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Postoperative delayed diaphragmatic hernia (DH) is a rare and uncommon event after adult orthotopic liver transplantation (OLT), which however could be potentially life-threatening complication, especially in the absence of early and correct diagnosis and appropriate surgical treatment. We present a case of 48 year-old male with left diaphragmatic herniation of left part of transverse colon, who thirty nine months before underwent OLT with right-sided allograft implantation and which was recently successfully managed by open abdominal approach in our institution. The postoperative course was uneventful and he was discharged at the 8th day after surgery. Our case illustrates, that delayed DH after the OLT in adults could be a new problem, which affect transplant recipients with long-term follow-up period. Hence, we consider, that once the diagnosis of DH is confirmed, the patient should be operated immediately, in order to avoid the possible life-threatening complications.

Biliary complications (BCs) are still a major cause of morbidity following liver transplantation despite the advancements in the surgical technique. Although Roux-en-Y (RY) hepaticojejunostomy has been the standard technique for years in pediatric patients, there is a limited number of reports on the feasibility of duct-to-duct (DD) anastomosis, and those reports have controversial outcomes. With the largest number of patients ever reported on the topic, this study aims to discuss the feasibility of the DD biliary reconstruction technique in pediatric living donor liver transplantation (LDLT). After the exclusion of the patients with biliary atresia, patients who received either deceased donor or right lobe grafts, and retransplantation patients, data from 154 pediatric LDLTs were retrospectively analyzed. Patients were grouped according to the applied biliary reconstruction technique, and the groups were compared using BCs as the outcome. The overall BC rate was 13% (n = 20), and the groups showed no significant difference (P = 0.6). Stricture was more frequent in the DD reconstruction group; however, this was not statistically significant (P = 0.6). The rate of bile leak was also similar in both groups (P = 0.6). The results show that the DD reconstruction technique can achieve similar outcomes when compared with RY anastomosis. Because DD reconstruction is a more physiological way of establishing bilioenteric integrity, it can safely be applied.

Thanks to technological developments, distance education helped new techniques and strategies to emerge in the instruction field. However, these developments may cause problems about integration of the interaction between students and instructors. Communication is seen as one of the biggest problems. Instructors' online communications and their attitudes towards this process affect quality of teaching and learning processes. Other factors affecting this process are learning environment and its effective use. This study is designed to incorporate a mixed method with the aim of reflecting instructors' experiences about different communication techniques and learning environments. In scope of this research, the researchers planned a four-week process using the communication that the researchers have been establishing with Ege University Faculty of Education's instructors. The researchers will use different mobile devices and feedback methods for the process.

Objectives Living-donor liver transplant for BuddChiari syndrome is particularly challenging because of the need for venous outflow reconstruction as grafts from living donors lack vena cava. In addition, recipient vena cava may be thrombotic and fibrotic to such an extent that it would not allow graft venous outflow reconstruction. Under these circumstances, the right atrium provides an easily accessible alternative for venous outflow reconstruction, omitting the need for vena cava replacement. Materials and methods Data from 3 patients who were treated using this technique were collected and evaluated with regard to surgical technique and outcomes. Results All patients were alive without vascular complications after a mean follow-up of 67 months. The applied surgicaltechnique was similar except with regard to vena cava preservation. Conclusions During the natural course of the disease, venous collaterals form as chronic thrombosis extends into the vena cava. The vena cava can be safely resected in these patients to facilitate hepatectomy through dense adhesions, which is another common clinical problem in this disease. Consequently, venous outflow reconstruction to the right atrium creates the feasible opportunity of draining the graftliver without having to replace the vena cava.

WOS: 000427075700013, PubMed ID: 29391313, Background/Aims: A liver transplant is the preferred treatment for patients with end-stage liver disease, as it usually results in long-term survival. However, due to the use of chronic immunosuppressive therapy, which is necessary to prevent rejection, de novo cancer is a major risk after transplantation. The aim of this study was to assess the incidence of post-transplant malignancies in children after liver transplantations. Materials and Methods: The study group consisted of 206 liver transplant recipients, with no history of cancer, including hepatocellular carcinoma, in two liver transplantation centers in Turkey between 1997 and 2015. Data were obtained from patient's data chart. Results: In the study group, de novo cancer was diagnosed in 13 of the 206 patients. Post-transplant lymphoproliferative disease (PTLD) occurred in seven (53.8%) patients and other malignancies in six of the 13 patients. The types of PTLD were as follows: B-cell origin (n= 2), Epstein-Barr virus (EBV)-related (n= 2), T-cell origin (n= 1), and Hodgkin's lymphoma (n= 2). EBV DNA was isolated from seven patients, three of whom developed PTLD. The others developed Kaposi's sarcomas, Burkitt's lymphomas, cutaneous large-cell lymphomas, Hodgkin's lymphomas, and liver sarcomas. Conclusion: After transplantation, immunosuppressive treatment is unavoidable, increasing the risk of malignancies. However, a close follow-up and periodic screening can reduce cancer-related mortality and morbidity.

Background Venous reconstruction in living-donor liver transplantation for Budd-Chiari syndrome (BCS) has challenges because the grafts from living donors lack vena cava, and hepatic venous anastomosis must be performed on an already-thrombosed and/or stenosed inferior vena cava. Several techniques are described to overcome this problem, and we represent our experience with 22 patients. Methods Medical recordings of 22 patients were retrospectively collected, and disease-specific data as well as recordings about surgical technique were analyzed. Results Creation of a wide, triangular de novo orifice was the main method used for venous drainage, which was used in 19 patients. The remaining 3 patients had totally thrombosed vena cava; thus, direct anastomosis to the supra-hepatic portion of the vena cava was used in 2 patients and an anastomosis to the right atrium was used in 1 patient. Conclusions Venous reconstruction in BCS can be achieved without the use of patch-plasty, and the inferior vena cava can be safely resected in selected patients. Living-donor liver transplantation is a feasible option for the treatment of BCS, considering the scarcity of cavaderic donors.

