OUP accepted manuscript

Calcified fibrous tumor (CFT) is a rare benign tumor of mesenchymal origin. Between 1988 and 2019, a total of 272 CFT cases were reported. CFTs can be seen in all anatomical regions with soft tissue. Histologically, mononuclear inflammatory infiltrates and the presence of psammomatous calcification in dense hyalinized collagen are characteristic features of the tumor. Currently, if the tumor is located in only one focus, surgical removal is recommended. Although CFT is a benign tumor, it may cause complications. Diagnosis is often difficult due to the confusion of tumor findings with many diseases. We present a patient with CFT, whose omental lesions were detected on abdominal computed tomography, and the diagnosis was confirmed by histopathological examination.

Sequential analysis of single-center experience of living donor kidney transplants with several vascular anastomosis techniques

Background and aim

Vascular variations of grafts are handled with various reconstruction techniques in renal transplantation. We aimed to analyze the effects of these reconstruction techniques and sites on patient/graft outcomes.

Materials and methods

Renal transplantation cases at the Transplantation Unit of the General Surgery Department, İstanbul Uni- versity Cerrahpaşa Medical Faculty between January 1st, 2000 and December 31st, 2012 were analyzed retrospectively. Postoperative duplex ultrasound results, urea-creatinine reduction rates, and complications were evaluated.

Results

There were 228 living-donor transplantation cases evaluated. For single-renal-artery living-donor transplantations, there were 45 end-to-side external iliac artery, 15 end-to-side internal iliac artery, 152 end-to-end internal iliac artery, and 3 end-to-side common iliac artery anastomoses performed. In cases with double-arteries, 3 had end-to-side external iliac artery anastomoses, and 10 had end- to-end internal iliac artery anastomoses. No statistically significant differences were found between reconstruction techniques with regard to complications or urea-creatinine reduction rates.

Conclusion

Internal, external, and common iliac arteries can be safely used for anastomoses. The presence of more than one renal artery creates no short or long-term problems when a side-to-side anastomosis is initially performed.

Prevention and acute management of biliary injuries during laparoscopic cholecystectomy: Expert consensus statement

Gallstone disease is very common and laparoscopic cholecystectomy is one of the most common surgical procedures all over the world. Parallel to the increase in the number of laparoscopic cholecystectomies, bile duct injuries also increased. The reported incidence of bile duct injuries ranges from 0.3% to 1.4%. Many of the bile duct injuries during laparoscopic cholecystectomy are not due to inexperience, but are the result of basic technical failures and misinterpretations. A working group of expert hepatopancreatobiliary surgeons, an endoscopist, and a specialist of forensic medicine study searched and analyzed the publications on safe cholecystectomy and biliary injuries complicating laparoscopic cholecystectomy under the organization of Turkish Hepatopancreatobiliary Surgery Association. After a series of e-mail communications and two conferences, the expert panel developed consensus statements for safe cholecystectomy, management of biliary injuries and medicolegal issues. The panel concluded that iatrogenic biliary injury is an overwhelming complication of laparoscopic cholecystectomy and an important issue in malpractice claims. Misidentification of the biliary system is the major cause of biliary injuries. To avoid this, the "critical view of safety" technique should be employed in all the cases. If biliary injury is identified intraoperatively, reconstruction should only be performed by experienced hepatobiliary surgeons. In the postoperative period, any deviation from the expected clinical course of recovery should alert the surgeon about the possibility of biliary injury.

The investigation of foxe1 variations in papillary thyroid carcinoma

BACKGROUND

Recent reports indicated that incidence of thyroid carcinoma is increasing throughout the worldwide. The aim of our study was to determine a possible relationship between Forkhead box E1 (FOXE1) gene variants and histopathological features of papillary thyroid carcinoma.

METHODS

FOXE1 gene variations; rs894673, rs1867277 and rs3758249 were analyzed in 57 Papillary thyroid carcinoma patients and 51 age matched healthy control subjects. Restriction fragment length polymorphism (RFLP) technique was used to specifically detect the variations.

RESULTS

There was a significant difference in the distribution of rs894673 genotypes in Papillary thyroid carcinoma cases (P=0.01). AA genotype presence of rs1867277 was more significantly associated with several histopathological parameters such as focal and diffuse capsular invasion, lymphatic invasion, P3 with P4 tumor grade and surgical margins. AA genotype presence in rs1867277 variation was significantly associated with the classical variant which is subtype of papillary thyroid carcinoma. Furthermore, the presence of the allel A was found to be related with lymph node invasion risk by 2.46 fold, capsular invasion risk by 2.97 fold, and pT3 with pT4 pathological stage risk by 4.13 fold and the presence of allele A in rs1867277 was significantly associated with classic variants. The presence of allele A in rs1867277 was more significantly associated with several histopathological parameters in classic variant in papillary thyroid carcinoma cases such as, the presence of the A allele was found relationship with lymph node invasion risk by 2.0 fold, capsular invasion risk by 2.39 fold , and pT3 with pT4 pathological stage risk by 3.57 fold. In addition, AATT, AAAA and GATT haplotypes (rs1867277 and rs894673) were evaluated for association with papillary thyroid carcinoma cases. Our results indicate that the significant difference according to two-allele haplotype distribution between papillary thyroid carcinoma cases and control groups.

