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Background: Our goal is to evaluate postoperative outcomes of continuous versus interrupted suturing techniques in ventricular septal defect (VSD) closure surgery., Methods: The study included 286 patients with isolated VSD who underwent VSD closure surgery between June 2010 and April 2017. VSD closure was performed by using the interrupted suturing technique in group 1 (n = 74, 25.9%) and the continuous suturing technique in group 2 (n = 212, 74.1%). The groups were compared in terms of mortality and rates of clinical morbidities such as infection and complete atrioventricular (AV) block., Results: Early mortality occurred in 3 cases in group 1 (4.0%) and 5 cases in group 2 (2.3%). There was no late mortality in either group. One patient from both groups required extracorporeal membrane oxygenation (ECMO) at postoperative 48 hours. Five patients in group 1 (6.8%) and 11 patients in group 2 (5.2%) developed complete AV block postoperatively and received permanent pacemaker implants., Conclusion: Complication rates were similar between the patient groups operated on by using continuous and interrupted suturing techniques in our study, suggesting that neither technique is superior for VSD closure surgery.

Introduction: Various surgical procedures for minimally invasive cardiac surgery have been described in recent decades as alternatives to median sternotomy. Cardiopulmonary bypass via femoral arterial and venous cannulation is the foundation of these procedures. In this study, we evaluated the mid-term outcomes of femoral cannulation performed with U-suture technique in patients undergoing robotic heart surgery., Methods: A total of 216 patients underwent robotic-assisted cardiac surgery between January 2013 and April 2017. Cardiopulmonary bypass was performed via femoral artery, jugular, and femoral vein cannulation, and a Chitwood clamp was used for aortic occlusion. A total of 192 patients attended the outpatient follow-up, and femoral arterial and venous flow pattern was examined using Doppler ultrasound (DUS) in 145 patients., Results: Hospital mortality occured in 4 of the 216 (1.85%) cases, but there was no late mortality in this patient group. Postoperatively, seroma (n=9, 4.69%) and cannulation site infection (n=3, 1.56%) were managed with outpatient treatment. DUS in 145 patients revealed triphasic flow pattern in the common femoral arteries in all patients except for 2 (1.38%). These patients were determined to have asymptomatic arterial stenosis. Chronic recanalized thrombus in the common femoral vein was also detected in 2 (1.38%) patients., Conclusion: Femoral artery cannulation with the U-suture technique can be successfully performed in robotic-assisted cardiac surgery, with good mid-term results.

The objective is to demonstrate safety and early clinical results of surgical transapical closure of paravalvular leaks (PVLs) following mitral valve replacement in significant regurgitation. Between March 2014 and February 2015, 12 patients (mean age 52.1 ± 6.0 years, 66.6% male) with severe symptomatic mitral PVLs (n = 13) underwent surgical transapical closure procedure through left mini-thoracotomy. All patients were in NYHA functional class III-IV and median logistic EuroSCORE was 24.2 ± 6.4% (range, 13.5-34.6%). Indications were heart failure (n = 10) and symptomatic hemolysis (n = 2) due to severe mitral regurgitation (MR). Amplatzer Vascular Plug-III devices (n = 9) were used for smaller and regular defects; whereas Atrial Septal Defect closure devices (n = 4) were used for larger defects. Technical success was achieved in 10 (83.3%) patients. One (8.5%) patient with 2 + MR was treated medically. A patient with residual 4 + MR underwent re-operation. There was no procedure-related complication including mortality, device migration, embolization, or cardiac laceration. Mean procedure and fluoroscopy times were 166.4 ± 39.5 (range, 90-210) and 25.7 ± 17.3 (range, 16-64) minutes, respectively. The mean intensive care and hospital stays were 2.1 ± 1.3 and 10.3 ± 6.5 days, respectively. Clinical efficacy was achieved in 9 (75%) of 12 patients at early follow-up of 8.5 ± 2.1 months. NYHA status was class II in two patients, and no hemolytic anemia was diagnosed. Echocardiographic studies revealed a significant reduction of preoperative MR (3-4+) to less than 1+ MR after operations (P < 0.05). Surgical transapical approach to PVL closure is a safe and effective procedure following mitral valve replacement. Early results show that this procedure can be an alternative to re-operation for high-risk patients. Further studies are needed to prove its effectiveness in the long term., (© 2016 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

Situs inversus totalis (SIT) with dextrocardia is an uncommon congenital positional anomaly, which is characterized by a symmetrical 'mirror-image' orientation of all organs in relation to the midline. Although sternotomy and thoracotomy is traditionally used in patients with SIT with dextrocardia, a totally endoscopic robotic surgery is an alternative surgical approach to intracardiac anomalies. Placement of robotic ports, transthoracic aortic clamp, cardioplegia delivery, and peripheral vascular cannulation is made from the left side of the chest, as a mirror orientation of the right-sided robotic cardiac procedures. Here, we present a patient who underwent concomitant robotic atrial septal defect closure and tricuspid annuloplasty with posterior plication using the da Vinci surgical system.