Type 1 tyrosinemia is a rare metabolic disorder of the tyrosine degradation pathway. Due to the rarity of the disease, the best evidence literature offers is limited to guidelines based on expert opinions and optimal treatment is still a debate. LT serves as a definitive treatment of the defective metabolic pathway in the liver along with other serious disease manifestations such as LF and HCC. Nitisinone is a relatively new agent that is currently recommended for the medical management of the disease. Its mechanism of action is well understood, and efficacy is well established when started presymptomatically. This study aims to evaluate outcomes of 15 patients with type 1 tyrosinemia who underwent LT in nitisinone era and discuss its effect on prevention of HCC. A LT database of 1037 patients was reviewed. Data from 15 patients with type 1 tyrosinemia were retrospectively analyzed. All the patients except one were treated with nitisinone prior to LT. Most common indications for LT were LF and suspicious nodules. Seven patients had HCC. Mortality rate was 20% (n = 3). Nitisinone treatment has opened new horizons in the management of type 1 tyrosinemia, but LT still remains the only option for the patients developing LF and in the event of HCC. Neonatal screening programs utilizing blood succinyl acetone as the marker should be encouraged especially in the countries, such as Turkey, with high prevalence of consanguineous marriages.

Background/aim In this study, the efficiency of using low-dose hepatitis B immunoglobulin (HBIG) plus antiviral treatment according to individual needs has been evaluated in posttransplant hepatitis B virus (HBV) patients. Materials and methods We retrospectively evaluated 179 patients who were admitted between 2009 and 2014. Five thousand IU intravenous HBIG was given in the anhepatic phase, and 400 IU/day intramuscular (IM) HBIG was given in the posttransplant period. After HBsAg seroconversion, 400 IU IM HBIG was continued as prophylaxis every two weeks. Results The average follow-up period was 26 (2–65) months. Seventy patients had hepatocellular carcinoma (HCC). The HBV recurrence was 4.5% in the first year, and 5.8% in the third year. The HBsAg became negative in 11 (2–63) days, and anti-HBs became positive in 9 (1–31) days. HBsAg positivity occurred in 6 patients during the follow-up period. Five of these patients were those who underwent transplantation due to HCC. In 5 of the HCC patients, in whom HBsAg became positive, tumor recurrence was observed after 0.3–9.9 months. HBsAg positivity was more frequently detected in patients with HCC (P = 0.009). Conclusion The HBV recurrence should be evaluated as a predictor of the HCC recurrence in patients who were transplanted due to HCC.

Introduction Several markers of systemic inflammation, including blood C-reactive protein, platelet lymphocyte ratio (PLR) and neutrophil lymphocyte ratio (NLR) have been identified as independent prognosticators for hepatocellular carcinoma (HCC). Methods To attempt to understand the significance of these markers, they were examined in relation to 4 tumour parameters, namely maximum tumour diameter (MTD), tumour multifocality, portal vein thrombosis (PVT) and blood alpha-fetoprotein (AFP) levels. Results Using linear and logistic regression models, we found that C-reactive protein and PLR on single variables, were statistically significantly related to the tumour parameters. In a logistic regression final model, CRP was significantly related to MTD, AFP and PVT, and the Glasgow Index significantly related to MTD and AFP. Results of the area under the receiver operating characteristic curves (ROC), showed that the areas for PLR and CRP were statistically significant for high versus low MTD and for presence versus absence of PVT. CRP alone was significant for high versus low AFP. Conclusions These analyses suggest that the prognostic usefulness of the inflammatory markers PLR and CRP (but not NLR) may be due to their reflection of parameter values for tumour growth and invasiveness.

Background/aims The aim of this study was to evaluate the effect of the Milan criteria on the hepatitis B virus (HBV) and hepatocellular carcinoma (HCC) recurrence in patients who underwent living donor liver transplantation due to HBV-induced cirrhosis and HCC. Materials and methods We evaluated a total of 142 patients, 88 who underwent transplantation due to HBV-induced cirrhosis and 54 due to HCC, between 2009 and 2014. In the posttranplant period, after the HBsAg seroconversion, 400 IU of hepatitis B immunoglobulin were applied intramuscularly every 2 weeks, and daily nucleos(t)ide analogs were continued as prophylaxis. The HBV recurrence was defined as the presence of HBsAg in serum. Patients were screened for alpha-fetoprotein levels and imaging for evaluation of HCC recurrence. Results The average follow-up period was 26 (2-65) months. Fifty-four patients had HCC. The HCC recurrence was observed in 12 patients during the follow-up period. The HBV recurrence was observed in four patients. Three of the patients who developed HBV recurrence had liver transplantation due to HCC. Tumor recurrence was observed 1.4-12 months following the HBV recurrence. The HCC recurrence within the Milan criteria and beyond the Milan criteria was 0% vs. 28.4 % in the first year and 3.4% vs. 47.5% in the third year. The cumulative incidence of the HBV recurrence was 2.8% and 3.7% for the first year and 3.7% for the third year. The HBV recurrence was more frequently detected in patients with HCC (p=0.048), especially with HCC beyond the Milan criteria (p=0.044). Conclusion The HBV recurrence should be evaluated as a predictor of the HCC recurrence in patients who underwent liver transplantation due to HCC with exceeding Milan criteria.

Aim: Liver transplantation (LT) is performed for several indications in the pediatric population, including malignancy and acute hepatic failure among others. LT has become an important treatment alternative for metabolic diseases. In most pediatric transplant centers, metabolic liver disease is the second most common indication for LT after biliary atresia. Our studies aim is to compare the post-transplant outcomes of those patients with metabolic and other liver diseases in our transplant program. Materials and Methods: One hundred eighty-nine patients who underwent LT between 1997 and 2015 due to metabolic diseases and acute or chronic liver failure were included in the study. This study was performed retrospectively. Results: We enrolled 189 patients in our study. 54% (n=102) male and 46% (n=87) female patients were included in the study. The metabolic disease group included 56 patients and the non-metabolic disease group contained 133 patients. Progressive familial intrahepatic cholestasis is the most common disease among metabolic diseases resulting in LT and Wilson disease is the second most common. Post-transplant immunosuppression was similar for both groups. There was no difference in both groups regarding the onset of post-transplant complications for graft type or recipient age. Biliary and portal vein complications were most particularly defined in the group with non-metabolic diseases. There was no significant difference in survival between the two groups. Conclusion: LT is an important treatment option for acute hepatic failure and end-stage liver diseases. In addition, LT is an alternative treatment option for some metabolic diseases.

