GÝRÝÞ ve AMAÇ: Laparoskopik kolesistektomi (LK) hastane kalýþ süresinin kýsa, postoperatif aðrýnýn ve görünür skar dokusunun az olmasr nedeniyle kolesistektomilerde “altýn standart” olarak kabul edilmiþ olan avantajlý bir cerrahi yöntemdir. Tüm bu avantajlarýn yaný sýra laparoskopik kolesistektominin güvenilir olmasý da gerekmektedir. LK lerde safra yolu yaralanma oranlarý klasik kolesistektomiye oranla daha yüksektir. LK de peropratuar kolanjiografi (POK) uygulanmasý iatrojenik safra yolu yaralanmalarýný önleyebilir.
YÖNTEM ve GEREÇLER: Surp Pirgiç Hastanesinde 2001 - 2003 yýllarý arasýnda LK uygulanmýþ olan 81 olgudan 21 inde (%26) laparoskopik peroperatuar kolanjiografi (LPOK) uygulandý. LPOK uygulama endikasyonlarý geçirilmiþ sarýlýk, kolestaz enzimlerinde yükselme ve yapýlan preoperatif ultrasonografide koledokta dilatasyonunun saptanmasýydý.
BULGULAR: Olgulardan 13 ü kadýn, 8 i erkek ve yaþ ortalamasý 54,6 idi. Toplam 21 olgudan 19 unda görüntülemede baþarý saðlandý. 10 hastada semptomatik safra kesesi taþý, 4 hastada akut ödematöz pankreatit, 5 hastada akut kolesistit mevcuttu. Olgularýn 2 sinde preoperatif ERCP uygulanmýþtý. Ortalama peroperatuar kolanjiografi süresi 23 dakika olarak ölçüldü. Hiçbir olguda anatomik varyasyon, anomali veya safra yolu taþý görülmedi. Hiçbir hastada peroperatuar kolanjiografiye baðlý komplikasyon olmadý.
TARTIÞMA ve SONUÇ: LPOK rutin olarak uygulanmasý gerekli olmasa da selektif olarak uygulanmasý gerekli olan ve bu nedenle bilinmesi gereken bir yöntemdir. Uygun endikasyonlarda ameliyatýn güvenli bir biçimde sonlandýrýlmasýný saðlayabilir.

INTRODUCTION: Laparoscopic cholecystectomy (LC) has the advantage of shortening hospitalisation, causing less postoperative pain and visible scarring associated with standard cholecystectomy. LC is considered as the “gold satandard” of cholecystectomiy. While LC seems to have great advantages, its safety must be established. The rate of bile duct injuries seems to be elevated in LC when compared to open cholecystectomy. Intraoperative cholangiography can prevent iatrogenic bile duct injury during LC.
METHODS: Between 2001 and 2003, out of the 81 laparoscopic cholecystectomies, intraoperative cholangiography was performed in 21 patients (26%) in Surp Pirgic Hospital. The indications of intraoperative cholecystectomy were past history of jaundice, elevation of cholestatic enzymes and dilation of common bile duct.
RESULTS: 13 patients were female and 8 patients were male. The mean age was 54,6 years. Intraoperative cholangiography was successful in 19 cases. 10 patients presented with symptomatic gall bladder calculs, 4 patients presented with acute edematous pancreatitis and 5 patients had acute cholecystitis. Two patients had ERCP in the preoperative period. The average period of cholangiography was 23minutes. No anatomic variations, anomalies or CBD stones were found. No complications due to laparoscopic cholecystectomy itself were encountered.
DISCUSSION AND CONCLUSION: Even if rutine use of laparoscopic intraoperative cholangiography does not seem to be necessary, Surgeons have to be techniquely capable of performing the procedure in selective cases. Intraoperative cholangiography (IOC) can prevent iatrogenic bile duct injury during LC.