Mitral valve repair has been one of the widely used applications of robotic surgery. Patients with rheumatic mitral disease usually present at an early age with thickening, retraction, or fusion of the leaflets and subvalvular apparatus. Robotic mitral repair can be feasible among this group of patients, rather than replacement. Herein, we describe a young woman who presented with rheumatic mitral valve insufficiency. A complex mitral repair with posterior leaflet extension with an autologous pericardial patch was successfully conducted using robot assistance.

Partial anomalous venous return from the right lung to the right atrium is a rare congenital heart anomaly in adults. We report a 20-year-old female, who presented with right partial anomalous pulmonary venous return and an associated inferior atrial septal defect. A complex repair was successfully done through a right atriotomy approach using a robotic surgical system. doi: 10.1111/jocs.12753 (J Card Surg 2016;31:394-397)., (© 2016 Wiley Periodicals, Inc.)

Aim: To investigate the efficacy of a novel intraoperative diagnostic technique for patients with preliminary diagnosis of autoimmune pancreatitis (AIP)., Methods: Patients with pancreatic surgery were reviewed to identify those who received a preliminary diagnosis of AIP between January 2010 and January 2014. The following data were collected prospectively for patients with a pathological diagnosis of AIP: clinical and demographic features, radiological and operative findings, treatment procedure, and intraoperative capillary refill time (CRT) in the pancreatic bed., Results: Eight patients (six males, two females; mean age: 51.4 years) met the eligibility criteria of pathologically confirmed diagnosis. The most frequent presenting symptoms were epigastric pain and weight loss. The most commonly conducted preoperative imaging studies were computed tomography and endoscopic retrograde pancreaticodoudenography. The most common intraoperative macroscopic observations were mass formation in the pancreatic head and diffuse hypervascularization in the pancreatic bed. All patients showed decreased CRT (median value: 0.76 s, range: 0.58-1.35). One-half of the patients underwent surgical resection and the other half received medical treatment without any further surgical intervention., Conclusion: This preliminary study demonstrates a novel experience with measurement of CRT in the pancreatic bed during the intraoperative evaluation of patients with AIP.

Objective: To investigate effect of body mass index (BMI) on survival and technique failure in patients undergoing peritoneal dialysis (PD)., Methods: In this retrospective study three hundred ninety-two consecutive patients undergoing peritoneal dialysis from September 1995 to January 2013 were included. Median PD duration was 53 (range: 4-189) months. Clinical outcomes were mortality and technique failure. Technique failure was defined as transfer to hemodialysis (HD) due to peritonitis, ultrafiltration failure, inadequate dialysis, exit-site and/or tunnel infection, and mechanical problems. Deaths within 3 months after transferring to HD were accepted as PD-related mortalities. The patient and technique survival rates were estimated using the Kaplan-Meier method. Mortality risks were analyzed using the multivariate Cox regression model in which we included (in a backward-wald manner) all the significant variables from the univariate analysis., Results: There were 164 (41.8%) deaths. Forty-six (11.7%) patients underwent renal transplantation whereas 132 (33.7%) patients were transferred to HD. The multivariate Cox regression analysis found that the patient survival rates were significantly associated with age, BMI, baseline serum creatinine and albumin levels, and total Kt/Vurea. All variables as potential risk factors for the patient survival were also assessed for technique survival in univariate analysis and technique survival rates were significantly associated only with BMI (p: 0.015)., Conclusion: BMI was associated with unfavorable patient survival in PD patients.

Background: Elective surgery for liver hemangioma is controversial. We reviewed long-term outcomes following elective hepatectomy or observation only for symptomatic and asymptomatic liver hemangioma., Methods: All patients (n = 307) with liver hemangioma referred to our hospital for surgical evaluation from January 1988 to December 2009 were identified, and imaging results, tumor characteristics, surgical indication, surgical mode, outcome of observation, clinical and/or postoperative outcome, and adverse events were retrospectively evaluated., Results: Complete median follow-up for 246 patients was 124 months. Elective surgery was performed in 103 patients (symptomatic [n = 62] and asymptomatic [n = 41]). Postoperative morbidity occurred in 17 % of the patients and was significantly lower in asymptomatic patients (p = 0.002). No perioperative mortality was registered. Surgery relieved complaints in most (88 %) patients. In the observation group (n = 143), 56 % of patients had persistent or new onset of hemangioma-associated symptoms. Major hemangioma-related complications occurred in 12 patients (9 %) during the follow-up period, and 2 patients died after traumatic hemangioma rupture. Overall the rate of adverse events was by trend lower in the surgical group than in the observation group (35 versus 57 %; p = 0.08)., Conclusions: The majority of patients with liver hemangioma can be safely managed by clinical observation. In a subset of patients, especially those with giant hemangioma and/or occurrence of symptoms, surgical treatment could be considered and is justified in high-volume centers.