Opioid dependence is an increasing public health problem. One of the complications of intravenous opioid use is hepatitis C virus infection, which, in turn, is one of the most common indications for liver transplantations throughout the world. Therefore, the treatment of opioid dependence in a liver transplant recipient requires special attention in terms of graft function, drug interactions, and patient compliance. Buprenorphine is a semi-synthetic opioid-derived agent with analgesic effects. To prevent buprenorphine abuse, it is combined with the opioid antagonist naloxone. This buprenorphine/naloxone combination is the only drug approved for the treatment of opioid dependence in Turkey. Although the literature includes data about the safe usage of buprenorphine in liver transplantation in animals, there is no such evidence in either case reports or clinical trials for the same in humans. In this article, we present a report of our treatment of 2 opioid-dependent patients with buprenorphine/naloxone after liver transplantation due to hepatitis C virus-induced liver cirrhosis.

This paper presents a generalized geometric model of cutting tools for the purpose of predicting the mechanics and dynamics of machining operations. The model starts by defining the tangent and rake face vectors at discrete elements along the cutting edge. The discrete cutting edge elements are assembled mathematically to form either an insert or solid cutting edge, which are further transformed to design turning, boring, drilling, milling and other tools by considering the geometry and kinematics of cutting operations. Homogeneous transformation matrices are used to successively locate and orient the cutting edge within the insert, tool and process coordinate frames. Industry-standard tool-in-use planes are used to obtain the effective geometry for all cutting operations. In total 15 geometric parameters are used for identifying the geometry of an arbitrary tool. Radial and axial runouts are considered in the model. Generalized model is demonstrated by modelling the geometry of sample drills, indexable and serrated milling tools. The generalized model allows unified prediction of machining operations with one mathematical model which covers all operations and tool geometries.

This paper presents the unified modeling of mechanics and dynamics of metal cutting operations such as turning, boring, drilling and milling. The distribution of chip thickness along the cutting edges of tools are evaluated using the generalized geometric and kinematic model of the operations [1] . The effect of relative vibrations between the cutting edge and workpiece segments are considered. The force contributed by each oblique cutting edge segment is evaluated from shear stress, shear angle and friction coefficient defined in orthogonal cutting data base. The tool cutting loads are evaluated by summing the differential cutting forces along all engaged cutting edges using the generalized geometric transformations presented in [1] . The chatter stability is solved in modal coordinate system, and the forced vibration marks left on the finish surface are predicted in discrete time domain. The process damping, multiple-regenerative phase delays which depend on the tool geometry and operations are considered. The application of the proposed unified mechanics and dynamics model is demonstrated experimentally in drilling, milling with indexable cutters and various end mills, and in opening large holes with multi-functional drilling/boring heads.

EgeUn###, The hepatocellular carcinoma (HCC) tumor marker alpha-fetoprotein (AFP) is only elevated in about half of the HCC patients, limiting its usefulness in following the effects of therapy or screening. New markers are needed. It has been previously noted that the inflammation markers C-reactive protein (CRP) and platelet-lymphocyte ratio (PLR) are prognostically important and may reflect HCC aggressiveness. We therefore examined these 2 markers in a low-AFP HCC cohort and found that for HCCs > 2 cm, both markers significantly rise with an increasing maximum tumor diameter (MTD). We calculated the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and Youden index value for each marker, and their area-under-the-curve values for each MTD group. Patients were dichotomized into 2 groups based on the CRP and PLR from the receiver-operating characteristic curve analysis. In the logistic regression models of the 4 different MTD patient groups, CRP and PLR levels were statistically significant to estimate MTD in univariate logistic regression models of MTD groups > 2 cm. CRP and PLR were then combined, and the combination was statistically significant to estimate MTD groups of 3-, 4-, and 5-cm cutoffs. CRP and PLR thus have potential as tumor markers for low-AFP HCC patients, and possibly for screening. (C) 2018 S. Karger AG, Basel, NIHUnited States Department of Health & Human ServicesNational Institutes of Health (NIH) - USA [CA 82723], This work was supported in part by the NIH grant CA 82723 (B.I.C).

Introduction Liver transplantation (LT) remains the best treatment option for hepatocellular carcinoma (HCC). Patient selection is crucial and debated ever since the emerging of the Milan criteria in 1996. As live-donor LT is being more routinely performed worldwide, numerous new and/or expansions of the original criteria have been suggested to allow more patients to benefit from this superior treatment modality. This study aims to contribute to the ever-growing data in search for better coverage of patients with acceptable outcomes. Methods Medical recordings of 187 adult patients who underwent LT for HCC in a 6-year period were retrospectively collected. Patients were classified by Milan and University of California, San Francisco, criteria. Survival times as well as tumor, liver disease, and recurrence-related data were recorded for each patient and the outcomes were statistically analyzed. Results Factors significantly affecting recurrence and survival were histologic differentiation, number and the size of the tumor, and the presence of vascular invasion. Serum alpha-fetoprotein levels did not significantly affect outcomes. Among the patients exceeding both of the criteria, having a total tumor size of less than 160 mm was significantly associated with better outcomes (P = .007). Conclusion HCC patients having tumors with vascular invasion, poor differentiation, exceeding 6 in number and 160 mm in total diameter demonstrate higher recurrence rates and worse outcomes.

C-reactive protein (CRP) is a blood marker for inflammation and is an independent prognostic factor for many human cancers. Combined with albumin levels, it forms the basis of the Glasgow Index for cancer prognosis. We reviewed the literature on CRP and HCC and also evaluated blood CRP levels and combination CRP plus albumin levels in a large HCC cohort. In order to understand the prognostic significance of CRP, we retrospectively examined a large HCC cohort and examined the relationship of CRP levels to tumor parameters. We report, that CRP alone and CRP plus albumin combined as well, significantly correlated with parameters of HCC aggressiveness, such as maximum tumor dimension (MTD), portal vein thrombosis (PVT) and blood alpha-fetoprotein (AFP) levels, both as individual parameters and all parameters together (Aggressiveness Index). This extends current thinking, to suggest a possible explanation for the usefulness of blood CRP levels in HCC prognostication.