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Bilinçli sedasyon/analjezi, hastanýn koruyucu refleksler üzerindeki kontrolünü sürdürürken istenmeyen duyularý tolere edebildiði, ilaçla sa¤lanan durumu ifade eder. Dokunsal ve sözel uyaranlara karþý anlamlý yanýtlar verebilme becerisi hastanýn kontrolü altýndadýr. Hastanýn solunum yolunu açýk tutmak için herhangi bir giriþim gerekmez, spontan ventilasyon yeterlidir. Kardiyovasküler fonksiyonlar ise genellikle sürdürülür. Hastanýn güvenliðini, rahatýný ve iþbirliðini artýrmak, gastrointestinal salgýlarý ve motiliteyi azaltmak ve amnezi saðlamak amacýyla endoskopik iþlemler öncesinde ve sýrasýnda ilaç uygulanabilir. Bilinçli sedasyon ve analjezi amacýyla kullanýlan ilaçlar çoðu zaman fentanil ya da meperidin gibi bir narkotik ajan ile midazolam veya diazepam gibi bir yatýþtýrýcý kombinasyonundan oluþmaktadýr. Ýntravenöz kateterler sayesinde dozaj titre edilebilir, ayrýca intravenöz sývý ve ilaçlar verilebilir. Gerçekleþtirilecek iþlemler için gereken sedasyon ve/veya analjezi dozu hastanýn yaþýna, kullandýðý ilaçlara, hastalýðýna, anksiyete düzeyine ve iþlemin türü ile süresine baðlý olarak deðiþir. Endoskopi iþlemleri sýrasýnda, hekimler tarafýndan direktife edilen ilaçlarý uygulama sorumluluðu hemþirededir. Hemþire, hastanýn yaþam bulgularýný, bilinç durumunu/düzeyini izler ve kaydeder. Ýlaçlarýn istenmeyen etkilerine karþý da uyanýk olmalýdýr. Bu makale, endoskopide çalýþan hemþirelere, sedasyon için kullanýlan ilaçlarýn farmakolojisi, etki mekanizmasý, endikasyonlarý, kontrendikasyonlarý ile bu ilaçlarýn etkilerini tersine çevirmede kullanýlan diðer ilaçlarla ilgili bilgi vermek amacýyla planlandý. Uygulamada hemþireler bu bilgileri, kaliteli bir hasta bakýmý saðlamak ve komplikasyon oranlarýný azaltmak için kullanabilirler.

Conscious sedation/analgesia (Moderate sedation) refers to the drug-induced state that allows the patient to tolerate unpleasent sensations while still maintaining control of protective reflexes. The ability to respond purposefully to tactile and verbal stimulation is within the patient’s control. No interventions are required to maintain apatent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Medication before and during endoscopic procedures may be used to diminish gastrointestinal secretions or motility, and to provide amnesia to ensure the patient’s safety, comfort, and cooperation. In general, the drugs used for moderate sedation and analgesia routinely consist of a combination of narcotic such as fentanyl or meperidine and a tranquilizer such as midazolam or diazepam. In patients who are resistance to sedation, the physician may request administration of other drugs to potentiate the action of the narcotic. An intravenous catheter allows for titration of dosage and permits administration of intravenous fluids and drugs. The amount of sedation or analgesia required for any procedure varies depending on the patient’s age, prior medications, associated illnesses, anxiety level, and type and duration of the procedure. The nurse is responsible for the administration of agents prescribed by the physician. During endoscopic procedures, the nurse monitors and documents the patient’s
state of consciousness and vital signs. The nurse must remain vigilant for untoward reactions to administered medication. This article is planned to provide knowledge to the nurses which are working in endoscopy units about the pharmacology of drugs used for sedation; mechanism of actions, indications, contraindications and the other drugs used to reverse their actions. Practicing nurses can use that knowledge to reduce complication rates and to enhance the quality of nursing care.

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Adenomyomatozis, safra kesesi duvarýnýn etyolojisi bilinmeyen benign hiperplastik hastalýðýdýr. Safra kesesinin incelmiþ kas tabakasýndan epitelin lokal ya da diffüz olarak invaginasyonu ile oluflan Rokitansky-Aschoff sinüsü ile karakterizedir. Bazý vakalar malign tümörlere benzemekle birlikte, ultrasonografik inceleme sýrasýnda ayýrýcý tanýda adenomyomatozis akla gelmelidir. Epigastrik aðrý ve dispeptik yakýnmalarý olan 50 yaþýndaki kadýn hastanýn yapýlan batýn ultrasonografisinde safra kesesinde polip saptandý. Laparoskopik kolesistektomi uygulandý. Histopatolojik inceleme sonucu safra kesesi adenomyomu tanýsý kondu. Olgumuzu safra kesesi polipleri ile alakalý kýsa literatür bilgisi vererek sunmayý amaçladýk.