Objective: To determine the risk factors for the development of gastrointestinal complications (GICs) after coronary artery bypass graft (CABG) surgery., Design: A single-center, retrospective study., Setting: A tertiary care hospital., Participants: Six thousand seven hundred ninety-four patients undergoing isolated CABG surgery between 2002 and 2006., Interventions: Clinical characteristics of the patients with GICs and control group patients were analyzed by stepwise logistic regression analysis. The control group consisted of a total of 95 patients randomly selected among the ones who had no gastrointestinal finding or symptoms (cohort: control, 1:5 ratio)., Measurements and Main Results: Nineteen patients (0.3%) developed major surgical GICs after CABG surgery. Overall, the 30-day mortality was 42.1% among patients with GICs and 2.6% without GICs. Multivariate analysis identified 4 independent predictors for GICs: age greater than 70 years (p = 0.001; odds ratio [OR] = 5.6; 95% confidence interval [CI], 2.1-25.9), reoperation for bleeding (p = 0.005; OR = 7.7; 95% CI, 2.8-56.2), a prolonged cardiopulmonary bypass time (p = 0.007; OR = 3.7; 95% CI, 1.3-15.6), and an increased postoperative creatinine level (p = 0.036; OR = 2.3; 95% CI, 1.1-13.4)., Conclusion: A delayed diagnosis of complications is an important problem in the management of major surgical GICs. The present results suggest that surgeons and intensivists must be alert to patients older than 70 years, a cardiopulmonary bypass time longer than 60 minutes, reoperation for bleeding after CABG surgery, and postoperative creatinine level higher than 1.7 mg/dL., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Pancreatic lipomatosis is characterized as massive lipid infiltration of the pancreatic tissue. Although its etiology is ill defined; obesity, diabetes mellitus, chronic pancreatitis, hereditary pancreatitis, and conditions that cause pancreatic ductal obstruction, for example tumors and stones, are related to its pathogenesis. Recently, with the increased use of computerized tomography and magnetic resonance imaging, it has become possible to observe the fat replacement of the pancreas. Herein, we report a 60-year-old man complaining of abdominal pain and weight loss. Preoperative work-up revealed a locally advanced (Stage III) pancreatic adenocarcinoma. Multimodal treatment was carried out and a 100% complete response was detected after neoadjuvant therapy. The patient underwent a standard pancreaticoduodenectomy, without complications. The tissue pathology revealed lipomatosis of the pancreas. He was disease-free and symptom-free at 1 year follow-up. To our knowledge, this is the first report in the literature of pancreatic head carcinoma with total fat replacement of the pancreas after neoadjuvant chemoradiotherapy.

Background: The ideal technique for abdominal closure of a Mercedes-type incision, which is still a serious issue among surgeons, has yet to be demonstrated clearly. The purpose of this study was to explain our novel technique for abdominal fascial closure in liver transplant patients., Methods: We analyzed retrospectively 180 consecutive adult-to-adult right lobe living donor liver transplants. The patients were divided into two groups based on two abdominal closure types used. Group A consisted of 78 patients who were submitted to abdominal closure with our new technique using three synthetic absorbable loop suture materials, and group B consisted of 102 patients whose abdominal closure was performed with another type of closure technique., Results: There were no significant differences between the demographic characteristics of the two groups. The mean closure time was significantly lower in group A than in group B (p <0.05). The incidence rates of ascites leakage and hernias were also significantly lower in group A (p <0.05)., Conclusion: Our results indicate that the novel technique used in this study contributed to overcoming early and late postoperative complications associated with closure of the abdominal fascia in liver transplant patients. In addition, this new technique has proven to be easily applicable, faster, safer and efficient in these patients; it is also potentially useful for conventional surgery., (Copyright (c) 2010 Asian Surgical Association. Published by Elsevier B.V. All rights reserved.)

