Seroma Cytology in Breast Cancer: An Underappreciated Issue

BACKGROUND

The presence of malignant cells in postoperative seroma has been ignored in current breast cancer treatment. We aimed to assess the presence of malignant seroma cytology and to evaluate its relationship with the known prognostic factors for breast cancer.

PATIENTS AND METHODS

The solution from irrigation of the operation field and postoperative drainage fluid from 68 patients were prospectively collected and examined for malignant cytology. The results were evaluated according to the tumor characteristics and patient demographics.

RESULTS

Malignant cytology was found in none of the intraoperative samples but was found in the postoperative samples from 4 patients. Of these 4 patients, 3 were free of axillary metastasis. None of the common risk factors for breast cancer was associated with the finding of malignant cytology.

CONCLUSION

Malignant cells can be seen in the drainage fluids from breast cancer patients independent of any contamination occurring during surgery, even in those without axillary metastasis.

Predictors determining the status of axilla in breast cancer: Where is PET/CT on that?

PURPOSE

18 F-FDG PET/CT has an acceptable specificity but a low sensitivity on the prediction of axillary lymph node (ALN) metastasis in breast cancer. We analyzed the factors that could possibly affect this prediction.

METHODS

The records of 270 patients with T1-2 invasive breast cancer who underwent surgery, 116 of whom had been evaluated by preoperative 18 F-FDG PET/CT were reviewed. Prediction of ALN status by PET/CT according to tumor stage, estrogen receptor (ER), progesterone receptor (PgR) and HER2 status, histology, age and sentinel node properties was assessed.

RESULTS

ALN metastasis was present in 62 of 131 T1 (43.7%) and 106 of 142 T2 tumors (74.6%), 20 of 46 (43.5%) ER(-) and 146 of 222 (65.8%) ER(+) tumors, 38 of 71 (53.5%) PgR(-) and 127 of 200 (63.5%) PgR(+) tumors. On multivariate analysis only the tumor size (>2 cm) independently correlated with ALN metastasis (Odds ratio/OR=3.1). None of the other parameters had statistical significance in terms of ALN prediction on FDG-PET/CT.

CONCLUSION

Though T2 tumors showed increased tendency to metastasize to the axilla, prediction of ALN metastasis in preoperative FDG-PET/CT was not associated with any of the predictive factors.

Incidence of congenital hemolytic anemias in young cholelithiasis patients

AIM: To clarify the incidence of congenital hemolytic anemias (CHA) in young cholelithiasis patients and to determine a possible screening test based on the results.

METHODS: Young cholelithiasis patients (< 35 years) were invited to our outpatient clinic. Participants were asked for comorbidities and family history. The number of gallstones were recorded. Blood samples were obtained to perform a complete blood count, standard Wright-Giemsa staining, reticulocyte count, hemoglobin (Hb) electrophoresis, serum lactate dehydrogenase and bilirubin levels, and lipid profile.

RESULTS: Of 3226 cholecystectomy patients, 199 were under 35 years, and 190 with no diagnosis of CHA were invited to take part in the study. Fifty three patients consented to the study. The median age was 29 years (range, 17-35 years), 5 were male and 48 were female. Twelve patients (22.6%) were diagnosed as thalassemia trait and/or ıron-deficiency anemia. Hb levels were significantly lower (P = 0.046), and mean corpuscular volume (MCV) and hematocrit levels were slightly lower (P = 0.072 and 0.082, respectively) than normal. There was also a significantly lower number of gallstones with the diagnosis (P = 0.007).

CONCLUSION: In endemic regions, for young cholelithiasis patients (age under 35) with 2-5 gallstones, the clinician/surgeon should pay attention to MCV and Hb levels as indicative of CHA.

Reaching proficiency in laparoscopic splenectomy

AIM: To investigate the proficiency level reached in laparoscopic splenectomy using the learning curve method.

METHODS: All patients in need of splenectomy for benign causes in whom laparoscopic splenectomy was attempted by a single surgeon during a time period of 6 years were included in the study (n = 33). Besides demographics, operation-related variables and the response to surgery were recorded. The patients were allocated to groups of five, ranked according to the date of the operation. Operation duration, complications, postoperative length of stay, conversion to laparotomy and splenic weight were then compared between these groups.

