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Background/Aim: In Endoscopic retrograde cholangiopancreatography (ERCP), Ampulla of Vater is found on the posteromedial wall of the second part of the duodenum. However, ectopic expansion of the common bile duct to the 3rd or 4th part of the duodenum or the proximal stomach, pylorus, or bulb was reported in the literature. This study primarily aims to investigate the risk of complications in patients with ectopic papillae and evaluate the applicability of endoscopic sphincterotomy in these patients. Methods: In this a case-control study, the data of 3,048 patients who underwent ERCP procedure in the ERCP unit of our clinic between January 2013 and December 2018 were retrospectively analyzed, and 30 patients with ectopic bulbar papillae and 30 randomly selected patients with normally localized papillae were compared in terms of age, gender, duration of the procedure, post-procedural biochemical tests, cannulation success, precision rate, postprocedural pancreatitis complications and the need for analgesics. Power analysis was performed with the G*power 3.1.9.7 package program (1-B = 0.95, alpha = 0.05). With a power of 0.954, the sample size to be reached was thirty-three for each group. Results: The rate of pancreatitis complications was higher in patients with ectopic bulbar papillae (50%) compared to those without (16.7%) (P=0.006). Even though the rate of pre-cut was higher in patients with ectopic bulbar papillae (33.3%) compared to patients with normally localized papillae (13.3%), this difference was not statistically significant (P=0.063). Cannulation success in patients with ectopic bulbar papillae (83.3%) was insignificantly lower than in patients with normally localized papillae (90.0%) (P=0.353). The need for both narcotic and non-steroidal anti-inflammatory analgesics was higher in patients with ectopic bulbar papillae (P

WOS: 000499472900013, Surgery is the only treatment method in pancreatic cancer. Unfortunately, metastatic diseases or invasion of the main vascular structures are observed in a majority of cases at the time of diagnosis; these structures originate from the body, neck, and tail of the pancreas and are considered inoperable. The first celiac artery resection for the treatment of cancer was described by Appleby in 1953. Here, we describe our hepatic artery reconstruction technique in a case with pancreatic body cancer. A 37-year-old male patient was admitted to our emergency department due to syncope. The patient was diagnosed with acute renal failure secondary to fluid loss.Thereafter, his general condition was stable and laboratory results improved. Abdominal computed tomography was performed. Pancreatic cancer originating from the pancreatic body was detected. A pancreatic biopsy was performed and neoadjuvant gemcitabine and paclitaxel chemoradiotherapy were initiated. Surgical treatment was recommended for the identification of regression after neoadjuvant chemoradiotherapy. Following intraoperative Doppler ultrasonography, en bloc distal pancreatectomy and splenectomy involving the celiac artery trunk and total gastrectomy were performed. However, surgical margin reliability in frozen section revealed that the tumor was still present. Therefore, the surgical procedure was replaced with total pancreaticoduodenectomy. Hepatic artery reconstruction was performed from the left main iliac artery using a 4-mm ringed GORE-TEX (R) graft. The iliac-hepatic bypass for hepatic artery reconstruction in pancreatic cancer could be an alternative surgical technique.

T-tube drainage is a widely used procedure among surgeons for various biliary conditions. However, various complications may occur, especially due to the breaking-off of the T-tube from the area where it enters the common bile duct during retraction. These complications often require subsequent surgical procedures to remove the T-tube fragment from the common bile duct lumen. In selected cases, the T-tube fragment can be extracted from the common bile duct by endoscopic retrograde cholangiopancreatography (ERCP). ERCP has a life-saving role that eliminates reoperation for such a complication. Herein, we present a 42-year-old female patient who was referred to our hospital, which is as an advanced center, due to breakage during T-tube withdrawal. The patient had previously undergone open cholecystectomy and T-tube drainage. When removing the T-tube, a breakage occurred at 3-4 cm from the T-tube leg, which was left in the common bile duct. In the ERCP, the leg of the T-tube was removed from the common bile duct lumen by basket compression following endoscopic sphincterotomy and a temporary plastic stent was placed. One month after the procedure, the stent was removed with the help of the ERCP. This case is presented as a rare indication of ERCP. T-tüp drenajı cerrahlar arasındaki çeşitli biliyer problemler için yaygın olarak kullanılan bir prosedürdür. Bununla birlikte, özellikle T-tüpün geri çekilmesi sırasında ortak safra kanalına girdiği bölgeden kopması sonucunda çeşitli komplikasyonlar meydana gelebilir. Bu komplikasyonlar genellikle ortak safra kanalı lümeninden T-tüp fragmanını çıkarmak için ardından gelen cerrahi prosedürler gerektirebilir. Bununla birlikte seçici olgularda T-tüp fragmanı, endoskopik retrograd kolanjiyopankreatografi (ERCP) ile ortak safra kanalından çıkartılabilir. ERCP, böyle bir komplikasyon için yeniden ameliyatı ortadan kaldıran hayat kurtarıcı bir role sahiptir. Bu çalışmada, T-tüpün geri çekilmesi sırasında kopması nedeniyle ileri merkez olarak hastanemize sevk edilen 42 yaşında kadın hasta sunuldu. Hastaya daha önce açık kolesistektomi ve T-tüp drenajı uygulanmıştı. T-tüp çıkarılırken, T-tüp bacağından 3-4 cm mesafede kopma meydana geldi. T-tüp bacağı ortak safra kanalında kalmıştı. ERCP’de T-tüpün bacağı, endoskopik sfinkterotomiyi takiben basket sıkıştırması ile ortak safra kanalı lümeninden çıkarıldı ve geçici bir plastik stent yerleştirildi. İşlemden bir ay sonra, stent ERCP yardımıyla çıkarıldı. Bu olgu, ERCP’nin seyrek endikasyonu olarak sunulmuştur.

Severe local and systemic tissue injury develop during reperfusion, which is a period during which arterial blood flow and tissue oxygenation are re-established. In this study, we aimed to investigate the anti-inflammatory, antioxidant and protective effects of nesfatin in IR damage developing in liver.Twenty-four male Wistar-Albino rats were divided to three groups which contained eight rats in all groups. The rats were subjected to 30 minutes of hepatic pedicule occlusion followed by 2h of reperfusion to induce I/R damage. Nesfatin1 (10 μg/ kg) was administered, 30 min prior to ischemia and immediately before the reperfusion period.The findings showed that while the blood levels of AST, ALT and LDH were markedly elevated in the I/R group, they returned to normal levels upon treatment in the Nesfatin group. While IL-1 α, IL-1β, IL-6, TNF-α and IFN- γ levels in blood and tissue were lower after therapy in the Nesfatin group compared to the I/R group, statistically significant decreases were only noted in IL-1β, IL-6, TNF-α and IFN- γ levels. TAS levels increased in the treatment group, while upon nesfatin treatment statistically significant decreases were noted in TOS and OSI levels. Histopathological investigations also showed statistically significant decreases in Bax and Caspase-3 staining intensity and the number of stained cells in the Nesfatin group.The nesfatin has antioxidant activity and anti-inflammatory effect on improvement of liver functions and histopathological findings in liver ischemia and reperfusion injury.Anti-inflammatory, Anti apoptotic Liver ischemia-reperfusion injury, Nesfatin-1.Durante la riperfusione, con il ripristino del flusso ematico arterioso e l’ossigenazione dei tessuti, si sviluppa una grave lesione tissutale locale e sistemica. In questo studio, abbiamo indagato sperimentalmente gli effetti antiinfiammatori, antiossidanti e protettivi di nesfatin in relazione al danno ischemia/riperfusione (I/R) che si sviluppa nel fegato. Per questo studio sono stati impiegati 24 ratti Wistar- Albino maschi, divisi in tre gruppi di otto individui ciascuno. I ratti sono stati sottoposti a 30 minuti di occlusione del peduncolo epatico seguiti da 2 ore di riperfusione per indurre il danno I / R. Nesfatin1 è stata somministrata alla dose di 10 μg / kg, 30 minuti prima dell’induzione dell’ischemia e immediatamente prima del periodo di riperfusione nel 3° gruppo, mentre il primo gruppo è stato utilizzato come controllo senza clampaggio del peduncolo, ed il secondo è stato sottoposto a 30’ di ischemia per clampaggio senza somministrazione di Nesfatin. . I risultati hanno mostrato che mentre i livelli ematici di AST, ALT e LDH erano marcatamente elevati nel gruppo I / R, ritornavano a livelli normali dopo trattamento nel gruppo Nesfatin. Mentre i livelli di IL-1 α, IL- 1β, IL-6, TNF-α e IFN-γ nel sangue e nei tessuti erano inferiori dopo la terapia nel gruppo Nesfatin rispetto al gruppo I / R, le diminuzioni statisticamente significative sono state osservate solo in IL Livelli -1β, IL-6, TNF-α e IFN-γ. I livelli di TAS sono aumentati nel gruppo di trattamento, mentre sul trattamento con nesfatin sono state notate diminuzioni statisticamente significative nei livelli TOS e OSI. Le indagini istopatologiche hanno anche mostrato diminuzioni statisticamente significative dell’intensità di colorazione di Bax e Caspase-3 e il numero di cellule colorate nel gruppo Nesfatin. L’attività antiossidante e l’effetto anti-infiammatorio del nesfatin determina dunque un miglioramento delle funzioni epatiche e dei risultati istopatologici nell’ischemia epatica e nel danno da riperfusione.