CONCLUSION

Our findings suggest that FOXE1 variations generate a higher risk for poor histopathological features of papillary thyroid carcinoma.

The effects of caffeic acid phenethyl ester (CAPE) on bacterial translocation and inflammatory response in an experimental intestinal obstruction model in rats

OBJECTIVE

Intestinal obstruction (IO) is a disease which generates approximately 20% of emergency surgery and tends to with high mortality. Prevention of oxidative stress, bacterial translocation and tissue damage caused by IO is an important medical issue. Caffeic acid phenethyl ester (CAPE) is an anti-inflammatory, antioxidant, anti-bacterial and immunomodulatory agent. In this experimental study, we aimed to investigate the effects of CAPE on bacterial translocation, inflammatory response, oxidative stress and tissue injury caused by intestinal obstruction in a rat model.

MATERIALS AND METHODS

Breafly, thirty Wistar albino rats divided into three groups as Sham (n=10), IO (n=10) and IO + CAPE (10 µmol/kg day, intraperitoneal) (n=10). The tissues from the study groups were examined biochemically, microbiologically and histopathologically.

RESULTS

In CAPE treated group, decreased serum levels of proinflammatory cytokines (TNF-α, IL-6, IL-1β) and CRP (p < 0.05), additionally increased serum levels of antioxidant parameters (PONS, TAS) (p < 0.05), were observed after IO. Microbiologically, the rates of positive cultures of the lymph node, spleen, liver and blood were significantly decreased in CAPE treated group compared to the IO group. Also histopathological examination showed that the intestinal mucosal injury score and hepatic portal inflammation score were significantly decreased in the CAPE treated group (p < 0.05).

CONCLUSIONS

It is suggested that intraperitoneal administration of CAPE might has potential antibacterial, anti-inflammatory, antioxidant and immunomodulatory effects in IO. So, further studies on IO are needed to evaluate exact antibacterial, antiinflammatory, antioxidant and immunomodulatory effects of CAPE.

Clinical Application of Six Current Classification Systems for Iatrogenic Bile Duct Injuries after Cholecystectomy

BACKGROUND/AIMS

Due to being a severe complication, iatrogenic bile duct injury is still a challenging issue for surgeons in gallbladder surgery. However, a commonly accepted classification describing the type of injury has not been available yet. This study aims to evaluate ability of six current classification systems to discriminate bile duct injury patterns.

METHODOLOGY

Twelve patients, who were referred to our clinic because of iatrogenic bile duct injury after laparoscopic cholecystectomy were reviewed retrospectively. We described type of injury for each patient according to current six different classifications.

RESULTS

9 patients underwent definitive biliary reconstruction. Bismuth, Strasberg-Bismuth, Stewart-Way and Neuhaus classifications do not consider vascular involvement, Siewert system does, but only for the tangential lesions without structural loss of duct and lesion with a structural defect of hepatic or common bile duct. Siewert, Neuhaus and Stewart-Way systems do not discriminate between lesions at or above bifurcation of the hepatic duct.

CONCLUSION

The Hannover classification may resolve the missing aspects of other systems by describing additional vascular involvement and location of the lesion at or above bifurcation.

Prognostic factors influencing survival in 35 patients with malignant peritoneal mesothelioma

Malignant mesothelioma is a rare but highly lethal form of cancer that affects the serosal membranes. Malignant peritoneal mesothelioma (MPM) is the second most common form of malignant mesothelioma (pleural mesothelioma is the most common). The aim of this study was to evaluate prognostic factors influencing the survival of patients with MPM. A retrospective analysis was performed on 35 patients who were admitted to our hospital between March 2005 and July 2013. The patients' demographic and clinical data, laboratory results, radiological signs, Eastern Cooperative Oncology Group (ECOG) performance status (PS), and treatment outcomes were evaluated. The mean age of the 35 patients was 59.0±14.4 years, the mean survival time was 16.2±12.9 months, and the majority of the histopathological types of MPM were epithelial (68.6%). 82.9% of the patients had been exposed to asbestos, and the mean duration of exposure was 28.3±14.5 years. The most frequent symptoms were abdominal distention/pain, weight loss, dyspnea, and chest pain. The mean interval between the onset of symptoms and the diagnosis was 4.6±3.3 months. Platinum-based combination chemotherapy in combination with supportive care was used in the treatment of 68.6% of the patients, while supportive treatment alone was used in the others. Our results revealed that patients who were >60 years old (p=0.019), who were exposed to asbestos >20 years (p=0.033), who had an ECOG PS of 3 (p=0.000) were more likely to have a poor MPM prognosis.In conclusion, increased age, duration of environmental asbestos exposure and ECOG PS are important factors that influence the prognosis of MPM patients.

Blunt trauma - related isolated pancreatic injury

BACKGROUND

Pancreatic injuries arising from blunt trauma are rarely seen. Diagnosis and treatment are difficult because of retroperitoneal localization of the organ. We present four pancreatic cases with isolated pancreatic injury due to blunt abdominal trauma.