ALTINTAS, Engin/0000-0003-0796-1456; Sonsuz, Prof.Dr.Abdullah/0000-0002-8336-5472; ALTINTAS, ENGIN/0000-0003-0796-1456; kuran, sedef/0000-0001-7019-8911; uskudar, oguz/0000-0003-2789-1467; EKIN, NAZIM/0000-0001-5302-8953; Akkiz, Hikmet/0000-0001-9745-8875; Tokmak, Salih/0000-0002-2727-5632; Carr, Brian/0000-0002-6111-5077 WOS: 000436297600001 PubMed: 30009156 Macroscopic portal vein invasion (PVT) by hepatocellular carcinoma (HCC) in the liver is one of the most important negative prognostic factors for HCC patients. The characteristics of a large cohort of such patients were examined. We found that the percent of patients with PVT significantly increased with increasing maximum tumor diameter (MTD), from 13.7% with tumors of MTD 10cm. There were similar numbers of HCC patients with very large tumors with and without PVT. Thus, MTD alone was insufficient to explain the presence of PVT, as were high AFP levels, since less than 50% of high AFP patients had PVT. However, the percent of patients with PVT was also found to significantly increase with increasing blood alpha-fetoprotein (AFP) levels and tumormultifocality. A logistic regressionmodel that included these 3 factors together showed an odds ratio of 17.9 for the combination of MTD >5.0cm plus tumor multifocality plus elevated AFP, compared to low levels of these 3 parameters. The presence or absence of macroscopic PVT may therefore represent different HCC aggressiveness phenotypes, as judged by a significant increase in tumor multifocality and AFP levels in the PVT positive patients. Factors in addition to MTD and AFP must also contribute to PVT development. NIHUnited States Department of Health & Human ServicesNational Institutes of Health (NIH) - USA [CA 82723] This work is supported in part by NIH Grant CA 82723 (Brian I. Carr)Y

Objective: Liver transplantation has been one of the areas in which microvascular surgery is frequently practiced. With the use of microsurgical techniques in hepatic artery anastomosis, the incidence of hepatic artery thrombosis has been signifi- cantly reduced. Hepatic artery anastomosis is realized after the anastomoses of the hepatic vessel and portal vessel are completed, and clamps are removed; in other words, after hepatic circulation starts. During hepatic artery anastomosis, bile runs towards the hepatic artery anastomosis line. This study aimed to investigate effects of bile on arterial anastomosis. Materials and Methods: Forty male Sprague Dawley rats were randomly divided into 2 groups. Femoral artery anasto- mosis was performed in rats of the control group (n = 20) through heparinized serum (10 U/ml) irrigation. In the rats of the study group (n = 20), however, femoral artery anastomosis was performed through heparinized serum (10 U/ml)+0.5 cc bile irrigation. After the 1st week, anastomosis patency was evaluated with color duplex ultrasonography. A 1 cm segment of the femoral artery involving the anastomosis line was removed for histopathological evaluation. Results: In the control group, no flow to the distal was observed in one anastomosis. All the anastomoses in the study group were patent. Histopathologically, perivascular polymorphonuclear leucocyte infiltration was observed in the study group. No statistically significant differences were observed for endothelial continuity and intimal thickening, and no statisti- cally significant differences were observed for anastomosis patency. Conclusions: In the light of these findings, it was determined that bile contamination did not have any negative or positive effects on artery anastomosis. [Arch Clin Exp Surg 2015; 4(3.000): 135-141]

rd, 10 th , and 30 th days of the hearing loss. All patients received 1 mg/kg IV prednisolone treatment in tapered amounts to be completed in 15 days. Based on the improvements seen in the audiograms, the patients were divided into two groups: responders and non-responders to treatment. RESULTS: PLR and NLR values of the patient group were significantly higher than in the control group (p

Background/aims Biliary atresia (BA) is the main cause of neonatal cholestasis and the primary reason for infant liver transplants worldwide. It is an obliterative cholangiopathy observed only in children and caused by progressive inflammation and fibrosis of the bile duct. We collaborated with a liver transplantation center to investigate the effects of follow-up in patients with BA. Materials and methods Medical records of 99 patients who were diagnosed with BA and monitored at our center from 1990 to 2002 (27 patients) and from 2003 to 2015 (72 patients) were analyzed retrospectively. Patients were evaluated for birth weight; age at jaundice onset; age at alcoholic stool detection; age at the time of Kasai portoenterostomy (KPE), if performed; age at admission to our center; age at liver transplantation; duration between KPE and transplantation; pediatric end-stage liver disease (PELD) scores during transplantation; and growth and developmental status. The periods 1990-2002 and 2003-2015 were defined as phases I and II, respectively. Results The median age of the patients at presentation to our hospital was 149 (range: 20-730) days during phase I and 61 (range: 28-720) days during phase II. The median age at jaundice onset was 7 days, and the median age at alcoholic stool detection was 15 days. There was no significant difference between phases I and II in terms of age at jaundice onset, age at alcoholic stool detection, or birth weight. Twenty-five (92.5%) of the 27 patients in the phase I group were admitted to our center after undergoing KPE. Forty-four (61.1%) of the 72 patients in the phase II group (median age at the time of KPE: 47 days) were operated at our center. Median ages of the patients at the time of KPE at our center were 67.5 (range: 25-220) and 47 (range: 28-139) days during phases I and II, respectively. The median age of the 28 patients who were transferred from another center was 70 (range: 45-105) days during phase II. Liver transplantation was performed in 55 of 99 patients (55.5%). Significant differences were observed in the age at transplantation, duration between KPE and transplantation, and PELD scores between patients with BA who underwent KPE at our center and who underwent KPE at other institutes from other institutes. Conclusion These findings demonstrate the importance of a timely diagnosis of BA and undergoing KPE before malnutrition and/or cirrhosis deteriorate the patient's health. Furthermore, follow-up of patients with BA at a liver transplantation center increased the success of KPE and improved survival rates.

factPresentation Sinonasal inverted papillomas are benign tumors of the nasal cavity and paranasal sinuses. The basic characteristics of these papillomas are their different localizations in the nasal cavity, local aggressive behavior and potential to transform into malignant tumors. The most common symptoms of those tumors are nasal obstruction, rhinorrhea, and epistaxis. Rare symptoms such as dysphagia and hoarseness may be seen in relation with the localization and the size of the tumor. In this article, we present an unusual case of a huge inverted papilloma originating from the superior turbinate, extending down to epiglottis, and causing dysphagia and dyspnea. Sinonazal inverted papillomlar, burun ve paranazal sinüslerin benign tümörleridir. Bu papillomların temel özellikleri; nazal kavite içinde farklı lokalizasyonlarda bulunabilmeleri, lokal agresif seyir göstermeleri ve malign tümörlere dönüşme potansiyelleridir. Burun tıkanıklığı, burun akıntısı ve burun kanaması bu tümörlerin en yaygın semptomlarıdır. Tümörün yerleşim yerine ve büyüklüğüne bağlı olarak, yutma güçlüğü ve ses kısıklığı gibi nadir semptomlara da rastlanabilir. Bu yazıda üst konkadan köken alan, epiglota kadar uzanan ve yutma güçlüğü ve nefes darlığına yol açan sıra dışı dev bir sinonazal inverted papillom olgusu sunuldu.