Patient: Female, 76-year-old Final Diagnosis: Left hepatic cyst hidatic fistula to gall bladder Symptoms: Biliary colic • icterus • Sepsis Medication: — Clinical Procedure: Multidiscipliner treatment Specialty: Surgery Objective: Rare disease Background: Cholecysto-hydatid fistula is a rare complication of liver echinococcosis; suppurative cholangitis due to cholecysto-hydatid fistula is even rarer. A multidisciplinary approach is required by radiology and surgery departments during the preoperative diagnosis and treatment processes of these cases. In this paper, a patient treated with suppurative cholangitis due to cholecysto-hydatid fistula is presented. Case Report: A 76-year-old female patient was admitted to emergency services due to cholangitis. Abdominal computerized tomography (CT) examination revealed that the common bile duct was dilated through the right liver in a wide and torsional pattern; the gallbladder cleaved into hepatic flexura and its wall became irregular. There was a cystic appearance 10×13×12 cm in size on the lateral segment of the left liver lobe. Endoscopic retrograde cholangiopancreatography (ERCP) was performed, and it showed the communication between the hydatid cyst pouch and the bile duct. The patient was taken to open surgery, which confirmed the imaging findings. The gallbladder and the adjacent cyst were excised, and a T-tube was placed in the choledochus. Postoperative recovery was uneventful. Conclusions: We suggest that cholecysto-hydatid fistula is a severe problem that requires close workup with both the radiology and surgery departments. Preoperative ERCP is beneficial for the visualization of the fistulization between gallbladder and hydatid cyst and for the treatment of suppurative cholangitis.

The incidence of complex hepatobiliary injury secondary to blunt abdominal injuries varies between 3.4 and 5%. A 25-year old male patient underwent an urgent operation due to a motorcycle accident. During intraabdominal exploration, Grade 4 laceration was detected at the liver and bleeding was controlled through primary repair. In the postoperative seventh day, he was referred due to 1500 cc bile leakage from the drainage tube. During the operation, an extensive Kocher maneuver was done and the second part of duodenum was observed to be exposed to total avulsion from the head of the pancreas. Pancreatoduodenectomy was planned due to presence of ischemic changes in the second part of duodenum. In the postoperative follow-up, the abdomen was closed with a controlled abdominal closure procedure. The clinical findings of biliary tract injuries secondary to blunt abdominal injuries often manifest themselves late and early diagnosis is possible only with suspicion.

Background: Endoscopic Retrograde Pancreoticocolangiography (ERCP) is performed for resolving cholestasis by sphincterotomy and/or stone extraction and is done with deep sedation or general anesthesia..

Endoskopik retrograd kolanjiopankreatografi (ERCP) profesyonelleşmek için uzun bir öğrenme eğrisi bulunan ileri endoskopik tekniktir. ERCP işleminde standart endoskopik tekniklere göre ciddi komplikasyonlar gelişme riski daha yüksektir. Perforasyon ERCP’nin nadir ancak en korkulan ve en fazla mortalite ile ilişkili olan komplikasyonlarından birisidir. Endoskopik sfinkterotomi (ES) prosedüre eklendiğinde %0.3’ten %1’e varan oranlarda perforasyon gelişmektedir ve bu hastalar da %16-18 oranla mortal seyretmektedir. Perforasyon ile operasyon arasında ge- çen süre mortalite ile ilişkili önemli bir faktördür. Geciken cerrahilerde mortalite önemli ölçüde artmaktadır. ERCP’ye bağlı perforasyonlarda standart bir cerrahi yaklaşım bulunmamaktadır. Bu çalışmada ERCP nedenli periampullar retroperitoneal perforasyon gelişen hastalardaki deneyimimiz nedeniyle ERCP perforasyonlarına cerrahi yaklaşımımızı aktarmayı amaçladık. Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic technique which has a long learning curve to develop proficiency and higher potential for serious complications than any other standard endoscopic technique. Perforation is a rare but one of the most feared complications complication of (ERCP), but it is surely associated with mortality. When endoscopic sphincterotomy (ES) added to procedure perforation occurs in 0.3% to 1% of patients, and that carries a mortality rate of 16% to 18%. The interval between the perforation and the operation is of great significance. The mortality rate increases dramatically with late surgical management. There is no standard surgical approach to perforations related with ERCP. In this study we present our experience for surgical management of ERCP-related periampullary retroperitoneal perforations.

Objective: This study presents the effects of intraoperative nerve monitoring on RLN injuries in patients who underwent primary surgery for benign thyroid pathology. Methods: We retrospectively evaluated the data of 273 patients who had primary thyroidectomy due to benign thyroid pathology between January 2012 and July 2017. The patients were classified into two groups. Group-1 consists of patients whose nerves were monitored. We separated the patients whose nerves were not monitored into Group-2. Results: There were 140 and 133 patients in Groups 1 and 2, respectively. Regarding the age, gender and surgical indication between the groups, statistically significant difference was not found (P > 0.05). In Group-1, transient paralysis developed in four patients (2.9%). The permanent paralysis developed in one patient (0.7%). In Group-2, transient paralysis developed in nine patients (6.8%). The permanent paralysis developed in four patients (3%). When the groups were evaluated, there was statistically significant difference in terms of transient and permanent paralysis (P=0.01, P =0.001, respectively). Conclusions: In view of the negative effects of RLN injury on the patient, we think that intraoperative nerve monitoring should be used routinely in benign thyroid surgeries.

Highlights • Developmental abnormalities of liver including ectopic liver are rare conditions. • Although it does not usually produce any symptom clinically, it can rarely result in serious complications such as bleeding, pyloric and portal vein obstruction. • Ectopic liver has the capacity of malignant transformation to hepatocellular carcinoma that makes it essential to be removed. • The vascular anatomy of ectopic liver should be identified before the dissection of gallbladder in order to prevent hemorrhage from the liver parenchyma., Introduction Developmental abnormalities of liver including ectopic liver tissue (ELT) are rare conditions. Few cases presenting ELT have been reported in literature till now. Even though the most common area seen is gallbladder, it is detected both abdominal and thoracic sites. There is a relationship between HCC and ectopic liver that necessitates the removal. Presentation of case A 51-year-old female was hospitalized because of abdominal pain. Gallstone and bile duct dilatation were determined during ultrasonographic (USG) evaluation. The patient was operated for cholecystectomy following a successful endoscopic retrograde cholangiopancreatography (ERCP). During operation, a mass located on gallbladder with its unique vascular support was identified and resected together with gallbladder. The mass had a separate vascular stalk arising from liver parenchyma substance and it was clipped with laparoscopic staples. The histopathological examination revealed that the mass adherent to gallbladder was ectopic liver confirming the intraoperative observation. The postoperative course of patient was uneventfull and she was discharged at the second day after the operation. Discussion Ectopic liver tissue is incidentally found both in abdominal and thoracic cavity. ELT can rarely be diagnosed before surgical procedures or autopsies. It can be overlooked easily by radiological techniques. Although it does not usually produce any symptom clinically, it can rarely result in serious complications such as bleeding, pyloric and portal vein obstruction. ELT also has the capacity of malignant transformation to hepatocellular carcinoma that makes it essential to be removed. Conclusion Although ELT is rarely seen, it should be removed when recognized in order to prevent the complications and malignant transformation.