METHODS

This retrospective study included four pancreatic patients who were operated on due to isolated injury caused by blunt abdominal trauma at our department between January 2004 and October 2010.

RESULTS

The patients consisted of three males and one female. One of them was in stage IV and the rest were in stage III. All underwent pancreaticojejunostomy, distal pancreatectomy, distal pancreatectomy + splenectomy and drainage, respectively. Fistula developed in two of them, and abscess developed in one, while the other one died.

CONCLUSION

Diagnosis may be delayed since the clinical condition is initially stable. Tomography remains one of the most important diagnostic tools. Common risk factors for morbidity and mortality are the presence of ductal injury and delayed laparotomy (Tab. 1, Fig. 4, Ref. 22).

The effects of pomegranate on bacterial translocation in rats with obstructive jaundice

BACKGROUND

Obstructive jaundice may promote bacterial overgrowth and altered intestinal barrier function, with resultant increased bacterial translocation.

AIMS

This study aimed to evaluate potential effects of pomegranate on bacterial translocation after bile duct ligation in rats.

MATERIALS AND METHODS

Wistar albino rats were randomized into four groups. Group 1 underwent sham operation; Group 2 underwent sham operation and simultaneous treatment with pomegranate; Group 3 underwent common bile duct ligation, and Group 4 underwent common bile duct ligation and simultaneous treatment with pomegranate. After 8 days, the samples of systemic blood, liver, spleen and mesenteric lymph nodes (MLNs) were obtained under sterile conditions for microbiological culture. The segments of the ileum were removed for histopathological examination.

RESULTS

Bacterial translocation significantly decreased in Group 4 compared to Group 3 (p = 0.007). The bacterial counts (Colony forming unit: CFU/g) of Group 3 were significantly higher than those of Groups 1, 2 and 4 (p < 0.05). The mean ileal villus heights in the Groups 1, 2, 3 and 4 were 480.5±20.5 µm, 494.7±17.3 µm, 356.3±25.7 µm and 420.7±23.7 μm, respectively. The mean villus height in Group 4 was higher than that of Group 3 (p = 0.010).

CONCLUSIONS

Pomegranate has significant protective effects on intestinal mucosa barrier in obstructive jaundice and reduces bacterial translocation.  

The effective risk factors on mortality in patients undergoing damage control surgery

BACKGROUND

Damage control surgery is a life-saving procedure used in fatal injuries. Morbidity and mortality rate are high in these patients due to massive trauma. The aim of this study was to analyze the risk factors associated with mortality in abdominal traumas that underwent damage control surgery.

PATIENTS AND METHODS

The retrospective study included 24 patients that underwent damage control surgery between January 2004 and September 2010. Age, gender, type of injury, period of time before admission, hemodynamic parameters, associated organ injury, injury severity score, surgical procedures performed, length of hospital stay, and complication and mortality rates were recorded.

RESULTS

The study included 16 (66.7%) men and 8 (33.3%) women, with a mean age of 32.3 years. Median period of time before admission was 30.83 minutes. All the patients were present with hypothermia and acidosis at admission, while only 5 of them were hemodynamically stable. Mean 6.75 units of blood were transfused in all of them. Common etiological factors included gunshot (50%) and motor vehicle accident (25%). Hepatic injury (83.3%) was the most common organ injury. Mean injury severity score (ISS) was 28.88. Damage control surgery was performed in all the patients. Skin-only closure was applied in 17 (70.8%), while 7 (29.2%) patients received Bogota bag application. Definitive surgery was achieved through de-packing over 36-48 hours in average. Total mortality occurred in 11 (45.8%) patients. Period of time before admission, core temperature at admission, pH levels and amount of blood transfusion were statistically different in the mortality group. A total of 16 complications occurred in 10 patients. Among these, intraabdominal abscess (46.2%) was the most common.

CONCLUSION

Hypothermia (< 35°C), acidosis (pH < 7.2), instability related to systolic blood pressure, massive blood transfusion, and delayed admission are predictive factors for mortality.

Sigmoid colon torsion: mortality and relevant risk factors

INTRODUCTION

Sigmoid volvulus is an important acute intestinal obstruction, leading to high mortality and requiring urgent operation. The purpose of this study is to analyze risk factors for mortality in patients that were operated on due to sigmoid volvulus at our Department.

MATERIALS AND METHODS

The retrospective study included 158 patients, who were operated on due to sigmoid volvulus between January 1994-December 2010, in terms of age, gender, complaints at admission, physical signs, period of symptoms before admission, associated diseases, laboratory and radiological parameters, hospital stay, morbidity, and mortality.