Background and Aim: Hepatic alveolar echinococcosis (HAE) involves both the vascular and biliary structures of the liver. Endoscopic retrograde cholangiopancreatography (ERCP) is said to be an alternative for the diagnosis and treatment of biliary complications of HAE. We present here our experience with ERCP in HAE., Methods: We followed 13 patients who underwent ERCP for the treatment of biliary complications of HAE in the endoscopy unit of our clinic at Ataturk University School of Medicine, Erzurum between January 2002 and June 2008., Results: Eight men and five women were followed up. Mean age was 43.2 (24-64 years). All patients had non-resectable HAE. Indications for ERCP were biliary fistula in seven patients, obstructive jaundice in five patients and cholangitis in one patient. Endoscopic sphincterotomy (ES) was carried out in 12 patients, and in one patient with biliary leakage, a stent was inserted into the right hepatic branch. ERCP findings were dilated common bile duct, irregular narrowing and distortion of the common bile duct and common hepatic duct, communication with the cystic cavity or biliocutaneous fistula and complete disappearance of the biliary tree above the level of the common hepatic duct or hepatic bifurcation. In patients with biliary leakage, biliary drainage decreased only in two patients after ERCP and in patients with obstructive jaundice, the high bilirubin levels decreased in only one patient., Conclusion: ERCP showed structural changes of the external biliary tract and ES has a limited effect on these changes and stents can be used in selected cases.

Introduction: Vascular intimal hyperplasia is associated with increased mortality and morbidity. The authors investigated the effects of atorvastatin on vascular intimal hyperplasia., Materials and Methods: Rats were divided into 4 groups. Groups 1, 2, and 3 had experimental aortic injury and received intraperitoneal injection of atorvastatin, solvent, or 0.9% NaCl, respectively. Group 4 was a nonintervention (laparotomy only) control group. Animals were sacrificed after 3 weeks. Blood samples and injured aortic segment were analyzed., Results: Atorvastatin administration significantly lowered total and low-density lipoprotein cholesterol levels (P = .012 and P = .001, respectively), intima-media ratio (P = .002), and intimal smooth muscle cell accumulation (P < .05) in group 1. Luminal narrowing in animals in group 1 was significantly lower than that in animals in groups 2 and 3, but was higher than in animals in group 4 (P = .009)., Conclusions: Atorvastatin suppresses intimal hyerplasia and aids in intimal regeneration by lowering blood lipids and intimal smooth muscle cell accumulation.

Objective: The aim of this study was to evaluate the negative effects of the Pringle maneuver on pancreatic tissue with respect to the time of performing the maneuver. Moreover, the efficacy of octreotide therapy on pancreatic changes at the time of the Pringle maneuver was assessed., Animals: Fifty male Wistar Albino rats were randomized into 5 groups., Design: The groups were formed as follows: Group A: sham operation, Group B: Pringle maneuver for 30 min plus octreotide (PM30-OCT), Group C: Pringle maneuver for 60 min plus octreotide (PM60-OCT) and Group D: Pringle maneuver for 30 min plus 0.9 % saline solution (PM30-SS), Pringle maneuver for 60 min plus 0.9 % saline solution (PM60-SS, Group E)., Main Outcome Measures: Blood samples for the evaluation of both amylase and lipase levels were taken via the portal vein. Levels of glutathione, glutathione reductase, catalase, myeloperoxidase, nitric oxide, xanthine oxidase, malondialdehyde, tumour necrosis factor alpha (TNF-alpha), and interleukin-1 beta (IL-1 beta) were assessed in the excised pancreatic tissue., Results: In the octreotide-treated groups, the catalase level was significantly higher in Group B (PM30-OCT) as compared to Group C (PM60-OCT). Amylase, lipase, NO and IL-1 beta levels were higher in Group C (PM60-OCT). In the saline solution-treated groups, the catalase level was significantly higher in Group E (PM60-SS) than in Group D (PM30-SS) while nitric oxide and glutathione levels were found to be significantly lower in Group E (PM60-SS) than in Group D (PM30-SS). Comparison of those groups using the Pringle maneuver for 30 minutes, the octreotide-treated group (Group B, PM30-OCT) was found to have a higher degree of edematous change than the saline-treated group (Group D, PM30-SS). Among the treatment groups, TNF-alpha expression decreased with increasing occlusion time., Conclusion: In this study, pancreatic damage and the duration of the Pringle maneuver are directly proportional to each other. Moreover, the administration of octreotide prior to the Pringle maneuver contributed to the pancreatic damage.

Introduction: Bronchobiliary fistula is an uncommon complication secondary to hepatobiliary surgery. Bilioptysis is a pathognomic finding for bronchobiliary fistulas. Diagnosis may be easily established in the light of clinical history, which can be aided by imaging studies to pinpoint the exact location. Some diagnostic procedures such as endoscopic retrograde cholangiopancreatectomy are also useful for treatment., Case Presentation: We present three Turkish patients with bronchobiliary fistula secondary to previous hepatic surgery due to hydatid cyst in two, a 19-year-old and a 47-year-old man, and iatrogenic trauma of the common bile duct by endoscopy in a 35-year-old man. All of the patients were successfully treated by minimally invasive methods including percutaneous drainage and endoscopic retrograde cholangiopancreatography., Conclusion: We suggest that bronchobiliary fistula could be managed through conservative treatment methods which do not require in-hospital follow-up, particularly in uncomplicated cases. Otherwise, surgical management can be unavoidable.