Aortoenteric fistulas (AEF) are uncommon but fatal complications during aortic surgery that can cause heavy gastrointestinal bleeding (GIB). We present a patient who underwent aortic surgery and developed GIB that led to hemorrhagic shock. A 66-year-old man was transferred to our emergency department (ED) because of deterioration in his general condition. On arrival at the ED, he was confused, pale, cooperative, cold, and sweaty. His blood pressure was 70/40 mmHg and pulse rate, 130/min. Plenty of fresh blood was seen in the nasogastric tube. We learned from patient’s family that he had undergone aortic surgery. The surgical team was notified regarding the possibility of an AEF. The patient was transferred to the operating room immediately without any imaging tests being performed. In patients with massive GIB who had undergone aortic surgery, AEF should be considered. When considering the diagnosis of AEF, surgical intervention should be performed as soon as possible before performing diagnostic tests. (Eurasian J Emerg Med 2015; 14: 145-7)

Background Use of transversus abdominis plane (TAP) block for postoperative analgesia is continuously increasing. However, few studies have investigated intraoperative effects of TAP block. We aimed to study the effects of TAP block in terms of cost-effectiveness and consumption of inhalation agents. Material and methods Forty patients undergoing laparoscopic cholecystectomy were enrolled in this study. Patients were randomly divided into 2 groups: Group 1 (n=20) patients received TAP block and Group 2 (n=20) patients did not receive TAP block. Standard anesthesia induction was used in all patients. For the maintenance of anesthesia, fractional inspired oxygen (FIO2) of 50% in air with desflurane was used with a fresh gas flow of 4 L/min. All patients were monitored with electrocardiography and for peripheral oxygen saturation (SpO2), end-tidal carbon dioxide (ET), heart rate (HR), noninvasive mean blood pressure (MBP), and bispectral index (BIS). Bilateral TAP blocks were performed under ultrasound guidance to Group 1 patients. The BIS value was maintained at between 40 and 50 during the surgery. The Dion formula was used to calculate consumption of desflurane for each patient. Results There was no difference between the groups with respect to demographic characteristics of the patients. Duration of anesthesia, surgery time, and dosage of fentanyl were similar in the 2 groups. However, the cost and consumption of desflurane was significantly lower in Group 1. Conclusions Total anesthesia consumption was lower and the cost-effectiveness of anesthesia was better in TAP block patients with general anesthesia than in non-TAP block patients undergoing laparoscopic cholecystectomy.

Objective Endoscopic retrograde cholangiopancreatography may be useful in the diagnosis and management of biliary system parasites. Material and methods Investigators retrospectively evaluated patients with biliary system parasites who underwent endoscopic retrograde cholangiopancreatography procedures over an eight-year period. We collected data regarding patient demographics, clinical features, and parasite type. We aimed to determine the utility of endoscopic retrograde cholangiopancreatography as a diagnostic and therapeutic intervention in patients with biliary system parasites. Results We identified 22 patients with biliary system parasites from a total of 3,450 endoscopic retrograde cholangiopancreatography procedures performed during an eight-year period. Parasite types included Echinococcus granulosus (n=19), Fasciola hepatica (n=2), and Ascaris lumbricoides (n=1). Fifteen patients with liver hydatid cysts underwent endoscopic retrograde cholangiopancreatography prior to surgery due to obstructive jaundice. The endoscopic retrograde cholangiopancreatography procedure enabled definitive treatment without the need for surgery in the remaining two patients. Two patients with fascioliasis underwent endoscopic retrograde cholangiopancreatography due to clinical presentation of cholangitis, cholecystitis, and obstructive jaundice, leading to presumptive diagnosis of cholangiocarcinoma. However, the final diagnosis was made using endoscopic retrograde cholangiopancreatography following inspection of flat, leaf-shaped, motile flukes extracted from the bile duct. In one patient with ascariasis, a longitudinal tubular structure was identified in the bile duct; emergency surgery was required. Conclusion The diagnosis of parasitic diseases is clinically challenging, and definitive diagnosis requires endoscopic retrograde cholangiopancreatography in some cases. Moreover, endoscopic retrograde cholangiopancreatography provides a therapeutic option for ascariasis, fascioliasis, and some forms of hydatidosis. Accordingly, the use of endoscopic retrograde cholangiopancreatography may change preoperative management and treatment strategies for biliary system parasite infections.