RESULTS

The study consisted of 135 men (85.4%) and 23 women (14.6%), with a mean age of 62.54 years. Cardiovascular disease and respiratory disease were present in 34 (21.5%) and 42 (26.6%) patients, respectively. Urgent operation was undertaken in 125, while 33 received elective surgery. Abdominal distension and pain was evident in all the patients. Generalized tenderness was detected in 58.2%, while 70.9% had hyperactive bowel sound with tympanism. Plain radiograph revealed an impression of "omega ans" in all patients, while free air was detected in 11.4% of them. Risk factors for mortality included age (p = 0.008), delayed admission (p = 0.001), cardiovascular and respiratory diseases (p = 0.001), fluid-electrolyte imbalance (p =0.001), presence of necrosis (p = 0.001), and major contamination (p = 0.001). Wound infection and intraabdominal abscess were more common in patients that developed mortality (p = 0.001 and p = 0.002).

CONCLUSIONS

Complications like wound infection and intraabdominal abscess are more frequent in the patients with the risk of mortality. Delayed admission results in higher risk of mortality. Mortality rates can be reduced by early admission, preoperative intensive resuscitation, suitable antibiotics, and emergent and viable surgery.  

The effects of curcumin on the liver and remote organs after hepatic ischemia reperfusion injury formed with Pringle manoeuvre in rats

BACKGROUND

We aimed to investigate the effects of curcumin on ischemia/ reperfusion (IR) injury of the liver and distant organs resulting from liver blood flow arrest.

MATERIALS AND METHODS

Totally 40 rats, divided into four groups, each included 10 rats were used. Group I as only laparatomy, Group II laparatomy and curcumin application, Group III hepatic IR; and Group IV as hepatic IR and curcumin application group. Ischemia was generated by hepatoduedonal ligament clamping for 30 minutes and then reperfusion is started. Curcumin capsules were opened and appropriate dose had been created within weighing scales. After calculations, the powder was diluted with saline. Fifteen minutes before the ischemia, curcumin was applied via oral gavage. Blood samples were taken from the animals for biochemical analysis at 60th minutes of the experiment in the first and second groups; 30 minutes after beginning reperfusion in the third and forth groups. Simultaneously, liver, lung and kidney tissues were sampled for biochemical and histopathological examinations.

RESULTS

Plasma malondialdehyde levels were found to be higher (p < 0.001), but total antioxidant activity values were not different in IR group compared with IR + curcumin group (p > 0.05). Biochemical and histopathological evaluation of tissue samples revealed that there were no differences in total antioxidant activity, total oxidant activity and histopathologic scores in IR + curcumin group compared with values of IR group (p > 0.05).

CONCLUSIONS

Curcumin did not reduce the effects of hepatic ischemia reperfusion injury on the liver and distant organs including kidneys and lungs significantly.

The comparison of the effects of hot milk and hot water scald burns and factors effective for morbidity and mortality in preschool children

PURPOSE

Scald burns are the leading cause of burns in children, especially in those younger than 5 years of age, however, they are easily preventable. Our aim in this study was to emphasise the importance and impact of scald burns caused by hot milk.

METHODS

A total of 334 patients below seven years of age were included in this study. Of these, 252 were admitted with acquired hot water scald burns (Group 1) and 82 with hot milk scald burns (Group 2) between August 2009 and September 2010. Demographic data of the patients were retrospectively investigated.

RESULTS

The depth of the burns was determined to be higher in Group 2 (p < 0.001). The total burnt body surface area in Group 1 and Group 2 were 17.1 ± 12.3 and 16.3 ± 10.9 (p = 0.99), respectively. Skin grafting was performed in 23 patients in Group 1 and 16 patients in Group 2 (p = 0.01) and complications developed in three patients in Group 1 and in five patients in Group 2 (p = 0.01). The mean length of hospital stay was 9.1 ± 7.4 days in Group 1 and 14.9 ± 9.8 days in Group 2 (p < 0.001) and the mortality rates were similar between the two groups.

CONCLUSIONS

More emphasis should be placed on the effects of hot milk scalding due to its ominous clinical course and the high healthcare costs associated with this type of scalding. We believe that taking simple precautions would help reduce the physical, psychological effects and financial consequences of hot milk scalds.

The effects of ellagic acid on the liver and remote organs' oxidative stress and structure after hepatic ischemia reperfusion injury caused by pringle maneuver in rats

INTRODUCTION

We aimed to investigate the possible protective effects of ellagic acid (EA) on the liver and remote organs against the hepatic ischemia-reperfusion injury.

METHODS

Forty Wistar-Albino rats were divided into four groups each containing 10 rats. Group I with laparotomy only, Group II with laparatomy and ellagic acid application, Group III with hepatic ischemia-reperfusion and Group IV with hepatic ischemia-reperfusion and ellagic acid application. Hepatic ischemia was induced by pringle's manoeuvre for 30 minutes followed by 30 minutes reperfusion period. After induction of ischemia, EA was applied via oral gavage at a dose of 85 mg/kg. Blood samples were taken from the animals for biochemical analysis at 60th minute of the experiment in all groups. Simultaneously, liver, lung and kidney tissues were sampled for biochemical analyses and histopathological examinations.

RESULTS

The administration of EA reduced serum malonyldialdehid levels (p<0.05) and liver's oxidative stress index compared with the non-use EA groups (p0.05). The use of EA did not exert significant protective effects against the effects of liver ischemia-reperfusion injury on the kidney and lung.