A hydrogen generation system utilizing sodium borohydride solution and a 200 W fuel cell system were developed for powering a small custom-designed and manufactured unmanned aerial vehicle. A complete hydrogen generation system having a special cobalt base catalyst, was able to produce 5.4 L/min of hydrogen in an 11 cm(3) reactor volume with durability of more than 10 cycle. This flow rate of hydrogen was enough to feed 50-cell fuel cell system to produce 218 W power (24.5 VDC and 8.9 A current). Hydrogen generation system mainly consisted of peristaltic pump to feed fuel, reaction chamber for catalyst, reaction product cooling, gas/water separation tank and flow control units. Fuel cell system had air cooling and air-breathing cathode providing air for the reaction. Hydrogen fed through porous gas diffusion layer structure and humidity of the membrane electrode assemblies were controlled by dead-end operation algorithm. The weight of the whole system was 7.5 kg including UAV. The energy density of power system (fuel cell, hydrogen generation system and fuel) is measured as 325 Wh/kg which is about two fold of lithium ion energy density of this particular application. (C) 2016 Hydrogen Energy Publications LLC. Published by Elsevier Ltd. All rights reserved.

Ya z›fl ma Ad re si/Ad dress for Cor res pon den ce Dr. Ayca Aykut, Ege Universitesi Tip Fakultesi, Tibbi Genetik Anabilim Dali, Izmir, Turkiye Tel.: +90 232 390 39 61 E-posta: aycaaykut@hotmail.com Ge lis ta ri hi/Re cei ved: 07.05.2014 Ka bul ta ri hi/ Ac cep ted: 24.07.2014 1Ege Universitesi Tip Fakultesi, Tibbi Genetik Anabilim Dali, Izmir, Turkiye 2Ege Universitesi Tip Fakultesi, Cocuk Sagligi ve Hastaliklari Anabilim Dali, Izmir, Turkiye 3Ege Universitesi Tip Fakultesi, Patoloji Anabilim Dali, Izmir, Turkiye 4Ege Universitesi Tip Fakultesi, Genel Cerrahi Anabilim Dali, Izmir, Turkiye Ayca Aykut1, Murat Cakir2, Huseyin Onay1, Deniz Nart3, Cigdem Arikan2, Funda Ozgenc2, Murat Kilic4, Funda Yilmaz3, Sema Aydogdu2, Rasit Vural Yagci2, Ferda Ozkinay1, Ozgur Cogulu1 The Journal of Pediatric Research 2014;1(3):138-41 DO I: 10.4274/jpr.76476

Background Living donor liver transplantation has been a new light of hope for patients with end-stage liver failure on the cadaveric waiting list. However, living donor liver transplantation still has ethical problems which cannot be overcome. Exposure of healthy donor candidates to major surgery which can be fatal is the largest of these ethical problems. In this study, we aimed to determine our rate of complications associated with surgery in donors who underwent right lobe donor hepatectomy. Materials and Methods Between September 2004 and December 2009, 548 liver donor candidates were examined. The right liver lobe donor hepatectomy was performed on 272 donor candidates who passed the elimination system. Demographic data as well as intraoperative findings, complication rates, and numbers were collected retrospectively. Donor complications were categorized according to the Clavien classification. Results Two hundred seventy-two donors who underwent right lobe donor hepatectomy were included in this study. One hundred sixteen (42.6%) of 272 donors were female, whereas 156 (57.4%) were male. There was no donor mortality. Grade 1 and grade 2 complications were observed in 105 (38%) of 272 donors. The most common complications were fever of unknown origin (20.9%) and prolonged hyperbilirubinemia (3.6%). Grade 3 complications and grade 4 complications were observed in 6 donors (2%) and 3 donors (1%), respectively. Three donors were underwent re-operation due to bleeding. The re-laparatomy rate in our series was detected as 1.10%. One donor, categorized as grade 4B according to the Clavien classification, had small bowel perforation and intra-abdominal sepsis secondary to mechanical bowel obstruction. Conclusions Donor mortality is a fact of living donor liver transplantation that cannot be ignored like donor morbidity. However, right liver lobe donor hepatectomy can be performed successfully with minimal complication rates with multidisciplinary and rigorous donor care in the preoperative and postoperative period.

Plasmacytomas are malignant tumors characterized by abnormal monoclonal proliferation of plasma cells. They originate either in the bone (osseous solitary plasmacytoma) or in soft tissues (extramedullary plasmacytoma) and could be either primary or a part of a systemic process during the course of multiple myeloma.

To investigate the morphological or functional differences of retina in amblyopia.Forty-one patients with unilateral strabismic, anisometropic or combined amblyopia were included in the study. A control group was composed of 16 normal children. All participants were tested with optical coherence tomography (OCT) and pattern electroretinography (PERG). The findings from amblyopic and nonamblyopic eyes were compared among the amblyopic groups. Also, amblyopic and nonamblyopic eyes were compared with the healthy control eyes.No significant difference was found in OCT parameters for amblyopic and nonamblyopic eyes among the amblyopic groups (p 0.05). In the combined and anisometropic groups, ganglion cell complex (GCC) was found to be significantly increased in both amblyopic and nonamblyopic eyes compared to the control group (p 0.05). In strabismic amblyopia, significant reduction in GCC thickness and increase in foveal thickness were found, compared to nonamblyopic eyes (p = 0.019, p = 0.08). There were no significant differences in PERG amplitude and latency between the amblyopic and the nonamblyopic eyes in amblyopic groups (p 0.05). PERG amplitude in amblyopic eyes was found to be significantly decreased compared with that in normal eyes (p 0.05). When the nonamblyopic eyes were compared with the control group, only the anisometropic amblyopia group demonstrated significant reduction in amplitude and prolongation in latency (p = 0.002, p = 0.026).We found no significant differences in morphological and functional measures among amblyopic groups. However, we detected significant differences in the retinal function and morphology of both amblyopic and nonamblyopic eyes compared with healthy control eyes.