Mimarlık nesnesi, tarih boyunca ortaya koyulmuş üretim ve durumlar üzerinden elealınan, başlangıcı, kaynakları ve üretim şekline dönük bakış açıları değişen mimarlıkfaaliyetinin ortaya çıkartmış olduğu olgudur. Tarihsel süreç içinde mimarlıkdisiplininin üretimleri ve o üretimleri ortaya çıkartan süreçler farklı şekillerde elealınmıştır. Tip kavramı ve tipoloji, mimarlık nesneleri arasındaki ve nesneler ileonların altında yatan fikirler arasındaki bağlantıyı okuyabilmek için önerilmişyaklaşımlardan birisidir. Araştırma tip kavramının disiplin içinde tarih boyuncadeğişen yaklaşımlar ile ele alınış biçimlerinden hareketle, güncel söylem veüretimlerde tipin ve tipolojinin mimarlık nesnesi üretimindeki rollerini ve olasıgörevlerini inceler.Araştırma kapsamında odaklanılan esas konu mimarlıkta tip kavramı üzerine enönemli eleştirilerden olan sabitleyici bakış açısının, tarih boyunca ve güncelyaklaşımlarda hangi şekillerde aşıldığı; tipolojik bakışla hangi şekilde farklılaşmaunsurlarının bulunduğu ve üretildiğidir. Buna bağlı olarak farklılaşma noktalarınınvarlığı ve durumu aynı zamanda tip ve tipoloji kavramlarının ve yaklaşımının yenidentanımlanmasına da aracı olacak durumdur.Mimarlıkta tipolojik bakış kapsamında farklılaşma unsurlarının değerlendirilmesi, tümtarihsel bakış açıları dahilinde mimarlık nesnesinin nasıl ele alındığı ve tip ileilişkilendirildiği ile başlar. Buradan hareketle araştırma, öncelikli olarak Vidler'ingruplandırışı ile tarih boyunca ortaya çıkmış 3 farklı tipoloji yaklaşımına; güncel pratikve teorik üretimlerde tip konusunun işleyişi ile birlikte değinerek tipin mimarlıkdisiplini içindeki kavranışını, mimarlık nesnesi ile bağlantılı olarak yerini vedurumunu inceler. Buna göre araştırmada tüm tarihsel görevi ile birlikte tipolojik bakışaçısının hangi şekillerde farklılık üretici unsur olarak kullanıldığı ve son tahlildeüzerine atılı olan sabitleyici olma durumu dışına nasıl çıktığı irdelenir.Araştırma sürecinde, mimarlık nesnesi özelinde farklılaşma kurgusunun gözlendiği ilkbağlantı tip ve model arasında bulunan iki yönlü bağlantıdır. Tip kavramının tarihselyaklaşımlardaki farklı ele alınışları üzerinden tip ve model ikilisi arasındaki bakış dayeniden tanımlanmış, tip kavramının ilk açıklamalarında modelden farkıvurgulanmakta iken, kimi zaman aralarındaki ayrım yok sayılarak tip kavramı modelüzerinden düşünülerek kurgulanmıştır. Tip ve model, ve tipolojik bakışta modellerarasındaki farklılık, yaklaşım olarak matematik biliminden ödünç alınan diferansiyelteriminden hareketle ulaşılan türev fonksiyonu üzerinden organize edilir. Bu yaklaşım,türev fonksiyonunun sunduğu bakışla tipe ve tipolojiye ilişkin bir karşılaştırmadüzlemi oluşturma girişimidir. Bunun gibi farklılık kavramının değerlendirilmesinoktasında Derrida'nın différance'ı ve Deleuze'ün farklılığa dair yaklaşımına dadisiplin dışı bakış açıları olarak başvurulmuştur. Tip ile ilişkili olarak ortaya çıkan prototip, stereo-tip, arketip gibi kavramlar, türevfonksiyonunun soyutladığı fikir-ürün, tip-model ikilileri arasındaki bağlantıları ortayaçıkartmayı hedefler. Buna göre yaklaşımları ve üretimleri anlamak için izlenecek yoltipolojik serileri oluşturmak, ya da oluşturulmuş olan serileri çözümlemektir. Tipolojikbakış kapsamında ortaya çıkan serilerin içerdiği nesneler arasındaki ilişkilerindeğerlendirilmesi sırasında da genetik biliminden ödünç alınan kavramlar olarakgenotip ve fenotipin sunduğu bakış açıları, konunun kavrayışı boyutunda yeniaçılımlara imkan verecek yaklaşımlar olarak ele alınmıştır.Tipolojik bakış dâhilinde farklılık üretiminin kökeni, farkın ne olduğunu ortayadökerek, üretici süreçlerdeki etkinlik biçimini ortaya çıkartmaktır. Tipolojik bakışaçısı ile ele alınan tasarım sürecinin çıktıları, tekrara dayalı tip bakış açısı dışında,üretici ve farklılaştırıcı bir yaklaşım tarif etmektedir. Bu bağlamda çizilecek kavramsalçerçeveden elde edilen çıkarımla Foreign Office Architects'in filogenetik ağaç olarakadlandırdığı üretimler arası, bütünsel ilişkiler kuran tasarım süreci vePeter Eisenman'ın diyagramatik ''EV'' tasarımları, üretimleri ve dolayısıylafarklılıkları ortaya çıkartan vektörlerin kurgulanışı bağlamında elealınacaktır. Yaklaşım olarak vektörler, tasarım sürecinde farklılaşmayı ortaya çıkartanbiçimi oluşturan yapısal kurgu (tip) ve biçimin üretimi (model) arasındaki dönüşümüsağlayan ilkesel hamleler olarak ele alınmaktadır.Son tahlilde tipolojik bakış açısının anlaşılması, farklılık üretimi ve bu farklılığı ortayaçıkartan unsurların anlaşılması ile gerçekleşir ve tip fikrinin tanımı değilse de, etkialanı ve taşıdığı bilginin niteliğine dair söz söyleme imkanı ortaya çıkar. The object of architecture has been approached from different points of view duringthe history of architecture. The roots of the object; in particular, the roots of theoutcome of architectural production, may lead a discourse of origins in order to explainthe historical point zero in terms of the production process of the architecture. Besidesthat, starting from the Plato and Aristotle of the Ancient Period, there has been adiscussion on the world of things as the dualistic approach as ideas and the sensiblephysical objects. This dualistic point of view through matter has also shown inthe typal and typological approaches of the thinkers and theorists. This distinction hasfirst appeared in the Enlightenment Period, as the division of idea as type; and thematerial production or representations as models. Starting from that point, concept oftype and typology is selected as the main frame of dissertation with all the differentpoints of view during the history. Besides that, this research focuses on the existenceand the creation of the notion of difference within the typological logic of the processof the architectural production. In order to understand the relationship and differencesbetween objects and relationship between ideas and objects, creations of typologicalseries are crucial. Upon the typological series, from the point of differential in order tounderstand difference, the function of derivative is used to frame the research. Thefunction of Derivative, here, is held as conceptual abstraction to understand and showthe different approaches and situations related to typology. Thus, in the thesis,typological series have been introduced with the sub-situations like prototype,stereotype, archetype and new type, being told and explained in respect to function ofderivative as a tool for abstraction. In the first chapter of the thesis, notions tounderstand the typology and the elements of differentiation are presented with themajor instances of the emergence of the typology in the history.Commonly, it is accepted that there are 3 different paradigms have been occurred sincethe notion of type had first appeared on the discourse of architecture. Firstly theapproach of Enlightenment Period searching for the historical origins with the idea ofimitation of nature, secondly the point of view through the object of architecture of themodernists as an object of mass production, and lastly with the occurrence of the NeoRationalistMovement right after the World War 2 in relation to the city and the sharedmemory of citizens. All the different approaches are different comments on thetypology with nuances in between and according to recent architectural theorists andtheir praxis; the notion of type and typology is still valid within different manners andtreatments. Apart from aiming to describe type and typology in the ''most correct'' way,the research instead focuses on the state of typology in the manner of creation ofarchitectural object as the single object with variations and changes although comingfrom the same structure of mind. In the first chapter of the dissertation, a briefconclusion sums up the direction of the research on the typology in order to understandthe difference which occurred related to to its own logic.With the beginning of the second chapter, typology, with its ways of understandingthe past design solutions and objects of architecture, and the ability of creating newseries within a shared form structure has been introduced in detail once more. Ratherthan searching for the historical approaches and changing logic of typology, in thesecond chapter, the logic of typology provides a systemization process to gather andlook to different individual architectural productions in a given shared ground. To beable to obtain that comparison ground, the research first divides the roles of typologyby generative and analytical typologies. The first reflects the way typology approachesand designs series of objects in respect to a shared logic, while the second one shapesthe ways of typology of understanding and relating produced individuals. In additionto these roles of typology as generative and analytical tools of architecture, the notionsretrieved from genetics represented to explain and organize the mission of typologyfocusing on the physical materializations of the objects as phenotypes, and theorganizing structure lying behind the physical configurations of form asgenotypes. Furthermore, phenotype includes architectural and tectonic elementsleading to the act of the building with all its stylistic attributions.Within the research, to be able to reach to genotypes that leads to the models orphenotypes, an abstractive point of view has been hired. At that point diagram as a toolto state the relationship between ideas and physical interpretations, is an outstandingactor being able to convert the conceptual ideas which genotype has, to the physicalrealization of objects or models, which phenotype is attributed. With the help of thediagram, the deep structure of type, which is abstract in its nature, could be convertedto the graphic schemes of dynamic relationships creating the object. What diagramdoes in this case is being a kind of bridge in between ideal knowledge of type andphysical conditions of produced models. Noting that diagram, in the research, is notaccepted as equivalent of the type or the drawn receipts, but rather accepted as themediator graphic representation, by determining the general conditions of the bordersof idea with all the possible options which come out from the root idea of type withinthe knowledge it carries and produces.In the case of the single architectural object; diagram, abstractly creates layers ofvectors as decisions and movements on the process of design, starting from the settingup of the idea to the materialization. This vectors, directs the steps of the process bycreating outcomes in order to create variations, as well as being used as the tool ofanalysis of a single object by reading its layers which produce it step by step. Thus,single object of architecture by the diagrammatic point of view can be analysed andproduced in order to grasp the idea creating the differences in between objects throughvectors. However, in order to create difference, it is needed to have different objectsto rely on and to compare with. In this case, the relationship in between single designsolutions, or models needed to be approached in groups, in other words in typologicalseries. Typology, here works as the incubator of difference by putting single objectstogether to analyze or generate them in order to create variations. Creation and theexistence of the differences within the variations, like the one in theDerrida's difference, constantly states, changes and re-states the type by delaying itsstatic conclusion and meaning. Thus, understanding the difference in the typologyleads to understanding of type without stating it with sharp descriptions. The framethat point of view of the derivative provides an alternative looking to the notion of typeand differentiation processes within it. By replacing type with a variable `x`, leads topermition of differentiation with the help of the diagrammatic vectoral moves of itwithout dealing with the exact meaning it has.In order to understand the creation of differences and variations, the multiple designprocesses of Foreign Office Architects called as phylogenies, and the Peter Eisenman'shouses analyzed within the dissertation. While FOA's phylogeny aims to createconsistency in between their production of buildings, organized by the logic of genetictree with all the relationships in between; Peter Eisenman's designprocess, creation of the houses starting from a cube shows the usage of thediagrammatic vectors in order to create different instances within the one singleprocess of design. 135

Background The aim of this study was to evaluate the potential effect of intraperitoneal administration of leptin on the hepatic regeneration and the mitotic index. Material and methods 56 Sprague-Dawley rats were divided into 7 groups each containing 8 rats. Group 1 was evaluated as the sham group and no surgical procedure was performed on animals. The rats in groups 2, 3, and 4 (named C24, C48, C72, respectively) were given intraperitoneal injection of 2 ml/kg normal saline 60 minutes before the surgical procedure consisting of laparotomy and 70% hepatectomy. These groups were used as controls at 24, 48, and 72 hours. The rats in groups 5, 6, and 7 (named L24, L48, and L72, respectively) were given intraperitoneal injection of 20 µg/kg doses of recombinant mouse leptin 60 minutes before the same surgical procedure. These groups were evaluated as the experiment groups at 24, 48, and 72 hours. Blood samples were collected for aspartate aminotransferase (AST) and alanine aminotransferase (ALT) and the remaining tissue samples were obtained for liver histopathology, regeneration rate, and mitotic index (MI). The weights of the remaining livers were also noted. Results The values of AST and ALT were higher in the groups that were administered leptin and they had significantly higher mitotic index than the other groups. Leptin also significantly increased the regeneration ratio as compared to the control group. The weights of the remaining livers were also higher in the leptin groups. Conclusions Intraperitoneal administration of leptin was observed to increase liver regeneration and mitotic rate in 70% hepatectomized rats.