CONCLUSION

In our experiments ellagic acid reduced the liver oxidative stress induced by ischemia-reperfusion injury. However, no significant histological improvement was found with EA. There were no significant protective effects on the remote organ injuries induced by ischemia-reperfusion (Tab. 3, Fig. 7, Ref. 37).

Splenic injuries: factors affecting the outcome of non-operative management

PURPOSE

The aim of this study was to evaluate the outcome of non-operative management (NOM) in patients with splenic injuries and to determine the predictive factors of NOM failure.

METHODS

Two hundred and six patients with splenic injury were admitted between January 2005 and April 2011. Of the 206 patients with splenic injury, 47 patients met the inclusion criteria of NOM. The mechanism of injury, grade of splenic injury, other intra- and extra-abdominal injuries, systolic blood pressure on admission, hemoglobin levels, number of transfusions, Injury Severity Score (ISS), Glasgow Coma Scale score, and hospitalization period were recorded. The patients were divided into two groups: those with NOM and those in whom the failure of NOM led to laparotomy. The patients were monitored for vital signs, abdominal findings, and laboratory data. NOM was abandoned in cases of hemodynamic instability, ongoing bleeding, or development of peritonitis. Independent predictive factors of NOM failure were identified. The patients managed non-operatively were compared with the patients for whom NOM failed.

RESULTS

NOM was successful in 40 of 47 patients. There were differences between the two groups for ISS, hemoglobin levels, need for blood transfusion, and the number of associated extra-abdominal injuries. The grade of splenic injury was determined to be an important and significant independent predictive factor for the success of NOM of splenic injuries.

CONCLUSIONS

The grade of splenic injury is an important and significant independent predictor factor for the success of NOM. NOM is not recommended in patients with high-grade splenic injury.

Retroperitoneal schwannoma

Retroperitoneal schwannomas are rare tumors and a correct pre-operative diagnosis is often not possible. They are usually identified incidentally via cross-sectional imaging. Diagnosis is based on histopathologic examination and immunohistochemistry. A 57-year-old man with a retroperitoneal schwannoma, as an unusual localisation, is presented.

Surgical management of pyogenic liver abscess

BACKGROUND AND AIM

Although Pyogenic Liver Abscess (PLA) has lower mortality rate in recent years due to the broad spectrum antibiotic usage, developed imaging techniques and improved intensive care services, it is still a potentially fatal disease. The objective of this study is to examine the treatment methods and our case load with the current literature.

MATERIALS AND METHODS

Of 55 patients with PLA, between January 2000 and December 2009, records of 28 who received surgical drainage treatment have retrospectively been analysed.

RESULTS

Nineteen (67.9%) of the patients were male, while 9 (32.1%) were female. Average age was 41.07 (15-76). Seven (25%) had associated disease. The most common symptoms were fever and abdominal pain. Twenty three (82.1%) patients had single and 5 (17.9%) had multiple cavitary lesion. Nineteen (67.9%) patients had abscess on the right and 7 (25%) had on the left one, while 2 (7.1%) had on both lobes. All were treated surgically, because of 11 (39.3%) inappropriate localization for percutaneous treatment, 6 (21.5%) insufficient percutaneous drainage, 6 (21.5%) intraabdominal free rupture and 5 (17.7%) multiple cavitary lesion. We observed 5 pulmonary complications, 5 wound infections and 2 perihepatic collections. The average hospital stay was 11.2 days. We observed only two deaths (7.1%).

CONCLUSIONS

Surgical treatment is the sole option for the patients with PLA who; (a) can't be treated by percutaneous drainage or had an unsuccessful one, (b) have multiple abscess cavity, (c) are thought to have perforated abscess, (d) have additional abdominal pathology requiring laparatomy.

Pancreatic cystic lymphangioma: report of a case

We herein present a patient referred to our clinic with the complaints of flatulence and left upper quadrant abdominal pain who was diagnosed to have pancreatic cystic neoplasia radiologically. The septated cyst was defined to be 9x12 cm in diameter by abdominal computed tomography and by ultrasonography originated from the tail of the pancreas. Distal pancreatectomy procedure with complete resection of the cystic lesion was performed in this patient. Pathologic examination revealed pancreatic cystic lymphangioma (PCL). Although PCL is very rare in adult patients, it can cause confusion due to the presence of other cystic pathologies of the pancreas. Complete excision of the cyst is mandatory to prevent recurrences. In our case, no recurrence was detected after a two-year follow-up.

Intestinal perforation due to miliary tuberculosis in a patient with Behcet's disease

Gastrointestinal manifestations of both Behçet's disease and intestinal tuberculosis include the signs and symptoms of abdominal pain, weight loss, fever, vomiting, diarrhea and palpable mass in the right lower quadrant. We report the case of a male patient with Behçet's disease who had multiple ileal perforations due to miliary tuberculosis. It was suspected that the perforations were due to intestinal manifestation of Behçet's disease, but the final pathology report and chest X-ray one week after surgery demonstrated the presence of miliary tuberculosis. To our knowledge, this is the first reported case of Behçet's disease with intestinal perforation due to miliary tuberculosis.