Background/aims: Mirizzi syndrome is an unusual presentation of prolonged cholelithiasis. This study aimed to analyze the diagnostic methods, operative strategies, and outcome of the surgical treatment of patients with Mirizzi syndrome., Methods: We retrospectively evaluated the patients with Mirizzi syndrome treated in our General Surgery Clinic. The data collected included demographic variables, clinical presentation, diagnostic methods, surgical procedures, and postoperative complications., Results: The study included 13 male and 21 female patients, with a mean age of 67.2 years. The incidence of Mirizzi syndrome was determined as 0.6% (34/5632), and type II was more frequently observed (52.9%); no patient was determined as type IV. The incidences of types I and III were 35.2% and 11.7%, respectively. Among the preoperative diagnostic evaluations, ultrasonography was the initial imaging study that was performed in all patients. Computerized tomography, magnetic resonance cholangiopancreatography, and endoscopic retrograde cholangiopancreatography were the other radiological studies. Surgical procedures included cholecystectomy for 83% of the patients with type I. The remaining cases and 14 of the type II patients (77.7%) underwent choledochotomy and T-tube insertion following cholecystectomy. Four of the patients with type II variety and all of the type III patients underwent cholecystectomy and roux-en-Y hepaticojejunostomy. All of the patients had complete recovery, with a morbidity rate of 5.8%, and there was no hospital mortality., Conclusions: The essential part of the management of patients with Mirizzi syndrome is to determine the best surgical procedure in the preoperative period. In type I patients, simple cholecystectomy is generally enough, but sometimes T-tube insertion may be required, while the cases with types II-IV require more complex surgical approach, such as cholecystectomy and bilioenteric anastomosis. Roux-en-Y hepaticojejunostomy is an appropriate procedure with good outcome.

Background/aims: Gastrocolic fistula has been associated with a variety of diseases. Causative factors are most commonly gastric/colonic cancers and benign gastric ulcers. Treatment modalities may change according to etiology., Methods: In this study, we present our cases with gastrocolic fistula and the treatment modalities utilized for this uncommon complication. The records of the patients with gastrocolic fistula between November 1996 and June 2006 were retrospectively analyzed., Results: Six patients with a mean age of 57.5 were determined. Of these, four had malignancy and two had gastric ulcer. The predominant symptoms were diarrhea and vomiting, weight loss, and abdominal pain. Diagnostic studies included barium enema, endoscopy, barium meal, colonoscopy, and computed tomography. After preoperative nutritional support, en-bloc resection of the involved gastrocolic region (4), simple excision (1), and wedge resection of the gastric part and closure of the colonic wall (1) were performed. One patient died of respiratory disorders and there was only one recurrence. In our series, therapeutic management for this unusual disorder included various resection procedures such as simple excision, which may result in recurrence, and wedge resection or en-bloc resection for benign cases, whereas en-bloc resection and reconstruction procedures remained the most applied management for malignant cases. En-bloc resection followed by combination of adjuvant chemotherapy results in long disease-free survival., Conclusion: Gastrocolic fistula should be suspected in patients with chronic diarrhea and vomiting of unknown cause with a high suspicion of gastrointestinal malignancy.

The hepatic venous reconstruction is one of the corner stones of pediatric LDLT. However, problems associated with hepatic venous outflow still remain to be an issue. In this study, we aimed at comparing two methods used in hepatic venous reconstruction. Between November 1999 and December 2006, 61 consecutive left lateral segment pediatric LDLT were performed at Ege University Organ Transplant Center, and two methods were used for hepatic venous reconstruction. In the former group (group 1: 32 patients) continuous anastomosis was performed between the donor LHV and common orifice of the recipient HV. In the later group (group 2: 29 patients), the posterior wall of the anastomosis was sutured continuously while the anterior wall was sutured with interrupted sutures. HV thrombosis was detected in one patient and stenosis was detected in four patients in group 1. No hepatic venous outflow obstruction was detected in group 2 (p < 0.05). In both groups, mortality was not associated with hepatic venous outflow obstruction. As our results indicate, the novel technique used in this study is a simple and safe anastomosis procedure that has contributed into overcoming hepatic venous outflow problems in pediatric LDLT.