Highlights • Class E injuries are the most common major bile duct injuries and can cause serious clinical condition including bile leak. • Iatrogenic operative injuries may be a cause of spontaneous postoperative choledochoduodenal fistula even in transaction type complete injuries. • Spontaneous closure of a postoperative bile fistula doesn’t guarantee that it is not a transaction type injury., Introduction Bile leak after cholecystectomy which is the frequency less than 2% is an important problem for patients. Some bile duct injuries occuring after laparoscopic cholecystectomy are the complex bile duct injuries and can cause bile leak and fistula. Presentation of case A 74-year-old woman has high output bile drainage from abdominal drain after laparoscopic cholecystectomy so an ERCP was performed. It was clear that there was a complete transaction of bile ducts, however this finding was inconsistent with the patient’s clinical situation. The bile drainage of the patient was ceased and she was discharged to home without any problem. Four months later the patient was admitted again for recurrent cholangitis episodes. Patient was operated to perform a biliary-enteric diversion for the suspicion of biliary stricture. There was a thin fistula tract over the duodenum that was previously seperated from the proximal choledochus. The distal part of the bile duct was ended blindly. A hepaticojejunostomy anastomosis over a transhepatic stenting was performed. Discussion The circumferential injuries are the most common and devastating injuries leading to bile leak, peritonitis and varying degrees of sepsis. The probability of a bile fistula to close spontaneously is almost impossible in cases of iatrogenic circumferential full thickness injuries. Conclusion In the present case we have reported a case of Bismuth type 2 (Strasberg type E2) injury in which the biliary drainage was closed spontaneously with the formation of spontaneous biliary-duodenal fistula. It is an extremely interesting case that has not been reported in the literature previously.

Biochemical Effects of Low-Flow Anesthesia with Inhalation agents in Patients undergoing Laparoscopic SurgeryThis study was designed to investigate the effects of low-flow anesthesia with sevoflurane and desflurane on renal and hepatic functions in patients undergoing laparoscopic abdominal surgery. Twenty patients with ASA I or II (American Society of Anesthesiologists classification) physical scores were included in the study. There were no significant differences between sevoflurane and desflurane groups with respect to age, weight, body mass index, duration of the operation and the anesthesia. In both groups, renal function parameters such as urea, BUN, creatinine and calculated creatinine clearance did not show significant differences at 24 and 48 hours. Homocysteine levels, which showed renal metabolic function, did not change significantly at 24 and 48 hours when compared to baseline levels in both groups. Transaminases were not significantly different between the two groups from baseline to 24 and 48 hours. These differences between the preoperative and postoperative values of biochemical parameters were similar for both anesthetic groups (p>0.05). Low-flow anesthesia did not cause impairment in terms of renal and hepatic functions.

The most common disease required emergency surgical operation is acute appendicitis. Appendectomy is the most common surgical procedure in the world and remains important due to be an efficient treatment method. We aimed to determine seasonal variations of acute appendicitis in our regions and identify the demographical and regional differences.We analyzed retrospectively data of the patients who were admitted to the Afyon Kocatepe University hospital and Sivrihisar State hospital between 2003 and 2012. 839 patients' data were analyzed.Mean age of the all patients was 33 ± 14.7 year. Acute appendicitis was seen more frequent in autumn and spring (P0.05). There was no significant difference between seasons in Afyon Kocatepe university hospital, while appendicitis was seen more common in autumn than winter in Sivrihisar state hospital (P0.05). There was not any relationship with the monthly average temperature, humidity, total precipitation amount and frequency of appendicitis (P0.05).Although appendicitis has a seasonal variation, other environmental factors and impact of nutritional habit should not be ignored. Etiology of appendicitis is still multifactorial. In the future multiparameter nationwide studies can present country-specific etiology of appendicitis.Appendectomy, Appendicitis, Seasonal variations.L’appendicite è la patologia che più comunemente richiede un intervento chirurgico in emergenza, e l’appendicectomia è il procedimento chirurgico più commune in tutto il mondo, importante in quanto rappresenta un trattamento efficace. Il nostro scopo è stato quello di determinare le variazioni stagionali dell’appendicite nella nostra regione e di indentificare le differenze demografiche e regionali, e per questo abbiamo analizzato retrospettivamente I dati dei pazienti ricoverati nell’ospedale universitario Afyon Kocatepe e nell’ospedale statale Sivrihisar State tra il 2003 ed il 2012, cioè 839 pazienti. L’età media di tutti i pazienti era di 33 ± 14.7 anni, e la maggior frequenza dell’appendicite acuta è risultata in autunno e nella primavera (P0.05). Non si sono osservate differenze sigfnificative stagionali nell’ospedale universitario Afyon Kocatepe, mentre l’appendicite si è manifestata più frequentemente in autunno che non in inverno nell’ospedale statale Sivrihisar (P0.05). non c’è stata nessuna relazione con la temperatura media mensile, l’umidità, l’entità delle precipitazioni e la frequenza dell’appendicite (P0.05). In conclusion, sebbene l’appendicite presenta una variazione stagionale, altri fattori embientali e l’impatto delle abitudini alimentari non vanno ignorate. L’etiologia dell’appendicite è comunque.multifattoriale, e nei futuri studi multiparametrici nell’intero territorio nazionale potrebbero evidenziarsi delle etiologie territorio-specifiche di questa patologia.

Objective: Endoscopic retrograde cholangiopancreatography (ERCP) is the process of displaying channelsthat provide pancreas, gall bladder and liver drainagePropofol is often used for conscious sedation during thisprocedure. In this study we aimed to compare the physician controlled sedation with propofol versus bispectralindex controlled sedation (BIS) during ERCP.Material and Methods: 60 patients aged between 18and 75 were enrolled in this study. Patients were dividedrandomly into two groups; Group 1 patients were administered intermittent doses of propofol to provide Ramsey Sedation Scale 3-4 by the physician monitorizationwhether Group 2 patients were given intermittent dosesof propofol to maintain the BIS level between 60 and 85.SPO2, systolic, diastolic and, mean blood pressures, heartrates, complications, adverse effects, duration of operation, patient awakeness were recorded five minutes periodically.Results: There was no statistically significant differencebetween the groups in terms of demographic characteristics. Patients’ hemodynamic data were similar too. There was no statistically significance in terms of complications between the groups. Both groups were close to eachother considering the average processing time whetherrecovery time of patients in the BIS group was detectedsignificantly shorter than the Ramsey group.Conclusion: Application of sedation with BIS is as safe asphysician-controlled sedation in ERCP., Amaç: Endoskopik retrograd kolanjiopankreatografi (ERKP) pankreas, safra kesesi ve karaciğerin drenajını sağlayan kanalların görüntülenmesi işlemidir. Bu işlem esnasında bilinçli sedasyon amacıyla propofol sıklıkla kullanılmaktadır. Bu çalışmamızda, ERKP işlemi esnasında propofolle uygulanan hekim kontrollü sedasyon ile bispektral indeks kontrollü sedasyonu (BİS) karşılaştırmayı amaçladık.Gereç ve Yöntem: 18-75 yaşları arasında, 60 olgu çalışmaya alındı. Hastalar rastgele iki gruba ayrıldıktan sonra grup 1 hastalara ramsey sedasyon skalası 3-4 olacak şekilde hekim tarafından propofol aralıklı bolus dozlar şeklinde verildi. Grup 2 hastalara ise BİS değeri 60-85 arasında olacak şekilde propofol bolus dozlar uygulandı. Hastaların her 5 dakikada bir SpO2, sistolik, diastolik ve ortalama kan basınçları, kalp atım hızı, komplikasyonlar ve yan etkiler, işlem süresi, hastanın uyanıklık durumu kaydedildi.Bulgular: Her iki grupta demografik veriler arasında anlamlı bir fark yoktu. Hastaların vital bulguları benzerdi. Gruplar arasında komplikasyonlar açısından istatistiksel olarak anlamlı fark bulunmadı. Her iki gruba bakıldığında ortalama işlem süreleri birbirlerine yakınken, hastaların derlenme süresi BİS kontrollü grupta anlamlı olarak daha kısa tespit edildi.Sonuç: ERKP esnasında uygulanan sedasyonda, bisipektral indeks monitörizasyonu hekim kontrollü sedasyon kadar güvenlidir.