Laparoscopic repair of ventral and incisional hernias: our experience in 150 patients

BACKGROUND

Incisional hernias develop in 2 to 20% of laparotomy incisions. Approximately 100,000 ventral hernias are operated on each year in the United States. The reported recurrence rates for open repair are 25-52% for primary and 12.5-19% for mesh repair. Compared to the open technique, laparoscopic repair has low rates of complications and recurrence, greater patient acceptance, and shorter hospital stay.

MATERIALS AND METHODS

Between April 1999 and April 2004, we treated 150 patients (111 female, 39 male) with ventral and incisional hernias laparoscopically. Data concerning the age and sex of patients, the location, number, and size of fascial defects, the type of hernias and their contents, the size and type of meshes used in repair, operative time, length of hospital stay, and postoperative complications were collected.

RESULTS

Of the 150 patients, 92 had incisional hernias and 58 had umbilical hernias. Polypropylene was used in 85 cases, dual mesh in 40 cases, and composite mesh in 25 cases. The mean age of the patients was 56.0 years (range, 33-81 years). Mean operative time was 63 minutes (range, 30-125 minutes). Mean postoperative hospital stay was 2.5 days (range, 1-15 days). The postoperative complication rate was 8.6% (seroma, paralytic ileus, small bowel injury, and suture-site neuralgia). The mean follow-up period was 32 months (range, 4-60 months). There was a 3% recurrence rate. Three subileus cases were detected during follow-up.

CONCLUSION

The laparoscopic approach to ventral and incisional hernias is safe, feasible, and a good alternative to the open approach. Our results are comparable with those of other reports in the literature.

Postoperative recurrence in hepatic hydatid disease

Recurrence of hepatic hydatid disease is still a serious problem in endemic areas like our country. In this study, we present the causes and management of recurrences after surgical therapy of the hepatic hydatid cysts. Hepatic hydatid cyst patients treated surgically and followed afterward at Istanbul University, Cerrahpasa Medical Faculty, Department of General Surgery between January 1998 and January 2003 were evaluated retrospectively. During this period, 172 primary patients with hepatic hydatid disease were attended to at our clinic. Morbidity and mortality rates for this series were 5.8% and 0.58%, respectively. Recurrence rate was 4.65% during the follow-up period of 60.5 months (range, 25-84 months). Primary causes of recurrence were thought to be unnoticed cysts with exophytic development due to inadequate incision and exposition and spreading of the disease during conservative operative interventions. It is concluded that selection of the proper incision allowing complete exposition, and performance of pericystectomy in solitary, peripherally located cysts prevent recurrence.

Simultaneous rupture of the liver and spleen in a patient on warfarin therapy: report of a case

Although there are many reports describing spontaneous rupture of either the spleen or the liver, the simultaneous rupture of both organs is a rare event, especially during anticoagulant therapy. We report a case of spontaneous rupture of the spleen and liver in a patient on warfarin therapy for deep venous thrombosis.

Inguinal endometriosis

INTRODUCTION

Extrapelvic endometriosis is a rarely seen condition and it is occasionally presented to the general surgeons. It is often diagnosed incidentally.

CASE REPORT

In this report we presented three cases of inguinal endometriosis all of which were thought to be inguinal hernia preoperatively. They were diagnosed during the operation for inguinal hernia repair and treated with simple excision of the lesions with a part of the round ligament.

Totally Laparoscopic Pericystectomy in Hepatic Hydatid Disease

Hepatic hydatid disease is still a commonly seen problem in endemic areas as well as in our country. There is a wide spectrum of therapeutic modalities ranging from simple medical treatment to radical liver resection. Progress in laparoscopic procedures made it possible to consider laparoscopic approaches in selected patients with hepatic hydatid disease. The current laparoscopic approach seems to be limited to cystotomy and drainage. There are fewer reports on hepatic resections or pericystectomy in the literature. In this article we present a case of laparoscopic pericystectomy performed in a selected patient.

Stump appendicitis and generalized peritonitis due to incomplete appendectomy

Stump appendicitis is a rare clinical situation when there is incomplete appendectomy. A wide spectrum of diseases in the differential diagnosis of right lower quadrant pain of the abdomen and presence of appendectomy operation in a patient's history delay the diagnosis. We report such a case of perforated stump appendicitis and generalized peritonitis occurring eight months after appendectomy.

Choledochal cysts in adults and the importance of differential diagnosis

BACKGROUND/PURPOSE

Choledochal cysts, congenital cystic dilatations of the hepatobiliary tree, present diagnostic dilemmas. In countries where hydatid disease is endemic, this rare pathology may be overlooked. The importance of this issue led us to reexamine our clinical material to evaluate our findings and management.

METHODS

This study examined 12 patients (11 females, 1 male) who were treated at the University of Istanbul, Cerrahpasa Medical Faculty, with the diagnosis of choledochal cyst between 1981 and 2000. The cases were examined retrospectively, and the complaints, diagnostic methods, findings, and management were discussed.