Objective: Spontaneous dissection of the abdominal aorta should be considered as a vascular surgical emergency. We report here our experience with this rare pathology., Methods: At our hospital, we operated on 200 patients for abdominal aortic aneurysm over a 4-year period, and aortic dissection was the underlying pathology in eight of them. Diagnosis was based on history, imaging study findings and visualization at surgery., Results: The mean size of the aorta at the time of diagnosis was 5.5 +/- 0.4 cm. Aortic dissection was complicated by acute ischemia of lower limb and paraplegia in 1 patient and four patients were admitted to hospital with severe abdominal and back pain. Two patients with contained rupture were admitted with hemodynamic collapse and shock. One of the patients who presented with abdominal pain experienced also sudden onset paraplegia. The diagnosis of dissecting abdominal aortic aneurysm was established incidentally in the remaining 2 patients. All patients were treated using open techniques with paramedian transperitoneal incision. We performed aorto-bifemoral bypass operation procedure in all patients; there was no post-operative mortality in our series. One patient had to be reoperated because of bleeding during early postoperative period. One patient required transient dialysis at early postoperative period because of transient rise of serum creatinine level., Conclusion: The surgical treatment of spontaneous abdominal aortic dissection is usually associated with low morbidity and mortality rates. However, the clinical form of presentation of acute abdominal aortic dissection is usually nonspecific, and diagnosis requires a high index of suspicion.

Background: Radical operation for hilar cholangiocellular carcinoma, including extended hepatic resection, seems to improve prognosis by increasing the surgical curability rate. Nevertheless, high postoperative morbidity and mortality have been reported in patients with obstructive jaundice. We describe the technique of "high hilar resection" and a modification of bilioenteric anastomosis for drainage of the multiple secondary or tertiary biliary radicals., Methods: Ten patients with advanced hilar cholangiocellular carcinoma underwent a high hilar resection with complete parenchymal preservation, and the biliary drainage was reconstructed by a sheath-to-enteric hepaticojejunostomy. Because of the technical difficulty caused by anastomosis line in the range of the biliary sheath, a modification was performed by dividing the biliary apertures of segments 5 and 4b., Results: A high hilar resection was successfully performed, and all patients were discharged from the hospital in good condition. No patient died postoperatively. The proximal resection margin was tumor-free in all patients. One patient died after 29 months of peritoneal carcinomatosis. None of the patients developed local recurrence around the hepaticojejunostomy. The remaining nine patients are alive after a mean follow-up of 28.8 months after surgery without any signs of recurrence., Conclusion: In highly selected patients with advanced hilar cholangiocellular carcinoma, a high hilar resection is technically safe and oncologically justifiable. In combination with our new technique of sheath-to-enteric anastomosis, the patients considerably benefit from the preservation of liver parenchyma with low postoperative morbidity and very short in-hospital stay.

Background/aims: The management of hydatid cyst of the liver, which is still endemic in Turkey, varies from medical treatment or percutaneous drainage to different surgical procedures. In this study, we aimed to compare the efficacy of radical surgical procedures and conservative interventions with respect to recurrence rates., Methods: Patients who underwent any type of surgical treatment between March 1994 and March 2007 due to liver cyst hydatid were retrospectively evaluated. Data collection included demographic variables, diagnostic methods, surgical procedures, and morbidity and mortality rates., Results: 242/258 (93.8%) patients with liver hydatid cyst underwent surgery, and the characteristics of 221 (91.3%) (123 female, 98 male) of these patients matched the criteria of the study. The mean age of the patients was 51 years (18-82 years). The diagnostic methods primarily included abdominal ultrasonography and computed tomography with a rate of 61.8% and magnetic resonance imaging in 12% of the patients. The patients were divided into two groups with respect to the treatment modality: Group A (n=92) - radical surgical treatment and Group B (n=129) - conservative surgery. The overall rate of recurrence was 15.3%. In Group B, this rate was 24% (n=31), whereas only 3.2% of the patients (n=3) in Group A had recurrence in the follow-up (p<0.05). The morbidity rate of the patients who underwent radical surgical modalities was also significantly lower., Conclusions: Although conservative surgical procedures are considered simpler and safer to perform, the rate of postoperative complications such as biliary fistula, residual cavity and recurrence, and cavity suppuration has been reported to be about 35%. On the other hand, radical surgery can be performed with low risk of recurrence (3.2%). We believe radical surgical procedures present a lower rate of recurrence and less morbidity, and thus should be the surgical treatment of choice for hepatic hydatid disease.

Visceral leishmaniasis (VL) is one of the parasitic infections causing different pathogeneses of various systems including intraabdominal solid organs. L. donovani and L.infantum, particularly in Turkey, have been diagnosed in systemic infections. In the present case study, a 43-year-old woman with left upper abdominal pain, persistent fever and splenic pathology according to the radiological findings was investigated. Laboratory findings showed elevated liver function tests and anemia while radiological studies revealed splenomegaly, and nodular infiltration and laceration of the spleen. Because of enlarged intraabdominal lymph nodes observed during surgery, a lymph node biopsy and a liver biopsy were also performed along with the splenectomy. Results from the pathological examination of the spleen were nonspecific and the liver biopsy confirmed a diagnosis of granulomatosis hepatitis. Further examination of the hepatic granulomatosis including parasitic evaluation and serological evaluation with the rK39 dipstick test revealed VL. In conclusion, in cases of visceral organ pathology accompanied by persistent fever, and hematological disorders, parasitic infections, particularly VL, should be considered in the differential diagnosis.