Gastrointestinal sistemin en sik rastlanan konjenital anomalisi Meckel divertikuludur. Cogunlukla asemptomatiktir. Genellikle komplikasyonlarin gelistigi durumlarda tani alirlar. Klinik yasa bagli degisiklik gostermektedir. Eriskin yas grubunda en sik rastlanan komplikasyon obstruksiyon tablosu iken ikinci sirayi divertikulit almaktadir. Bu makale ile obstruksiyon ve divertikulit tablosunu es seansli barindiran bir olguyu literatur bilgileri isiginda sunmayi amacladik

AIM: To report the results of open surgery for patients with basket impaction during endoscopic retrograde cholangiopancreatography (ERCP) procedure. METHODS: Basket impaction of either classical Dormia basket or mechanical lithotripter basket with an entrapped stone occurred in six patients. These patients were immediately operated for removal of stone(s) and impacted basket. The postoperative course, length of hospital stay, diameter of the stone, complication and the surgical procedure of the patients were reported retrospectively. RESULTS: Six patients (M/F, 0/6) were operated due to impacted basket during ERCP procedure. The mean age of the patients was 64.33 ± 14.41 years. In all cases the surgery was performed immediately after the failed ERCP procedure by making a right subcostal incision. The baskets containing the stone were removed through longitudinal choledochotomy with the stone. The choledochotomy incisions were closed by primary closure in four patients and T tube placement in two patients. All patients were also performed cholecystectomy additionally since they had cholelithiasis. In patients with T-tube placement it was removed on the 13th day after a normal T-tube cholangiogram. The patients remained stable at postoperative period and discharged without any complication at median 7 d. CONCLUSION: Open surgical procedures can be applied in patients with basket impaction during ERCP procedure in selected cases.

Kist hidatik hastaligi hayvanciligin yaygin olarak yapildigi yerlerde halen ciddi bir saglik sorunudur. En sik karacigerde yerlesim gosterir. Hastalar cogunlukla asemptomatik olmakla birlikte karin agrisi gibi nonspesifik sikâyetleri de bulunabilmektedir. Tani cogunlukla rastlantisal olarak konmaktadir. Tedavi edilmeyen kist hidatik hastaligi safra yoluna acilma, obstruksiyon, ruptur ve buna bagli anaflaktik sok gibi olumcul komplikasyonlara neden olabilmektedir. Tedavisi icin farkli yontemler olmakla birlikte hastaligin primer tedavisi cerrahidir. Cerrahi icin klasik yaklasim sekli abdominal yolla olmaktadir. Ancak karindan ulasimin guc oldugu karaciger kubbe yerlesimli kist hidatikleri icin torakotomi ile transdiyafragmatik yaklasim da alternatif bir tedavi yontemi olabilir. Bu yazi ile transtorasik yaklasimla tedavi edilen karaciger kubbe yerlesimli uc kist hidatik olgusunu sunmayi amacladik.

Objective: Although radiological imaging modalities like barium enema and computed tomography provide some clues, endoscopic methods still maintain superiority in assessment and differential diagnosis of large intestinal symptoms and complaints that require biopsy. We aimed to present the results of colonoscopic procedures performed in our general surgery clinic in detail. Material and Methods: Seven hundred patients who presented to Afyon Kocatepe University, Faculty of Medicine, Department of General Surgery Endoscopy Unit between January 2011 and July 2012 with an indication for colonoscopy were retrospectively evaluated. Results: Out of the 700 patients enrolled in the study 356 (50.8%) were male while 344 patients (49.2%) were female. The mean age of the patients was found to be 49 years. Within the group of 700 patients who underwent colonoscopic examinations, the terminal ileum and cecum have been reached on the first attempt in 432 patients (61.7%) and colonoscopic success has been achieved. Results of colonoscopies performed on 700 patients in our clinic revealed malignancy in 42 (6%) patients, and all of these patients were treated surgically in our clinic. Mortality was not observed in this series. Procedure-related bleeding and perforation developed in 6 patients. One patient developed respiratory arrest due to sedation and patient was responsive to resuscitation. The complication rate in our series was 1%. Conclusion: In the study where we revised our own clinical experience, we found that our success rate was lower than the literature, and our complication rate was higher. The main reasons are accepted as our colonoscopy unit’s being young and the low patient volume.

Amaç: Yapısında bulunan metiyoninlerin serbest radikaller tarafından oksidasyona uğratılması sonucu alfa-1-antitripsin; antiproteaz aktivitesini kaybeder. Bununla beraber vitamin B12, kofaktör olarak metiyonin sentezinde etkin bir rol alır. Sonuç olarak vitamin B12 verilmesi ile kararlı bir metiyonin seviyesi sağlanarak alfa-1-antitripsin sentezi arttırılabilir.Yöntem: Araştırma bir gözlemsel çalışma olarak planlandı. Serum vitamin B12 seviyesi 300 pg/ml değerinin altında olan ve dışlama kriterlerine uyan 169 hasta çalışmaya alındı. Ölçümü yapılan serum alfa-1-antitripsin değerleri ve hastalara ait serum vitamin B12 değerleri hastaların demografik özellikleri ile karşılaştırıldı. Tedavi protokolüne uyan ve kontrole gelen 27 hastada tedavi öncesi ve sonrasındaki serum alfa-1-antitripsin değerleri karşılaştırıldı.Bulgular: Yaş ve Vücut Kütle İndeksi arttıkça serum alfa-1-antitripsin seviyelerinin azaldığı bulundu. Kronik hastalık nedeniyle ilaç kullananlarda serum alfa-1-antitripsin seviyeleri yüksek bulundu. Vitamin B12 tedavisi sonrasında serum alfa-1-antitripsin seviyelerinde (tedavi öncesi 121,67±13,884, tedavi sonrası 138,04±16,922 ve P=0,001) artış olduğu bulundu.Sonuç olarak elde ettiğimiz bulgular bize başta Kronik Obstrüktif Akciğer Hastalığı olmak üzere alfa-1-antitripsin yetersizliğinde görülen birçok hastalığın etiyopatogenezinde vitamin B12 eksikliğinin önemli bir rol oynadığını göstermektedir. Objective: Because of the methionines in the structure of alpha-1-antitrypsin are exposed to oxidation, alpha-1-antitrypsin lose it?s antiprotease activity. However vitamin B12 takes an active role as a cofactor during the synthesis of methionine. As a result, alpha-1-antitrypsin synthesis are claimed to increase for providing a continuous and stable levels of methionine by vitamin B12 therapy.Methods: Research was planned as an observational study. One hundred sixty nine patients were enrolled. The measurement levels of serum alpha-1-antitrypsin and vitamin B12 were compared with demographic characteristics of patients. Among the 169 patients, only 27 patients?s-who have accomplished therapeutic protocol and who have come to controls- alfa-1-antitripsin levels were controlled after treatment and compared with the before treatment levels.Results: It?s found that the higher age and Body Mass Index increase, the more alpha-1-antitrypsin levels decrease. Among the patients who use medications due to chronic diseases serum alpha-1-antitrypsin levels were found higher. Following treatment with vitamin B12, the levels of serum alpha-1-antitrypsin (before treatment 121,67±13,884, after treatment 138,04±16,922 ve P=0,001) were found increased.In conclusion, our findings show that vitamin B12 deficiency plays an important role in the ethiopathogenesis of many diseases associated with alpha-1-antitrypsin deficiency, including particularly chronic obstructive pulmonary disease. 52

Laparoscopy produces ischemia reperfusion injury mediated by inflammatory cytokines. Preconditioning is a protective maneuver in laparoscopic surgery; however, there is an argument in the literature about the length and number of the preconditioning sequence(s), thus the present study evaluates the effects of short (5 min) and long (10 min) periods of preconditioning on laparoscopy-induced inflammatory response.Thirty-two rats were enrolled into 4 groups: control, laparoscopy, 5 min preconditioning and 10 min preconditioning groups, each containing 8 rats. Laparoscopy was performed by application of 60 min of pneumoperitoneum with 15 mmHg. The preconditioning maneuvers were performed before laparoscopy in respective groups. Following the cessation of experiment blood samples were obtained to determine the TNF-alpha and IL-6 levels.Laparoscopy produced significantly increased levels of plasma TNF-alpha and IL-6 values as compared to the sham group. Five min preconditioning caused significant decrease in plasma TNF-alpha and IL-6 values compared to laparoscopy group. Although 10 min preconditioning caused partially decreased levels of TNF-alpha and IL-6 values, they were still higher than that of the 5 min preconditioning group.Preconditioning maneuvers longer than 5 min lose protective activity and begin to produce ischemia reperfusion injury. We found that 5 min of inflation followed by 5 min of deflation seems to protect against subsequent post-laparoscopic inflammatory response. Thus it is advisable not to use any preconditioning maneuvers longer than 5 min in order to avoid increasing the operation and anesthesia times.