RESULTS

Ten of the cysts were type I (83.3%), one was type II (8.3%), and one was type IV (8.3%). Three of the patients underwent operation with the diagnosis of liver hydatid cyst, but during the operation the cysts were found to be choledochal cysts. In six of the patients, the cysts were correctly diagnosed, and they were excised.

CONCLUSIONS

Contemporary approaches to treating choledochal cysts focus on total removal of the cyst. In a country where hydatic diseases are endemic, hepatobiliary cystic lesions are often misdiagnosed clinically and radiologically as hydatid cysts. Considering that percutaneous and laparoscopic approaches are being increasingly adopted for treatment of hydatid cysts, the problematic area must be subjected to thorough examination for cystic lesions. The possibility of choledochal cysts must always be kept in mind; otherwise, an unfavorable process may begin for both patient and surgeon.

Primary splenic hydatidosis

BACKGROUND

A hydatid cyst is still a serious health problem in endemic areas. Invasion of the spleen is rare in hydatid disease. In the medical literature, reports about isolated splenic hydatidoses are quite rare. Also there is not a consensus about the way of treatment.

METHODS

Between 1978 and 2000, in our clinic approximately 900 patients were operated on for an abdominal hydatidosis; 850 of these patients were treated for a hepatic hydatidosis and 14 patients for an isolated splenic hydatidosis. Six (42.8%) of the latter patients were male and 8 (57.1%) were female. The mean age of the patients was 47.14 +/- 4.9 (range 17-72) years. Ten patients (71.4%) presented with a painful mass in the left upper quadrant of the abdomen, and the other 4 patients (28.5%) were asymptomatic and were diagnosed incidentally.

RESULTS

All of the patients underwent elective splenectomy. There was no mortality, but complications occurred in 4 (28.5%) patients. The period of hospitalization ranged from 7 to 17 days with a mean of 9.8 days. 1 patient died from an acute myocardial infarction during the 2nd postoperative year, and 1 patient died as a consequence of a traffic accident during the 5th postoperative year. Nine patients, after follow-up periods of between 2 and 14 years, are living free from disease. No recurrence occurred in any of them. In the remaining 3 patients, long-term follow-up could not be maintained.

CONCLUSIONS

A hydatid cyst must be included in the differential diagnosis of cystic lesions of the spleen. A splenic hydatid cyst should be treated surgically due to the high risk of a rupture, and the ideal procedure in adulthood is standard splenectomy.

Comparison of PTFE, pericardium bovine and fascia lata for repair of incisional hernia in rat model, experimental study

Incisional hernia is a frequent complication of abdominal surgery developing in 11-20 % of patients undergoing an abdominal operation. Regarding morbidity and loss of manpower, incisional hernias continue to be a fundamental problem for surgeons. In this experimental study, three commonly used mesh materials (Goretex PTFE; Tutoplast Fascia lata; Tutopatch Pericardium bovine) were compared according to effectiveness, strength, adhesion formation, histological changes, and early complications. Three groups, each consisting of 14 rats, have been formed as group A: polytetrafluoroethylene (PTFE), group B: pericardium bovine and group C: fascia lata. Evaluations were achieved at the end of the first and second postoperative week, respectively. Adhesion formation, wound maturation, bursting pressure, and tensile strength were evaluated. No statistically significant difference regarding adhesion formation was observed between groups although adhesion formation was less significant in PTFE and pericardium bovine groups than in the fascia lata group. Bursting pressure and tensile strength values were significantly higher in PTFE group than in the fascia lata group ( P<0.05). No statistically significant difference was observed between groups regarding wound maturation. In this experimental model, PTFE and pericardium bovine were found to be superior to fascia lata in abdominal wall repair.

Partial fistulotomy and modified cutting seton procedure in the treatment of high extrasphincteric perianal fistulae

AIM

In our prospective study the method of partial distal fistulotomy and modified cutting seton for high extrasphincteric perianal fistulae is discussed.

METHODS

10 patients (9 males and 1 female) with high extrasphincteric perianal fistulae were treated with partial distal fistulotomy and modified cutting seton. Four or five threads were introduced through the tract; one was tied tightly at the end of the operation, others were tightened every 10th day. While the tied thread cut the tissue, the others drained the tract. The follow-up period ranged from 3 months to 9 years.

RESULTS

None of the patients developed major fecal incontinence. 2 of the 10 patients complained of incontinence due to flatus.

CONCLUSION

Distal fistulotomy and modified cutting seton can be used in perianal fistulae with high anal or rectal opening, because it combines the effects of both cutting and loose setons and because the postoperative results regarding continence are satisfactory.

Sacrococcygeal pilonidal sinus disease with Limberg flap repair

Sacrococcygeal pilonidal sinus disease affects younger persons, resulting in long-term loss of productive power. It also has a high rate of morbidity because there is no standard treatment approved by all surgeons. In this study, early and late results of 85 cases treated with excision and Limberg flap in our clinic were investigated. The patients were followed for 9-120 months. The complication rate was 4.7% and the long-term relapse rate was 3.5: Insufficient personal hygiene and inadequate excision were the main causes for recurrence. On the basis of the literature and our previous experiences, we conclude that the Limberg flap is the ideal treatment for sacrococcygeal pilonidal sinus disease with low morbidity, mortality and recurrence rates.