Adenomyomatosis of the gallbladder is a condition of benign hyperplasia of unknown etiology, characterised by local or diffuse thickening of the muscular layer, with invagination of the epithelium, forming Rokitansky-Aschoff sinuses. In some cases it looks like a malignant tumor. The diagnosis can be suspected during ultrasound examination. Gall bladder polyp was detected in the abdominal ultrasonography of a 50-year old female patient with epigastric pain and dyspeptic complaints. Laparoscopic cholecystectomy was carried out and gall bladder adenoma was diagnosed according to histopathological examination. We aimed to present our case with brief relevant literature
information.

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GÝRÝÞ ve AMAÇ: Bu çalýþmada akalazya tanýsýyla laparoskopik modifiye Heller myotomi ve Dor fundoplikasyon uyguladýðýmýz hastalarý deðerlendirmeyi ve bu konudaki deneyimizi aktarmayý amaçladýk.
YÖNTEM ve GEREÇLER: Çaluþmaya Ocak 2006 –Ocak 2008 yýllarý arasýnda Akalazya tanýsý ile Ýstanbul Týp Fakültesi Genel Cerrahi Anabilim Dalý’nda laparoskopik modifiye Heller myotomi ve Dor fundoplikasyonu uygulanan 20 hasta alýnmýþ ve dosya bilgileri retrospektif olarak incelenmiþtir.
BULGULAR: Ortalama yaþ 45.3± 10.9 yýl, K/E oran› 1.86/1 (13/7) olarak saptandý. Hastalarýn ortalama þikayet süresi 17±4.9 ay olarak bulundu. Ameliyat öncesi dönemde hastalarýn 14 (%70)’ine 1 kez, 6 (%30)’sýna 2 kez balon dilatasyon, 4 (%20) hastaya ise ameliyat öncesi dönemde botulinum toksini ile tedavi denenmiþti. Ameliyat öncesi manometrik incelemede ortalalama AÖS basýncý 24,2±11,6 mmHg saptandý. Hastalarýn tümüne myotomi ve 180° Dor fundoplikasyon uygulandý. Ortalama ameliyat süresi 62 ±17.6 dk olarak saptandý. Ameliyat sýrasýnda 1(%5) hastada mukozal açýlma oldu ve laparoskopik olarak tamir edildi. Hastalar›n ortalama hastanede kalýþ süresi 2.3±0.6 gün olarak bulundu. Ameliyat sonrasý dönemde 1(%5) hastada port yerinden geliþen kesi fýtýð dýþýnda herhangi bir komplikasyon saptanmadý. Hastalar ortalama 26,2±20,2 ay takip edildi. Takip süresi içinde hastalarýn hiçbirinde nüks saptanmadý. Ýki (%10) hastada takip süresi içinde hafif gastroözofageal reflü semptomlarý geliþti. Bu hastalarda uygulanan medikal tedavi ile semptomlar geriledi ve ek giriþim gerekmedi.
TARTIÞMA ve SONUÇ: Akalazyalý hastalarda günümüzde en etkin tedavi yöntemi laparoskopik modifiye Heller myotomidir. Myotomiye antireflü bir prosedür eklenmeyen hastalarda ameliyat sonrasý patolojik reflü saptanma riskinin daha yüksek olmasý nedeni ile Heller myotomiye anti reflü giriflim olarak Dor fundoplikasyonunun da eklenmesi gerektiðini düþünmekteyiz.

INTRODUCTION: In this study we have retrospectively evaluated the patients which underwent laparoscopic modified Heller myotomy for achalasia.
METHODS: Between January 2006 and January 2011, 20 patients underwent laproscopic Heller myotomy and Dor fundoplication in Istanbul Faculty of Medicine Department of General Surgery. The files of the patients were evaluated retrospectively.
RESULTS: The mean age of the patients were 45.3± 10.9 years and female /male ratio was 1.86/1 (13/7). The mean symptom period was 17±4.9 months. In the preoperative period, 14(%70) patients underwent one, 6 (%30) patients underwent two times of pneumatic esophageal dilatation. Botox treatment was performed in 4 (%20) of the patients before the pneumatic dilatation. The mean lower esopghageal sphincter (LES) pressure of the patients was 24,2±11,6 mmHg. All of the patients were underwent laproscopic Heller myotomy and Dor fundoplication. The mean operation time was 62 ±17.6 minutes. The esophageal mucosal rupture occured in 1 (%5) patient during the operation and repaired laparoscopically. The mean hospitalization time was 2.3±0.6 days. The mean follow-up time was 26,2±20,2 months. No recurrence was occured during the follow-up period. Gastro-esophageal reflux (GER) was occurred in 2 (%10) patients with mild symptoms and treated medically. Port site hernia was occured in 1 (%5) patient.
DISCUSSION AND CONCLUSION: Laproscopic Heller myotomy is the most effective treatment for esophageal achalasia. Because of the higher GER rates in patients without antireflux procedure, we recommend that Dor fundoplication should be added to the Heller myotomy.