Infection with the adult form of Ascaris lumbricoides develops in the small intestine. Despite its rareness, one of the most severe complications of the disease is pancreatobiliary system obstruction. Herein we report a patient presenting with suppurative cholangitis that caused by A. lumbricoides. Choledochotomy + T-tube drainage procedures were performed and found that the common bile duct was obstructed with an adult form of A. lumbricoides. Despite of the antibiotic treatment, the patient has died due to bacterial sepsis. Choledochal ascariasis is an unusual and a relatively rare clinical entity. It should be considered in the differential diagnosis of unexplained suppurative cholangitis with sudden onset, obstructive jaundice and so on.

Besides its haematopoietic effect, erythropoietin (EPO) has multiple protective effects, i.e. antiapoptotic, antioxidant and angiogenic properties. The neuroprotective effects of EPO against ischaemia have all been demonstrated in cell culture and animal models. The aim of the study was to evaluate the effect of erythropoietin on ischaemia-reperfusion injury (I/R injury) of the liver.Forty-eight adult male Sprague-Dawley rats weighing 250-300 g were divided into three groups: group I, hepatic ischaemia-reperfusion (Hepatic I/R); group II, hepatic ischaemia-reperfusion + EPO (Hepatic I/R+ EPO); group III, sham. Hepatic ischaemia was created by placing a microvascular clamp on the hepatic pedicle for 45 minutes. EPO was given to group II at a dose of 1000 U/kg 120 minutes before the onset of the ischaemia. Blood samples and liver tissues were obtained after 45 minutes of reperfusion from half of the rats in each group. The remaining rats were killed after a 24-hour observation period and blood and tissue samples were obtained. Blood alanine aminotransferase, tumour necrosis factor-alpha (TNF-alpha), interleukin-2 (IL-2) and liver tissue malondialdehyde (MDA) levels were determined. Liver tissue histopathology was also evaluated by light microscopy.In rats with hepatic ischaemia, serum levels of ALT, TNF-alpha, IL-2 and liver tissue levels of MDA were reduced by the administration of erythropoietin and the histopathological score was also less severe.This study demonstrates that pre-ischaemic administration of EPO has protective effects on hepatic I/R injury.

The role of epidermal growth factor (EGF), a polypeptide containing 53 amino acids, on protection and repair of ethanol-induced gastric mucosal injury was investigated in rats. In addition, the effects of EGF on the gastric damage were evaluated histopathologically. We used 48 Spraque-Dawley rats which were divided into [corrected] three groups as control rats, ethanol treated rats and ethanol+EGF treated rats. The ethanol group was given a gastric gavage containing 1 ml of 80% ethanol (v/v) prepared in distilled water. EGF (100 microg/kg) was given by intragastric gavage 30 min before the administration of ethanol. We studied histopathological evaluation and the histochemical heterogeneity of mast cells and its degree of degranulation. Besides, gastric tissue malondialdehyde (MDA), protein sulfhydryl groups (SH), and protein carbonyl levels were measured. EGF treatment stabilized mast cells degranulation and had lower polymorphonuclear leukocytes (PMNL) infiltration, ulcer index, histamine, and MDA; protein carbonyl levels were also lower, compared to the non-treated animals. EGF exerts a protective effect on gastric mucosa to ethanol-induced gastric injury probably through antioxidant and mast cell stabilizing mechanism.

Background Pneumoperitoneum (Pp) induces ischaemia in intra-abdominal tissues. We investigated the effects of ischaemic preconditioning (IP) and low-pressure Pp methods used to reduce ischaemic injury during Pp on oxidative stress and inflammatory cytokine response. Methods Thirty-two rats were divided into four groups. Rats in the control group were subjected to only anaesthesia for 90 min. The other groups were subjected to Pp for 60 min with 15 (Pp15), 10 (Pp10) or 15 mmHg intra-abdominal pressure (IAP) after IP (IPPp15), all of which were followed by deflation (D) for 30 min. IP was defined as 10 min of Pp with 15 mmHg IAP followed immediately by 10 min of D. Peritoneum and blood samples collected at the end of the experiment were examined to determine inflammatory cytokine [tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6)], oxidative stress [malondialdehyde (MDA)] and antioxidant [reduced glutathione (GSH) and glutathione reductase (GR)] levels. Results Blood and peritoneum MDA values and peritoneum TNF-alpha and IL-6 values decreased, while GR values increased in the Pp10 group in comparison with the Pp15 group. Blood and peritoneum MDA, TNF-alpha and IL-6 values decreased and GR values increased in the IPPp15 group in comparison with the Pp15 group. Blood MDA and IL-6 values in the IPP15 group were lower than those in the Pp10 group, whereas GR values were higher in the former. Except for high peritoneal IL-6 levels, no difference was found between the parameters in the IPP15 and those in the control group. Conclusions IP may be more effective than low-pressure Pp in reducing ischaemic insult associated with laparoscopy.

Objective: To determine the effect of increasing inferior vena cava blood flow by means of distal arteriovenous fistula on the patency of a peritoneal tube graft. Materials and methods: In 16 mongrel dogs, a 3–4 cm long circular defect was created at the infrarenal inferior vena cava. The defect was interposed with peritoneal tube graft. A temporary distal femoro-femoral arteriovenous fistula was also constructed in 8 dogs just after the caval interposition. Graft patency was evaluated by Doppler ultrasonography and angiography. Histological evaluation was also performed. Results: Seven dogs in each group survived. All control grafts occluded within the first week, compared to no occlusions in fistula group (Fisher's exact test, p

In this study, we investigated the effect of different values of intra-abdominal pressure on bacterial translocation. Twenty-four Wistar-Albino rats were divided into four groups. The animals belonging to the Control group were not subjected to any increased intra-abdominal pressure. In groups I, II and III, an intra-abdominal pressure of 14, 20, and 25 mmHg, respectively, was established by carbon dioxide pneumoperitoneum for a period of 60 minutes. Four hours after the pneumoperitoneum, all animals were sacrificed to evaluate the degree of bacterial translocation at this time. Liver, spleen and mesenteric lymph nodes were excised under sterile conditions. Bacterial growth was assessed using standard bacteriological techniques and compared statistically. The Kruskal-Wallis and Mann-Whitney U tests were used for the statistical analysis. Different amounts of bacterial growth were found in all of the animals subjected to increased intra-abdominal pressure, except for the controls. Bacterial translocation was detected at an intra-abdominal pressure of 14 mmHg but this finding was not statistically significant (p > 0.05). There was a significant increase in bacterial growth in animals subjected to an intra- abdominal pressure of 20 mmHg or above (p < 0.001). As a result, we found that bacterial translocation started when the intra-abdominal pressure reached a level of 14 mmHg. Patients should be closely monitored for septic complication risks following laparoscopic procedures in which the intra-abdominal pressure exceeds 20 mmHg.

Squamous cell carcinoma (SCC) is a rare type of breast malignancy and little is known about long-term outcome. In the present report, the clinical features, histopathologic findings and postoperative course of a patient with squamous cell carcinoma are described. We have treated a 47-years-old woman who admitted for right breast mass without any discharge, bleeding and pain. The tumor was, 3 × 2 × 1.5 cm in size with central abscess formation. The result of surgical biopsy revealed large cell keratinizing type of SCC. The metastatic work-up studies ruled out any other probable sources of primary tumor. The patient was performed modified radical mastectomy and axillary dissection and received two cycles of chemotherapy. Squamous cell carcinoma of the breast (SCCB) is a rare entity and should be considered in patients with rapidly progressing breast mass. It should also be considered in breast lesions with abscess formation. The initial therapeutic approach should be surgical excision after histopathological diagnosis.