This paper presents a unified mathematical model which allows the prediction of chatter stability for multiple machining operations with defined cutting edges. The normal and friction forces on the rake face are transformed to edge coordinates of the tool. The dynamic forces that contain vibrations between the tool and workpiece are transformed to machine tool coordinates with parameters that are set differently for each cutting operation and tool geometry. It is shown that the chatter stability can be predicted simultaneously for multiple cutting operations. The application of the model to single-point turning and multi-point milling is demonstrated with experimental results.

Mucormycosis is a rare lethal complication of organ transplantation that progresses rapidly, and the prognosis is dismal if diagnosed late. We present a surviving liver transplant recipient in whom severe rhino-orbita-maxillary mucormycosis developed 1 month after liver transplantation. Prompt diagnosis with tissue biopsy, local control of the underlying condition with aggressive surgical debridement, and appropriate administration of systemic antifungal therapies are essential to improve prognosis and survival.

Objectives This study aims to constitute a valid and reliable Turkish version of the original Singing Voice Handicap Index. Patients and methods An authorized committee assessed the reliability and validity of the content, scope, and language of the original Singing Voice Handicap Index which underwent a back translation process. The Turkish version of the questionnaire was answered twice with a 7 to 10-day interval by two singing voice groups with or without singing voice problems. The reliability and validity analyses were performed based on these answers. Results Of a total of 123 individuals (64 females, 59 males; mean age 26.2±7.3 years), 81 were without a voice pathology and 42 were with a voice pathology. The total Cronbach's alpha coefficient was 0.917. The item-total correlations ranged between 0.51 and 0.89. The weighted kappa values of test-retest correlation values of the items were 0.82-0.91. The Cronbach's alpha values of two part of the questionnaire based on the split-half method were 0.89 and 0.84. The mean total scale scores were 21.8±18.5 and 53.6±28.9 in normal and pathology groups, respectively and there was a statistically significant difference in scores between these two groups (p=0.000). Conclusion The Turkish version of the Singing Voice Handicap Index is a valid and reliable scale which can be used in the evaluation of voice problems of Turkish-speaking singing voice users.

A unified cutting mechanics model is developed for the prediction of cutting forces in milling, boring, turning and drilling operations with inserted tools. The insert and its orientation on a reference tool body are mathematically modeled by following ISO tool definition standards. The material and cutting edge geometry-dependent friction and normal forces acting on the rake face are transformed into reference tool coordinates using a general transformation matrix. The forces are further transformed into turning, boring, drilling and milling coordinates by simply assigning operation specific parameters. The unified model is validated in cutting experiments.

This paper presents dynamic modelling of peripheral milling systems with axially varying dynamics. The end mill is divided into differential elements along the cutter axis, and discrete nodes are assigned along the axial depth of cut. The cutting forces, which include regenerative and process damping components, are distributed to nodes. The equation of motion is transformed into modal space as periodic, delayed differential equations which cover one tooth period for regular, and one spindle period for variable pitch cutters. The directional coefficients are averaged and the stability is solved in frequency domain using Nyquist criterion. The presented model is experimentally verified in peripheral milling tests with low radial and high axial depth of cut.

Objective. To evaluate liver anatomy with a view to access unerring surgery in liver donors. Summary Background Data. Liver transplantation, the unique curative treatment option for end-stage hepatic failure, has become routinely practicable, which was inconceivable in the past. But, the vascular and biliary anatomy of the liver has not been completely disclosed yet. Methods. From 1994 to 2009, we have done a research on 496 liver donors. The data were accumulated and categorized according to the most widely used classification systems. Results. Of 496 liver donors, 393 (79.1%) underwent the right donor hepatectomy, 98 (19.9%) were performed the left lateral segmentectomy, and 5 donors (1%) underwent the left donor hepatectomy surgery. Given the data regarding to 398 liver donors undergone right and left donor hepatectomy, arteries, bile ducts, and portal vein showed classical anatomy in 107 (21.6%) donors. Variations in all three systems were found in 16 donors (3.2%). In the remaining 275 donors (75.2%), anatomical variations were found at either of arterial, biliary, or portal system. Conclusions. Our study could come up to actual estimate in liver anatomy as any of donors have not been removed in our institute due to high hilar dissection technique.

Aplastic anemia is a rare complication after liver transplantation. Its incidence has been estimated to be 0.007%. Aplastic anemia was observed in 23.2 33% of patients who underwent liver transplantation for fulminant non-A-E viral hepatitis. In this paper, we describe a child suffering from aplastic anemia who eventually died from sepsis after liver transplantation for non-A-E fulminant hepatic failure.

Hepatocellular damage takes place as a result of ischemia and reperfusion during liver transplantation (LT). To discriminate the type of cell death and quantitate its severity may provide new insights into the mechanisms of hepatocellular damage. Therefore, we investigated the type of cell death by ELISA-based assays in patient sera. Apoptosis was specifically assessed by measuring a novel soluble biomarker, the caspase-cleaved cytokeratin 18, while total cell death (apoptosis and necrosis) by cytokeratin 18 released from dead (necrotic and apoptotic) cells. Twenty-seven live (LDLT) and 14 deceased (DDLT) donor liver transplantations were analyzed before the operation, at the anhepatic stage, first, sixth and 24th hour after the reperfusion. Both apoptosis and total cell death have successfully been demonstrated although they have not been confirmed by the liver biopsy that is impossible to perform in this setting. Apoptosis was not induced in LDLT. Total cell death (primarily necrosis) only transiently appeared the first hour after the reperfusion in LDLT, while it sharply increased the first hour after the reperfusion and maintained its level in DDLT. Soluble cytokeratin 18 biomarkers seem to be useful to discriminate and quantitate the type of cell death during early ischemia and reperfusion periods of LT.