Gastric duplication cyst

BACKGROUND/AIM

The aim of this study is to evaluate the diagnostic and therapeutic difficulties of gastric duplication cysts.

METHODS

A 38-year-old female patient presented with dyspepsia and repeated episodes of epigastric pain. She was operated with the diagnosis of pancreatic pseudocyst according to her US and CT scans, and found to have a gastric duplication cyst. A cyst about 80x80 mm, localized on the posterior wall of the corpus of the stomach close to the fundus, was dissected from the surrounding tissues and partially from the gastric wall. The cyst did not have muscle layer on the common wall with the stomach, so the cystic mucosa was stripped away from the gastric muscle layer. The gastric lumen was not entered.

RESULTS

Although gastric duplication cysts do not have specific symptoms and signs, CT, MR and endoscopic ultrasonography may help the preoperative diagnosis, but the diagnosis is usually confirmed at laparotomy. Needle aspiration may cause complications.

CONCLUSION

Because of the complications that may occur after needle aspiration and malignant potential of the tissue, the treatment of these cysts is surgical.

Management of a patient with hepatic-thoracic-pelvic and omental hydatid cysts and post-operative bilio-cutaneous fistula: a case report

In humans, most hydatid cysts occur in the liver and 75% of these are single. Our patient was a 31 year-old male. His magnetic resonance imaging (MR) showed one cyst (15 x 20 cm) in the right lobe and three cysts (5 x 6 cm, 8 x 6 cm, and 5 x 5 cm) in the left lobe of the liver, two cysts (4 x 5 cm and 5 x 5 cm) on the greater omentum, and two cysts (15 x 10 and 10 x 10 cm) in the pelvis. The abdomen was entered first by a bilateral subcostal incision and then by a Phennenstiel incision. Partial cystectomy + capitonnage was done on the liver cysts; the cysts on the omentum were excised, and the pelvic cysts were enucleated. The cyst in the right lobe of the liver was in communication with a thoracic cyst. An air leak developed from the thoracic cyst which had underwater drainage and bile drainage from the drain in the cavity of the right lobe cyst. Sphincterotomy was done on the seventh post-operative day by endoscopic retrograde cholangiopancreatography (ERCP). No significant effect on mean bile output from the fistula occurred. Octreotide therapy was initiated, but due to abdominal pain and gas bloating the patient felt and could not tolerate, it was stopped on the fourth day; besides, it had no decreasing effect on bile output during the 4 days. Because air and bile leak continued and he had bile stained sputum, he was operated on on post-operative day 18. By right thoracotomy, the cavity and the leaking branches were closed. By right subcostal incision, cholecystectomy and T-tube drainage of the choledochus were done. On post-operative day 30, he was sent home with the T-tube and the drain in the cavity. After 3 months post-operatively, a second T-tube cholangiography was done, and a narrowing in the distal right hepatic duct and a minimal narrowing in the distal left hepatic duct were exposed. Balloon dilatation was done by way of a T-tube. Bile drainage ceased. There was no collection in the cavity in follow-up CT scanning, so the drain in the cavity, and the drainage catheter in the right hepatic duct were extracted. Evaluation of the biliary ductal system is important in bilio-cutaneous fistulas, and balloon dilatation is very effective in fistulas due to narrowing of the ducts.

Ectopic thyroid in the abdomen: report of a case

Ectopic thyroid tissue can be seen anywhere along the path of the descending glands, but it is rarely seen in the abdominal cavity. An ectopic thyroid was encountered incidentally in the pancreas of a 50-year-old woman who underwent a bilateral truncal vagotomy and pyloroplasty for a duodenal ulcer. There were no signs or symptoms of a thyroid tumor.

Effects of cyclosporin and somatostatin on liver regeneration after partial hepatectomy in rats

The major hepatic reaction which occurs in response to degeneration or partial loss of the liver is compensatory hyperplasia. After finding out that hemodynamic factors have no influence in hepatic regeneration, the investigations have been focused on some trophic factors which have been found in the blood and which have been believed to provide the basic control of regeneration. In our controlled experimental study we have tried to evaluate the effects on hepatic regeneration of cyclosporin and somatostatin which are known to act on the hepatic regeneration ability or which are thought to have effects on regeneration because of their mechanism of action. For the purpose of evaluating the regenerative response findings like the weight of the regenerated liver, mean Ag nuclear organizer region (AgNOR) number, the mitosis index, cells with double nuclei and hyperchromatic nucleus were taken into consideration. The results of the cyclosporin group were higher than of the controls, but there was no statistically significant difference between them. In the somatostatin group, an inhibition of regeneration related to the dose and to the duration at the beginning and a delayed augmentation of the regeneration rate due to the withdrawal of the drug were observed. Values of AgNOR were significantly higher compared to the control group on the 5th day postoperatively, while the liver weight was lower on the 1st day (p < or = 0.05).