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GÝRÝÞ ve AMAÇ: Günümüzde özofagusun çok sýklýkla malign hastalýklarýnýn palyasyonunda stentler kullanýlmaktadýr. Ancak çýkarýlabilir stentlerin kullanýma girmesiyle birlikte birçok benign hastalýkta da stent kullanýmý giderek yaygýnlaþmaktadýr. Bu stentlerle çeþitli selim özofagus darlýklarý ve fistülleri tedavi edilebilmektedir. Çýkarýlabilir stentlerin kullaným alanýnýn kalýcý stentler kadar geniþ olacaðýný düþünmekteyiz.
YÖNTEM ve GEREÇLER: Üç hastada çýkarýlabilir, kendiliðinden geniþleyen nitinol stent, endoskopi ve fuloroskopi yardýmý ile yerlefltirildi. Ýþlem sýrasýnda hiçbir komplikasyon olmadý.
BULGULAR: Hastalarýn yaþlarý 48-50-54 ve üçü de erkekti. Ýlk hastada üst özofagus darlýðýnda tümör vardý. Hastanýn orofarinkse yakýn tümörünün olmasý ve stentin tolerasyonundan emin olunmadýðý için çýkarýlabilir stent tercih edildi. Sonraki süreçte tümör ingrowth geliþimi göz önüne alýnarak, stent içinden geçilerek PEG uygulandý. Ýkinci hasta larinks kanseri nedeniyle opere edilmiþti ve servikal özofaustaki darlýða stent uygulandý. Son hasta kardia tümörü nedeniyle opereydi, patolojide cerrahi sýnýr pozitifliði vardý, erken anastomoz darlýðý geliþmiþti ve yeniden planlanan cerrahiye köprü olmasý amacýyla stent uygulandý.
TARTIÞMA ve SONUÇ: Çýkarýlabilir stentler ile ilgili çalýþmalar literatürde az sayýdadýr. Öncelikle iyi huylu darlýklarda kullanýlmasý düþünülse de kanser nedenli darlýklarda da kullanýlmýþtýr. Çýkarýlabilir stenler oldukça kolay uygulanmakta ve diðer stentler kadar da etkin olmaktadýr. Hasta sayýmýz çalýþmamýza yeni baþaldýðýmýz için az olmakla birlikte ilk üç hasta bilgilerimizi vermek istedik. Ýlerleyen zamanlarda daha yüksek hasta sayýlarý ile sonuçlarýmýzý vermeyi düþünmekteyiz.

INTRODUCTION: Today, a variaty of stents are used to palliate for symptoms in esophagial cancer. But with retrievable stents produced in recent years, benign stenosis or fistulas of esophagus are being managed in common. We hypothesise that retrievable stent usage will be as common as the other stents.
METHODS: In three patients, retrievable nitinol stents have been placed with the aid of endoscopy and fluoroscopy. No complication occured during the procedure.
RESULTS: The ages of three patients were 48-50-54 in respectively. In the first patient, there was a stenosis in the upper segment of esophagus close to the oropharinx which was due to tumor. As to the presumption of intolerance of patient to any of stent, retrievable stent were preferred. After stent placement, PEG insertion was done through the stent because of tumor ingrowth was expected in near future. The second patient had a history of larynx surgery due to cancer and retrievable stent was palced in the servical stenotic region. The third patient had a surgery of cardia tumor and pathology showed positive tumor cells in the anastomosis and stenosis were found endoscopically. As a bridge to the definitive surgery, retrievable stent were placed.
DISCUSSION AND CONCLUSION: In the literature there are limited numbers of studies related to retrievable stents. Although it is used in benign stenosis in the first studies then there are several studies reporting its usage in malign stenotic lesions. It can be placed as easy as the other stents and effectivness of the retrievable stents remain the same as the others. In our study, the numbers of patients are so low but we will report the late results as our numbers growed.

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