We analyzed infections that occurred within one month prior to LT, identified factors associated with their occurrence and effect of infections on post-transplant mortality. The study group included 40 consecutive children who underwent LT. Sites and types of infection and culture results were recorded prospectively. IID was assessed. Risk factors for the infectious events were analyzed. Forty infection episodes were found in 24 patients (60%); 90% were bacterial, 7.5% fungal, and 2.5% viral. Overall, IID was 38.2 per 1000 patient days. Sites of bacterial infection were urinary tract in 13 events (36.1%) and blood stream in 11 events (30.5%). Bacteremia (culture positive infection episodes) was identified in 19 events (52.7%). Gram-negative isolates were twice as frequent as Gram-positive infections (63.1% vs. 36.9%). Risk factors for the infectious complications were young age, low body weight, prior abdominal surgery, chronic liver disease related to biliary problems, presence of ascites, portal hypertension and cirrhosis, and high PELD score (p < 0.05 for all). Infectious complications in pediatric LT candidates are common. Preventive measures are important not only to reduce the infectious complications but also to prevent the post-operative mortality.

Matrix metalloproteinases (MMPs) are known to play an important role in cell migration during cancer invasion by degrading extracellular matrix proteins. This study aimed to determine the role of MMP-9 in hepatocellular carcinoma (HCC) carcinogenesis. Eighty-nine cases who underwent liver transplantation for HCC in cirrhotic liver were selected for this study. The tumor characteristics such as nodule number, maximal diameter, portal vein invasion, and the preoperative alpha-fetoprotein levels were reviewed. The intensity of immunostaining and the percentage of immunoreactive cells with MMP-9 were evaluated. All patients were evaluated for HCC recurrence and/or death, and cause of death was noted. There was a lower survival and more recurrence risk among participants with 4 or more nodules exceeding 3 cm in diameter, with poorly differentiated tumor, and with large-vessel involvement. Eleven patients developed recurrent HCC (12.4%). Twelve patients died as a result of HCC (13.5%). Among 89 HCCs, the incidences of a weak (+) and moderate (++) expression of MMP-9 in carcinoma cells were 30.3% (23/89) and 43.8% (39/89), respectively. Increased expression and intensity of MMP-9 were found to be inversely associated with poor tumor differentiation (P = 0.016, P = 0.009, respectively). A significant correlation between expression and intensity of MMP-9 and large vascular invasion (P = 0.01, and P = 0.03) was also observed. As far as prognosis is concerned, increased immunoreactivity and intensity of MMP-9 were found to exert an unfavorable impact on overall survival rates (P < 0.01, P = 0.01, respectively) and recurrences (P = 0.001, P = 0.02). Multivariate analyses revealed that MMP-9 staining percentage (P = 0.007) and portal vein invasion (P = 0.002) were independent predictors of survival, whereas the only independent predictor of recurrences was portal vein invasion (P = 0.007). In this study, our results indicate a positive association between MMP-9 expression and histopathologic parameters that indicate poor prognosis. We conclude that together, MMP-9 staining percentage and portal vein invasion in HCC may aid to predict poor outcome. Nevertheless MMP-9 staining percentage is expected to be a potential predictive marker on survival and needs to be studied more in detail. Liver Transpl 16:621-630, 2010. © 2010 AASLD.

SRL is a new and potent immunosuppressive agent that has been successfully introduced in organ transplantation. In contrast to other immunosuppressive agents, SRL has a potent antitumor activity both in vitro and in vivo. Herein, we report a child with Kaposi's sarcoma that was diagnosed 30 months after LDLT and treated successfully with only conversion to SRL monotherapy. KS regressed completely at the end of the first month and remained in remission during 28 months follow-up.

Intrahepatic cholangiocarcinoma is subdivided as mass-forming, periductal-infiltrating, and intraductal-growing types. Intraductal-growing type is an entity described in recent years as mucin-producing intrahepatic cholangiocarcinoma or intrahepatic (biliary) intraductal papillary mucinous neoplasia (b-IPMN). b-IPMN is classified as adenoma, borderline tumor, carcinoma in situ, and carcinoma, from benign to malignant. Using a different classification, b-IPMNs are subdivided into intestinal, pancreatobiliary, gastric, or oncocytic based on morphology of the cells forming the lesion and expression of MUC1, MUC2, and MUC5 gene proteins in the mucin family. The clinical and histopathological features of b-IPMN diagnosed in three cases are presented herein. Case 1 was classified as borderline. Case 2 was diagnosed as carcinoma in situ. Case 3 had large invasive areas, and was diagnosed as carcinoma. In all three cases, immunohistochemical investigation revealed MUC1 and MUC5AC to be positive, and MUC2 to be negative. We present herein three cases diagnosed with the clinical and pathological findings of a new entity in the literature, b-IPMN, and we discuss the macroscopic, histological, and immunohistochemical features.

Toxoplasmosis is a serious and potentially life-threatening disease in liver transplant recipients while they are immunosuppressed. We report the clinical and laboratory findings related to active toxoplasma infection associated with 40 immunosuppressed liver transplant procedures that took place over a 12-month period at a major transplant unit in Izmir, Turkey. Twenty-seven (67.5%) of the 40 transplant recipients were found to be seropositive for toxoplasma infection and therefore at risk of reactivated infection. From the serological status of the donors, which was ascertained in 38 of 40 cases, we identified 3 (7.9%) of 38 transplants to be from a seropositive donor to a seronegative recipient. In 10 (26.3%) of 38 transplants, both the donor and recipient were seronegative, and this excluded toxoplasma as a risk. A comparison of real-time polymerase chain reaction (PCR) and nested PCR was undertaken in combination with a range of serological assays (the Sabin-Feldman dye test, enzyme immunoassay immunoglobulin M, and immunosorbent agglutination assay immunoglobulin M). Ethylene diamine tetraacetic acid blood samples from 3 of the 30 recipients at risk from toxoplasma were found positive by PCR, but only 1 of these was found positive in both assays. Among the 3 PCR-positive patients, immunoglobulin M and immunoglobulin G antibody levels increased in only 1 patient. Correlations between symptoms, laboratory findings, and clinical management (use of anti-toxoplasma therapy) are presented. Our findings suggest that toxoplasma presents a significant risk to our liver transplant population and that PCR is a helpful addition in identifying active infections and hence in informing clinical management decisions.

