Diarrhoea following renal transplantation

In this study, we retrospectively evaluated all attacks of diarrhoea in our renal transplant recipients that came to our medical attention between 1985 and 2000. Also, the clinical features of patients with diarrhoea were compared with the features of recipients without diarrhoea. We diagnosed 41 attacks of diarrhoea in 39 (12.6%) of 308 renal transplant recipients during this time period. An aetiology was detected in 33 (80.5%) of all diarrhoeal episodes and in seven (17.1%) of those the specific agent was diagnosed with the help of stool microscopy. The most frequent causes of diarrhoeal attacks were infectious agents (41.5%) and drugs (34%). Six (14.6%) episodes of diarrhoea were chronic and six were nosocomial. About two-thirds of diarrhoea developed within the late post-transplant period (>6 months). When recipients with diarrhoea were compared with those without diarrhoea, it was seen that diarrhoeal patients had significantly higher creatinine and significantly lower albumin levels when compared with the latter group (p < 0.05). Also, the frequency of antibiotic usage was significantly higher in diarrhoeal patients than in the control group (p < 0.05). Four (10.2%) patients with diarrhoea died despite institution of the appropriate therapy. Two of these deaths were primarily related to diarrhoea and the aetiological agent was Clostridium difficile in both these cases. During the 15-yr study period, 3.6% of all deaths and 5.1% of infection-related deaths in transplant recipients were secondary to diarrhoea. As a result, we observed that infections and drugs were the most frequent causes for diarrhoea in our series of renal transplant recipients. Also, diarrhoea was an important cause of mortality in this patient population.     

Laparoscopy in Turkish Bariatric Surgery: Initial Experience

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

Ocular and visual side effects of systemic cyclosporine.

In this study, we investigated the ocular and visual side effects of systemic cyclosporine used as an immunosuppressant in 51 renal transplant recipients during the postoperative period. Three different treatment schemes were used. The patients in the first group received cyclosporine and a corticosteroid. The second group was given azathioprine and a corticosteroid. Those in the third group were treated with azathioprine, a corticosteroid, and cyclosporine. Cotton-wool exudates, retinal hemorrhages, and retinal artery branch occlusion were observed only in one patient each in the second group, and these patients were excluded from the statistical evaluation. Macular hyperpigmentation was observed as a new finding in each group, but there was no statistical difference between the groups. The same results were found for cataract; this probably was related to the use of steroids. Trichomegaly, visual hallucinations, and cerebral blindness were not observed by contrast with previous studies. We suggest that systemic cyclosporine does not have significant ocular and visual side effects.     

Menstrual cycle-dependent changes in white-on-white visual field analysis of diabetic women

AIM: To determine the effect of the menstrual cycle on white-on-white perimetry (WWP) tests of diabetic women. SUBJECTS AND METHODS: Left eyes of 129 normally menstruating women (81 type 1 diabetes mellitus (DM) with mild (n = 43) and severe (n = 38) non-proliferative diabetic retinopathy (NPDR), and 48 healthy control females) were included in the study. All subjects underwent complete ocular examination and WWP tests both in the follicular (7-10th day of the cycle) and luteal phases (days 3-7 before the bleeding) of two consecutive menstrual cycles. WWP was performed using Humphrey Field Analyzer II with SITA Standard, central 30-2 program. Mean sensitivity (MS) of points located at central 3, 9, 15, 21 and 27 degrees retinal locations (4, 12, 18, 24 and 16 points, respectively) were calculated in all menstrual phases. RESULTS: The mean age of diabetic patients with mild and severe NPDR and control subjects were 28.8 +/- 4.7, 30.1 +/- 5.9 and 29.4 +/- 5.1 years, respectively (p > 0.05). Their mean MS values were 30.7 +/- 1.0, 30.4 +/- 1.0 and 30.8 +/- 0.8 dB, respectively (p > 0.05). Diabetic patients with severe NPDR demonstrated significant decreases in mean MS values of peripheral 21 and 27 degrees visual field locations in the luteal phase (p < 0.05). However, changes in that of the locations within central 15 degrees visual field were non-significant (p > 0.05). Diabetic patients with mild NPDR and control subjects demonstrated no significant changes in mean MS values of any of the visual field locations (p > 0.05). CONCLUSION: Peripheral, rather than central, locations of central visual field of diabetic women with severe NPDR demonstrated a significant retinal sensitivity loss in the luteal phase. These findings should be taken into consideration during the clinical follow-up of diabetic women at risk of glaucoma and ocular hypertension.     