Alveolar echinococcosis (AE) is a chronic and serious, even lethal, parasitic infection caused by the helminth Echinococcus multilocularis (EM). AE is an endemic disease in Turkey and it is particularly common in people living in the eastern Anatolia Region. In addition to various clinical presentations, symptoms which lead to diagnosis, however, are usually associated with the metastatic lesions. We herein reported a 62-year-old man who had liver alveolar hydatid disease with simultaneous lung and brain metastasis. We think there was only one therapeutic option, namely medical treatment with albendazol, which is the usual treatment for patients living in eastern Anatolia and who are admitted late resulting in a subsequent inoperable situation. Thus, radiological screening studies for the public in this region may increase the possibility of surgical treatment for alveolar hydatid disease.

Background and Aim: Living donor liver transplantation (LDLT) has particular advantages for Turkey where hepatitis B virus (HBV) infection is the most common cause of cirrhosis, both because LDLT circumvents the difficulties encountered in the emerging world in providing deceased donor organs, and because it allows preemptive antiviral therapy. The aim of this study was to review one institution's experience with LDLT in patients with chronic HBV infection., Methods: A total of 109 patients with chronic HBV infection underwent LDLT between September 1999 and June 2005, of whom 40 were coinfected with hepatitis D virus and 23 had hepatocellular carcinoma. Antiviral prophylaxis was attempted in all, beginning prior to transplantation with lamivudine or adefovir, and continuing after transplantation with low dose intramuscular hyperimmune B immunoglobulin (HBIg) plus lamivudine or adefovir., Results: In a median follow up of 20 months (range 1-66 months), there was no donor mortality. One-year recipient survival was 90%, and in total 16 recipients died. None of the deaths was related to HBV. Recurrence of HBV infection was detected by reappearance of serum hepatitis B surface antigen in six patients (5.5%) at 5, 8, 12, 17, 34 and 46 months after transplantation, respectively. There was no influence of donor hepatitis B core antibody status on the likelihood of recurrence of HBV in the allograft., Conclusion: The results indicate that LDLT with antiviral treatment and low dose HBIg provides excellent results for donors and recipients.

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.

There are several surgical complications which can occur following simultaneous pancreas-kidney transplantation (SPKT). Although intestinal obstruction is known to be a common complication after any type of abdominal surgery, the occurrence of small bowel volvulus, which is one of the rare causes of intestinal obstruction, following SPKT has not been published before. A 24-year-old woman suffering from type I diabetes mellitus with complications of nephropathy resulting in end stage renal disease (ESRD), neuropathy and retinopathy underwent SPKT. On the postoperative month 5, she was brought to the emergency service due to abdominal distention with mild abdominal pain. After laboratory research and diagnostic radiological tests had been carried out, she underwent exploratory laparotomy to determine the pathology for acute abdominal symptoms. Intra-operative observation revealed the presence of an almost totally ischemic small bowel which had occurred due to clockwise rotation of the mesentery. Initially, simple derotation was performed to avoid intestinal resection because of her risky condition, particularly for short bowel syndrome, and subsequent intestinal response was favorable. Thus, surgical treatment was successfully employed to solve the problem without any resection procedure. The patient's postoperative follow-up was uneventful and she was discharged from hospital on postoperative day 7. According to our clinical viewpoint, this study emphasizes that if there is even just a suspicion of acute abdominal problem in a patient with SPKT, surgical intervention should be promptly performed to avoid any irreversible result and to achieve a positive outcome.

Congestion of the anterior sector may lead to graft failure in right lobe grafts. Selective drainage of the prominent segment 5 and/or 8 veins is proposed to overcome this problem. Different vascular conduits may be used during drainage of the anterior sector. In this study, we evaluated the efficiency of the vascular conduits. Between June 1999 and December 2005, 190 patients underwent living donor right lobe liver transplantation and reconstruction of segment 5 and/or 8 veins was performed in 48 patients (25.2%). Two groups were formed according to the types of vascular conduits. Cryopreserved cadaveric iliac artery (n = 28) and cryopreserved cadaveric iliac vein (n = 8) were used in group A. In group B, recipient saphenous vein (n = 6), recipient umbilical vein (n = 5) and recipient collateral omental vein (n = 1) were used for reconstruction. The graft-recipient weight ratio, mean duration of anhepatic phase and MELD scores between two groups were not significantly different. All of the conduits were found to be patent just after reperfusion and in the early postoperative period by Doppler ultrasonography. In follow-up period of 1 year, four (11%) patients died in group A, two patients (16%) in group B. One of these patients died because of sepsis started from the saphenous vein incision site. None of the patients dying in the two groups were lost due to venous outflow problems. This study proves the efficacy of drainage of segment 5 and/or 8 veins using cryopreserved cadaveric vascular conduits. Every effort should be employed to store cadaveric iliac vessels, otherwise, whole other additive surgical intervention to ensure vascular conduit may lead uninvited serious complication.

