results

MMPs values were significantly high at hernia groups, especially at bilateral hernia group (p < 0.05), whereas TIMPs values were significantly low at bilateral hernia group (p < 0.05). MMPs values were increasing at hernia groups in an order as control, indirect, direct, and bilateral. TIMPs values were decreasing at hernia groups in an order as control, indirect, direct, and bilateral.

Conclusion

Increased levels of MMP-1-2-9-13 and decreased levels of TIMP-1-2-3 may have played role in the formation of inguinal hernia. Hernia is not only a local defect, but a reflection of systemic disease. This is even more significant for bilateral hernias.

     

Use of Stapling Devices for Safe Cholecystectomy in Acute Cholecystitis

Many techniques are described for the ligation of a difficult cystic duct (CD). The aim of this study is to assess the effectiveness and safety of stapling of a difficult CD in acute cholecystitis using Endo-GIA. From January 2008 to June 2012, 1441 patients with cholelithiasis underwent laparoscopic cholecystectomy (LC) at the Department of General Surgery, Haydarpasa Numune Education and Research Hospital. Of these, 19 (0.62%) were identified as having a difficult CD and were ligated using an Endo-GIA stapler. All patients were successfully treated with a laparoscopic approach. The length of hospital stay was 3.4 days. There were umbilical wound infections in 4 patients (21%). The length of follow-up ranged from 1.0 to 50.4 months. In conclusion, Endo-GIA is a safe and easy treatment method for patients with a dilated and difficult CD. The cystic artery should be isolated and ligated if possible before firing the Endo-GIA stapler. If isolation and stapling are not possible, fibrin sealant can be applied to avoid bleeding. The vascular Endo-GIA can be applied in a large CD, but for acute cholecystitis with an edematous CD, the Endo-GIA roticulator 4.8 or 3.5 stapler is preferred.Key words: Cholecystectomy, Endo-GIA, Acute cholecystitis, StaplerAfter the introduction of laparoscopic cholecystectomy (LC) in 1987,¹ LC replaced open cholecystectomy as the gold standard for the treatment of cholelithiasis in international guidelines.² LC was initially considered to be contraindicated for acute gallbladder inflammation, but it is currently a common procedure for acute cholecystitis.Some of the difficult situations a surgeon is likely to face during the performance of a laparoscopic cholecystectomy include anatomic anomalies such as a sessile gallbladder or short cystic duct and pathologic entities such as an empyema, Mirizzi syndrome, or a frozen Calot''s triangle secondary to infection and fibrosis.³It is suggested that laparoscopic surgery should be carried out within 72 hours from the onset of the symptoms because after that time there are higher rates of conversion to open procedures, increased risks of complications, and longer operative times.^4–6 The generally accepted procedure in patients whose symptoms started 72 hours before admission is to “cool down” the patient with appropriate medical therapy and to perform LC after a period of 6 to 12 weeks.^7,8 This approach aims to avoid a potentially more difficult cholecystectomy during an emergency admission and to avoid the difficulties of access to an emergency room.^9,10 However, more than 20% of patients may fail to respond to conservative treatment and require an urgent and rather more difficult cholecystectomy, and a further 25% of patients will require readmission with a severe acute complication of cholelithiasis while awaiting a cholecystectomy.^11,12 The scar formation, distortion, and organized adhesions around the gallbladder occurring secondary to the chronic inflammation in Calot''s triangle make the dissection difficult. The cystic duct (CD) is sometimes edematous, fibrous, or enlarged owing to inflammation and adhesions in acute cholecystitis and may be difficult to manage. Several methods were proposed for ligating the CD, including titanium or absorbable endoclip, endoloop, tie, ultrasonic or bipolar sealer, and the Endo-GIA stapler (Covidien, Mansfield, Massachusetts).^13–19This study proposes an effective, safe, and easy procedure for the stapling of dilated or difficult CD using the Endo-GIA.     

Eculizumab therapy in a patient with dense-deposit disease associated with partial lipodystropy

Background

Dense deposit disease (DDD) (also known as membranoproliferative glomerulonephritis type II) in childhood is a rare glomerulonephritis with frequent progression to end-stage renal disease (ESRD) and a high recurrence after kidney transplantation. The pathophysiologic basis of DDD is associated with the uncontrolled systemic activation of the alternative pathway (AP) of the complement cascade.

Case-diagnosis/treatment

A 14-year-old girl presented with edema and nephrotic range proteinuria. Blood tests showed hypoalbuminemia, nephrotic range proteinuria, normal renal function, and a low C3 level. Renal biopsy confirmed the diagnosis of crescentic DDD. Complement analysis revealed strong AP activation (low C3), positive C3 nephritic factor (C3NeF), and a decreased complement factor H (CFH) levels with CFH polymorphisms. Therapy with eculizumab was considered after the failure of corticosteroid and plasmapheresis to modulate the ongoing massive proteinuria and persistence of low serum C3 levels. There was a marked clinical and biochemical response following the administration of eculizumab.

Conclusions

Our case emphasizes the efficacy of eculizumab in the management of crescentic DDD in a patient with a normal renal function, in a short follow-up period. Considering previously reported cases, it appears that eculizumab represents a promising new approach which may prevent progression to ESRD in a subset of patients with DDD.