A very rare cause of recurrent apnea: congenital nasopharyngeal teratoma

A three-month-old girl patient born at the 37th week of gestation as one of twins was admitted to our hospital with cardiac arrest. There was past medical history of multiple hospitalizations with symptoms of cyanosis, respiratory distress, and frequent and severe attacks of apnea since her birth. On nasopharyngeal computerized tomography a mass (25x24 mm) occupying the right side of the nasopharynx was detected. The pathological evaluation of the excised mass revealed benign teratoma. After the removal of the nasopharyngeal mass under general anesthesia, respiratory distress and attacks of apnea disappeared completely. In every neonate with unexplained stridor and recurrent apnea, beside the common causes like respiratory distress syndrome, sepsis, and asphyxia, the possibility of oropharyngeal and nasopharyngeal mass should be kept in mind.     

Internal herniation concurrent with ileosigmoid knotting or sigmoid volvulus: Presentation of 12 patients

BACKGROUND: Internal herniation concurrent with ileosigmoid knotting or sigmoid volvulus is an unusual and complex form of closed-loop obstruction that may result in a fatal outcome unless treated timely and properly. The aim of this article was to review our experience with this condition, with emphasis on the etiopathogenesis, clinicopathologic features, and treatment options. METHODS: We conducted a retrospective analysis of medical records of 12 patients treated at 2 university hospitals over a period of 30 years between 1970 and 2000. RESULTS: In this series, the internal herniation resulted in ileosigmoid knotting in 8 cases, whereas it was concomitant with sigmoid volvulus in 4 cases. The types of internal herniation were identified as transmesenteric through the Treves field in 8 patients and as transomental, intersigmoidal, pericecal, and around omphalomesenteric fibrous cord in 1 patient each. The rate of gangrenous bowel was 100%. En bloc resection for combined gangrene of small bowel and large bowel was the treatment of choice in 7 patients, of whom 5 underwent the Hartmann's procedure and 2 underwent primary sigmoidectomy-anastomosis in addition to primary enterectomy-anastomosis. Primary sigmoidectomy-anastomosis and Mikulicz's procedure were performed in 2 patients for gangrenous sigmoid colon only. Three patients underwent primary enterectomy-anastomosis for gangrenous small bowel only. The morbidity rates and the mortality rate were both 33.3%. The mean length of hospital stay following emergency operations was 11.2 days. CONCLUSIONS: In particular, surgeons who are from developing countries that form the world's "volvulus belt" should be aware of this entity's features and be ready to perform an appropriately selected surgical option for a given patient to accomplish the optimal clinical outcome.     

Retropharyngeal space and lymph nodes: an anatomical guide for surgical dissection

Identification of the alar fascia is the key part of surgical dissection of the retropharyngeal lymph nodes (RPLNs). In cases where mandibulotomy is not performed for the removal of the primary tumor and/or the posterior pharyngeal wall is not incised, the medial or lateral approaches described in this paper can be performed.Surgical dissection of the RPLNs may improve prognosis and locoregional control in oropharyngeal, hypopharyngeal and cervical esophageal carcinomas. There have been no previous anatomical studies concerning landmarks and approaches for the surgical dissection of the RPLNs. This study was designed to illustrate the fascial anatomy of the retropharyngeal region (RPR), provide anatomical guidelines for RPLN dissection and describe and compare approaches for surgical removal of the RPLNs.Twelve fixed cadavers were used. Slices were obtained from the necks of the first three cadavers and the RPRs of the slices were dissected under an operating microscope. The other nine cadavers were dissected in a surgical position to expose the RPLNs and the fasciae of the RPR.In the coronal plane, the alar fascia divides the space between the buccopharyngeal and prevertebral fasciae into two compartments and constitutes the posterior border of the retropharyngeal space, which contains the RPLNs. The alar fascia, an important landmark for reaching the RPLNs, can be identified by the cervical sympathetic trunk, superior sympathetic ganglion and superior laryngeal nerve. Two approaches can be performed to remove the RPLNs, namely medial or lateral to the internal and external carotid arteries, internal jugular vein and vagus nerve.     

Pseudoaneurysm and aortobronchial fistula after aortic coarctation repair by patch aortoplasty

Pseudoaneurysm and aortobronchial fistula are very rare complications of aortic coarctation repair by means of patch aortoplasty, and are usually fatal if not treated surgically. A 26-year-old man with recent-onset massive hemoptysis had undergone aortic coarctation repair by means of Dacron patch aortoplasty at the age of 10 in our hospital. Computed tomography of the chest showed a descending aortic pseudoaneurysm. Left heart bypass was used for distal perfusion while the patient underwent graft interposition. Lung parenchyma around the fistula was repaired, and the patient was discharged after an uneventful postoperative course. When hemoptysis occurs in a patient with a history of thoracic aortic surgery, aortobronchial fistula should be suspected. Close follow-up is mandatory for patients who have undergone coarctation repair.