6. ÖZET Sertralin, selektif serotonin re-uptake inhibitory (SSRİ) ilaçlardan birisidir. Klinikte antidepresan tedavide yaygın olarak kullanılan sertralinin yan etkileri arasında mesane gibi periferik organlara ait olanlar da yer almaktadır. Bu çalışmada, sıçan mesanesinde sertralinin doğrudan ve farklı mekanizmalarla kasılma oluşturan kasıcı ajanlar üzerine etkileri incelenmiş ve santral mekanizmalarla etki gösteren bir ilacın yan etkilerinin olası mekanizmaları arasında periferik kaynaklı olanların da yer alabileceğinin gösterilmesi amaçlanmıştır. Preparatlar eterle anesteziye edilmiş sıçanların (200-300g) mesanelerinden trigon kısımları atıldıktan sonra hazırlandı. Hazırlanan preparatlar Tyrode solüsyonu içinde klasik farmakolojik yöntemlerle organ banyolarına yerleştirildi ve 1 g istirahat gerilimi uygulanarak 60 dakika süreyle dengelenmeye bırakıldı. Dengelenme sağlandıktan sonra asetilkolin (10® - 10`3 M), potasyum klorür (KCI, 20, 40, 60, 80, 100 ve 120 mM) ve serotonin (5-HT, 10`10 - 10`4 M) kümülatif konsantrasyon yanıtları; ortamda sertralin (10`6 M, 10`5 M, 3 x 10~5 M) varken ve yokken değerlendirildi. Elektriksel alan stimülasyonu (EAS) frekans (1, 3, 6, 12, 24, 48 ve 96 Hz) yanıtları değerlendirildi ve aynı işlem sertralin banyo ortamında varken yapıldı. Kayıtlar FDT 10-A transdüser aracılığıyla bilgisayar ortamında MAY Polwin 97 programında kaydedildi. Elde edilen verilerin analizi Mann Whitney-U testi ile yapıldı ve yanılma olasılığı 0.05 olarak kabul edildi. Sertralin, sıçan mesane düz kasında asetilkolin, KCI, serotonin ve EAS tarafından oluşturulan kasılmaları doza bağımlı olarak inhibe etmiştir. Sonuç olarak sertralin, vas deferenste olduğu gibi mesane düz kası kontraksiyonları üzerine de inhibitor etkisini muhtemelen kalsiyum kanallarını bloke ederek göstermiştir. 7. SUMMARY Sertraline is a selective serotonin re-uptake inhibitor used in the treatment of depression. Side effects related to peripheral organs like urinary bladder can be observed. Peripheral effects of sertraline on rat urinary bladder was investigated. Bladder tissue samples were prepared by extracting the trigonal part of urinary bladder of rats (200-300 g) under ether anaesthesia. The strips were placed into the organ baths containing Tyrode solution and allowed to equilibrate for 60 min by a resting tension of 1 g. The responses to acetylcholine (109 -10`3 M), KCI (20, 40, 60, 80, 100 and 120 mM) and serotonin (10`1° -10`4 M) alone and after sertraline treatment (for 30 min) were recorded. The responses to electrical field stimulation were also recorded and were repeated after sertraline treatment (for 30 min). The responses were measured by force displacement transducer (FDT 10-A) and recorded through the MAY Polwin 97 software. For statistical analysis Mann-Whitney U test was used and a P value smaller than 0.05 was considered to be significant.. Sertraline inhibited the contractions caused by acetylcholine, serotonin and KCI. Sertraline treatment also inhibited the responses to electrical field stimulation. In conclusion sertraline showed inhibitory effects on urinary bladder contractions probably by blocking the calcium channels like in vas deferense. 41

Dear Editor, Primary fallopian tube malignancies are one of the rarest tumors of female genital tract.[1,2] Tubal sarcomas, particularly malignant mixed mullerian tumors (MMMT) are extremely rare forms of fallopian tube malignancies. Most of the patients are postmenopausal, the mean age is 57.5 years,[2] and usually advanced at the time of application. Generally, like the epithelial ovarian cancers, cytoreductive surgery to remove all of the tumor and its metastases is possible and platinum-based chemotherapy is done. But unfortunately, prognosis is poor.[3] Usually, the patients have nonspecific abdominal distention, pain or watery/bloody vaginal discharge.[2,4] If the tumor is located on the fimbriated end of the fallopian tube, watery/bloody vaginal discharge may emerge.[5] We report a case of primary MMMT located on the distal tubal region. A 64-year-old, woman was referred to our clinic due to new onset of watery/bloody vaginal discharge and lower quadrant abdominal pain. She had a 12 × 10 × 8.5-cm heterogeneous left tuboovarian mass and approximately 7-cm intracavitary fluid collection in uterus detected by abdominal ultrasonography (US). On physical examination, she had a palpable mass in the midline and lower quadrant. Transvaginal US and magnetic resonance imaging determined approximately 14-cm length and 4-5-cm width tubulocystic mass including hemorrhagic components. In addition, at the distal end of this structure, approximately 6-cm heterogeneous solid mass was determined [Figure 1]. Initial complete blood count, liver, and kidney function tests were normal. The preoperative carcinoembriogenic antigen, alpha-fetoprotein, human chorionic gonadotropin and CA-125 levels were in the normal range. Because of intracavitary fluid collection, endometrial tissue sampling was done. The results were reported as adenocarcinoma. Papanicolaou smear was negative. In the light of the findings, the patient underwent cytoreductive surgery. During the operation, left tubal mass of 14 cm length was seen. The mass was adherent to the adjacent pelvic structures tightly. Other intraabdominal organs were grossly normal. In addition, hematogenous fluid (approximately 100 mL) was stand out in abdomen. After the cytologic sampling of the fluid, mass resection was performed. The tubal mass contained hematoma areas and a solid area of 6 cm at the distal end. After that, right unilateral salpingo-oophorectomy, left oophorectomy, hysterectomy, omentectomy, and pelvic-paraaortic lymphadenectomy were performed. Biopsies were taken from suspicious intestinal serosa and peritoneal areas. Appendectomy was done 30 years ago. The final pathologic diagnosis was MMMT [Figure 2], and cytologic sampling of the fluid was reported as malignant cytology. All lymph nodes, omentum, and biopsies were negative for cancer. Thus, the patient was categorized as International Federation of Gynecology and Obstetrics FIGO Stage IIc and 1 month after the operation, six cycles of paclitaxel (taxol, 175 mg/m2) followed by carboplatin (AUC 5) administered at 3-week intervals. She is now doing well without any recurrence 15 months after the surgery. Figure 1 Pelvic MR images of the patient: (a) sagittal T2 weighted (T2W) magnetic resonance imaging (MRI); (b) coronal T1 weighted (T1W) MRI; (c) axial fat-suppressed T1W MRI; (d) axial fat-suppressed contrast-enhanced T1W MRI. MR imaging reveals that the fallopian ... Figure 2 Bleeding necrotic tumor formation developing into the tuba lumen (H and E, ×20) MMMTs of fallopian tube are uncommon neoplasms, with the first case being reported in 1970.[6] Although prognosis is poor in a way, lower incidence of advanced disease is seen in these patients than in patients with epithelial ovarian carcinomas, presumably because of the earlier occurrence of symptoms, particularly vaginal bleeding or unusual vaginal discharge.[7] As known, most important prognostic factor is spread of the tumor at diagnosis. Indeed, because of the prominent watery/bloody vaginal discharge, our patient was categorized as FIGO Stage IIc during the diagnosis. Because of the aggressive nature of this kind of sarcomas, a complete surgical staging and pathological classifications is very important. In addition, only half of the reported events till now have heterologous components.[8] More importantly, the number of patients who have heterologous components and also have tumor in the fimbriated end are less than 10.[5,9] In our case, the heterologous component has been reported as chondrosarcoma and there was a 6-cm mass at the fimbriated end. As was mentioned in many studies, cytoreductive surgery followed by platinum-based chemotherapy could be an effective treatment for MMMT of the fallopian tube.[3,9] Kawaguchi et al.[9] demonstrated that paclitaxel and carboplatin therapy reduced the size of a measurable tumor effectively in their patient with MMMT of the fallopian tube. In addition, radical surgery followed by chemo/radiotherapy could be an alternative and effective treatment for adenosarcoma of the cervix or pouch of Douglas location.[10,11] In the differential diagnosis of a hematosalpinx and hematometra, the disease is not seen much in that age group. As is known, even hematometra is mostly related with an imperforate hymen, a patient with hematosalpinx suggests a rarely seen pathology, i.e., tubal endometriosis. Endometrial implants involve the fallopian tubes in 6% of women with endometriosis, and adhesions involve the salpinges (26%).[12] However, endometriosis is not found in this age group, suggests malignancy first. As in our patient, presence of a rare tumor type of tuba at the fimbrial end has caused hematosalpinx and hematometra and as a result, bloody/watery vaginal discharge happened. So, a relatively early-stage diagnosis is thought to make a positive contribution to the prognosis. Based on these findings, the patients presenting watery/bloody discharge, especially during postmenopausal period may have tubal tumor that may cause distal tubal obstruction.