Spontaneous rupture of intrahepatic biliary ducts is a rare cause of acute abdomen due to biliary peritonitis. We report a 92-year-old woman with 48-h history of upper abdominal pain, nausea and vomiting and peritoneal signs. CT scan showed free fluid in the abdomen and mild dilatation of the common bile duct. Exploratory laparotomy showed bile in the abdominal cavity with leak-age from a ruptured bile duct radicle in segment 3, as confirmed on intraoperative cholangiography. She underwent cholecystectomy, choledochotomy with removal of gallstones, repair of the perforation with primary suture and placement of a T-tube. She had an uneventful recovery.

Background: Currently, a popular method for right hepatectomy is hepatic resection with the liver hanging maneuver. The aim of this study is to present an alternative and safe approach during this maneuver without using any instrument, thus avoiding injury., Patients and Methods: From March 2005 to April 2006, a bimanual 'bi-finger' liver hanging maneuver (BBLHM) was planned in 22 right hepatectomies and the data were collected prospectively after operation., Results: BBLHM was performed in 21/22 patients (95%). The maneuver was stopped in one patient, due to manual detection of an accessory hepatic vein during finger dissection in the retrohepatic space. This vein did not allow completion of the BBLHM. The indications for right hepatectomy included 11 primary hepatic tumors (52%), 8 metastatic right hepatic tumors (38%), and 2 hydatid cysts (9%). Intraoperative ultrasound (IOUS) demonstrated the normal anatomical configuration type of the hepatic veins. Bleeding occurred in one patient (4%), which was interrupted with the use of continuous 6/0 polypropylene suture., Discussion: The most important step during the liver hanging maneuver is to develop the avascular space without any complication. In the present study, the index fingers were used instead of forceps during the blind dissection. BBLHM not only reduced the rate of damage to the hepatic veins but was also predictive for the presence of any accessory vein by its manual detection prior to injury. This maneuver allowed easier clamping of the hepatic veins and controllable hepatic resection. Dissection of retrohepatic space with the BBLHM produces a safer method, using both index fingers instead of a surgical instrument.

Objective: The aim of this article is to report our experience in the surgical treatment of arterial aneurysms in patients with Behçet disease., Methods: From October 2001 through May 2004, 18 arterial aneurysms were diagnosed in 16 Behçet patients. All patients were male. The patients ranged in age from 24 to 52 years (mean, 37.4 +/- 5.2 years). There were six abdominal aortic, three common femoral, two iliac, two popliteal, two superficial femoral, and two anterior tibial aneurysms and one subclavian artery aneurysm. All patients but four were in remission at the time of diagnosis. Those 4 patients received immunosuppressive therapy before the surgical intervention to induce remission. After hospital discharge, all patients were followed up regularly at 3-month intervals. The mean duration of follow-up was 17 +/- 4.2 months (range, 6-24 months)., Results: All patients underwent a successful surgical intervention. During the study period, we performed five aortic tube graft interpositions, two aortofemoral bypasses, one aortobifemoral bypass, three common femoral artery graft interpositions, and two femoropopliteal bypasses. The popliteal artery (n = 2), anterior tibial artery (n = 2), and subclavian artery (n = 1) aneurysms were repaired primarily. There was no in-hospital mortality. One patient with an abdominal aortic aneurysm had to undergo reoperation because of postoperative bleeding. The postoperative hospital stay was 8.5 +/- 4.3 days. Two patients were lost to follow-up. During the follow-up period, two false aneurysms of the common femoral artery were repaired with a graft interposition procedure. Another patient who had undergone an aortic tube graft interposition was readmitted 9 months later with an external iliac artery aneurysm. The external iliac artery was ligated through a retroperitoneal approach, and femorofemoral bypass was performed. In addition, one femoropopliteal interposition graft was occluded, without disabling ischemia., Conclusions: Although aneurysmal disease is rare in Behçet disease, it can complicate the clinical picture and cause life-threatening complications. We believe that the establishment of remission before the surgical intervention decreases the incidence of postoperative complications. Because recurrence at the site of anastomosis is possible, prolonged monitoring is required.