The molecular basis underlying the clinical response to acute liver stress remains to be clarified. Postreperfusion syndrome (PRS) occurring after the meeting of grafted liver with the recipient blood is characterized by hemodynamic instability that develops immediately after reperfusion of an orthotopic liver transplantation (OLT). Cytokines have a role during PRS. The aim of this study was to evaluate the role of some cytokine gene polymorphisms on PRS in patients. Materials and Methods Forty-six patients who underwent OLT were divided into two groups: with versus without PRS. Cytokine genotyping using patient blood was determined by the PCR-SSP method. Results Liver transplant patients as a whole are usually characterized as low producers of tumor necrosis factor (TNF)-α and interleukin (IL)-10, high producers of transforming growth factor (TGF)-β1 and IL-6 and intermediate producers of interferon (IFN)-γ. However no significant relationship was shown between the development of PRS and cytokine gene polymorphisms of TNF-α (−308 G/A), TGF-β1 (C/T codon 10, C/G codon 25), IL-10 (−1082 G/A, −819 T/C, −592 A/C), IL-6 (−174 G/C), or IFN-γ (+874 A/T). Conclusion It seemed that our limited data did not substantiate a role of certain cytokine gene polymorphisms on PRS occurence during OLT. A larger study population may be required to examine this relationship.

Hepatitis B virus (HBV) and hepatocellular carcinoma (HCC) recurrences affect both patient and graft survivals post-orthotopic liver transplantation (OLT) in HBV patients with HCC. We analyzed the relationship between HBV and HCC recurrence in a large cohort of HBV-OLT patients with versus without HCC.Two hundred eighty-seven HBV patients with OLT (72 also with HCC) were included in the study. Mean follow-up in the post-OLT period was 31.7 +/- 24.7 (range, 3-119) months.Post-OLT HBV recurrence observed in 10.1% of patients was more prevalent among the HCC group; 23.6% versus 5.5% in patients with and without HCC, respectively. The mean interval for the development of HBV recurrence was 39.5 +/- 28.5 (range, 2-99) months. Among 72 HCC patients, 8 patients (11.1%) had recurrent HCC, and 7 of them also had HBV recurrence. The mean interval for the development of HCC recurrence was 11.2 +/- 7.85 (range, 2-23) months after OLT. OLT patients with HCC with tumors exceeding the Milan criteria had worse 1-, 3-, and 5-year survival rates than patients with HCC meeting the Milan criteria. HBV and HCC recurrence-free survivals were significantly lower in patients with HCC and HBV recurrence, respectively. In the 7 patients with both HCC and HBV recurrence, mean HBV recurrence time was 9.42 +/- 6.75 months and mean HCC recurrence time was 9.57 +/- 6.75 months. There was a strong correlation between HBV and HCC recurrence times. Cox proportional hazards regression analysis showed that only HCC recurrence was a significant independent predictor of HBV recurrence (P.001; hazard ratio [HR] = 26.94; 95% confidence interval [CI] = 10.81-67.11). On the other hand, HBV recurrence (P = .013; HR = 5.80; 95% CI = 1.45-23.17) and nodule count (P = .014; HR = 13.08; 95% CI = 1.70-100.83) were significant predictors of HCC recurrence.HBV and HCC recurrences demonstrate a close relationship in patients with OLT.

Objectives: The hepatopulmonary syndrome (HPS) is characterized as a triad: liver disease, intrapulmonary vascular dilatatiton, and arterial hypoxemia. The aim of this study is to analyze outcome of children with HPS in liver transplant era. Methods: Between September 1996 and November 2006, 172 cirrhotic patients (median age 5 years; range 0.2–22 years, M/F; 97/75) were followed at Ege University Pediatric Gastroenterology, Hepatology and Nutrition Unit. All patients were evaluated by chest radiography, arterial blood gas analysis, and alveolar-arterial oxygen tension difference, contrast echocardiography (CEE) after and before the liver transplantation. Results: HPS was diagnosed in 33 patients (19%) by CEE. None of them had pulmonary hypertension. HPS was not found related to etiology of the liver disease. Portal hypertension was found related to the development of HPS (75.7% in patients with HPS and 54.6% in others, p = 0.02). 17 of 33 patients with HPS underwent liver transplantation. Preoperative and postoperative period of these patients was uneventful. Patients were extubated in the operating room except for two. Median follow up of transplanted children was 1.9 year (range; 0.75–10 years). Arterial blood gas analysis and CEE positivity regressed in all of them by postoperative 6th month. Conclusions: HPS is a serious and important complication of cirrhotic children that leads to tissue hypoxia and central cyanosis. HPS seems reversible after liver transplantation in all patients.

Background: Treatment of post-transplantation recurrence of hepatitis B virus (HBV) infection despite prophylaxis with hepatitis B immunoglobulin (HBIG) and lamivudine combination therapy is not easy. Because HBV reinfection has a severe course and could result in graft failure in liver transplant recipients, prompt medication is essential. Herein is reported the authors’ experience with adefovir dipivoxil (AD) therapy in 11 liver transplant recipients who had HBV reinfection despite the administration of lamivudine and HBIG. Method: Two-hundred and nine patients underwent liver transplantation (100 deceased donor liver transplantations [DDLT], 109 living donor liver transplantation [LDLT]) due to chronic hepatitis B infection between April 1997 and May 2005 in Ege University Medical School, Liver Transplantation Unit. Patients had prophylaxis with lamivudine and low-dose HBIG combination after liver transplantation. Treatment of recurrence consisted of AD 10 mg once a day and lamivudine 300 mg/daily and HBIG was discontinued in those patients. Results: In total there were 11 HBV recurrences: five occurred in DDLT recipients and six in LDLT recipients, at a median follow up of 18 months (range, 6–48 months). In one of 11 patients, pretransplant HBV-DNA and HBeAg were positive. Three patients had a severe course and one patient had fibrosing cholestatic hepatitis. After AD treatment, HBV-DNA level decreased in all patients and became negative in seven patients. Two patients died due to hepatocellular carcinoma recurrence after 12 and 14 months of follow up. Serum creatinine level increased mildly in one patient and no other side-effect was observed, and all patients continued therapy. Conclusion: Adefovir dipivoxil is a safe, effective treatment option for post-transplant HBV recurrence even among patients with fibrosing cholestatic hepatitis caused by lamivudine-resistant HBV.