RESULTS: There was a significant difference regarding operation times between the groups (P = 0.001). An improvement was observed after the first 5 cases. The learning curve was flat up to the 25th case. Following the 25th case the operation times decreased still further. There was no difference between the groups regarding the other parameters.

CONCLUSION: Unlike the widely accepted “L” shape, the learning curve for laparoscopic splenectomy is a horizontal lazy “S” with two distinct slopes. Privileges may be granted after the first 5 cases. However proficiency seems to require 25 cases.

Acute torsion of the gallbladder: a case report

INTRODUCTION

Torsion of gallbladder is an uncommon cause of acute abdomen. Volvulus occurs along the long axis of the gallbladder mesentery, and according to the degree of rotation symptoms, and signs may vary.

CASE PRESENTATION

A 79-year-old woman presented with a one-day history of acute onset of right upper abdominal pain. The patient underwent laparotomy with a preoperative diagnosis of acalculous cholecystitis with possible gangrene. At laparotomy, the gallbladder was distended, and multiple necrotic areas were observed. It was rotated more than 180 degrees clockwise around the mesentery, and cholecystectomy was performed.

CONCLUSION

Cholecystectomy is the treatment of gallbladder torsion. Clinical signs and radiographic studies may be helpful to diagnose gallbladder torsion. Early diagnosis and surgical treatment lower the mortality of disease.

Prospective randomized controlled trial comparing V-Y advancement flap with primary suture methods in pilonidal disease

BACKGROUND

An ideal treatment method for the widely prevalent pilonidal sinus disease is not yet available. The most commonly practiced technique is simple closure following resection of the effected tissue. However, high recurrence rates in some series have led to the search for other methods. One of these methods is the V-Y advancement flap (VYAF), which in theory results in the flattening of the natal cleft without tension in the suture line.

METHODS

In this prospective randomized controlled study, the VYAF method was compared to 2 simple primary closure techniques. In 238 patients, following resection, in the AL (all layers) group, all layers were closed with polypropylene sutures. In the SS (subcutaneous suture) group, polyglactin subcutaneous sutures were used to approximate the wound edges. Skin was closed separately in the SS group. In addition, demographic variables, past history, physical examination findings, defect dimensions, and wound tension were recorded.

RESULTS

Surgical site infection was observed in 23.9%, 17.4%, and 10.2% of the patients in AL, SS, and VYAF groups, respectively (P = .129). Early wound dehiscence without infection was detected in 11.9%, 7.4%, and 10.2% of the patients in groups AL, SS, and VYAF, respectively (P = .665). Mean follow-up was 29.7 +/- 15.6 months. Survival (time without recurrence) was not significantly different between groups (P = .648). In the whole group, independent predictors of recurrence according to logistic regression analysis were younger age, recurrent disease, presence of discharge on physical examination, and development of postoperative surgical site infection.

CONCLUSIONS

VYAF is not superior to simple primary closure techniques in terms of postoperative complications, recurrence, and patient satisfaction. For most cases, simple primary closure would suffice. Patients should be informed of the increased risk of recurrence if any of the independent predictors (being a recurrent case, presence of discharge, development of postoperative infection) are present.

Mucinous cystadenoma of the appendix: a rare cause of acute abdomen

BACKGROUND

We aimed to assess the acute abdominal conditions due to appendiceal mucinous cystadenomas.

METHODS

We retrospectively evaluated 11 patients with histopathologically confirmed appendiceal mucinous cystadenoma. Patient charts and data on patient demographics; clinical features; ultrasonography (US), colonoscopy and computed tomography (CT) findings; pathology reports; and operative and postoperative management were reviewed.

RESULTS

The incidence of appendiceal mucinous cystadenoma was 0.95% of all appendectomy specimens reviewed. In our review, there were 11 patients, five of whom were women. The median age was 70 years (50-85 years), and the most common presentation was abdominal pain (81.8%). On US in eight patients, findings were abdominal cystic mass and cyst wall calcification. The CT finding was well-encapsulated cystic mass in eight patients. In one case, a colonic mass was found in colonoscopic examinations. There was one patient with concomitant colon cancer. Appendectomy was performed in nine patients and right hemicolectomy was performed in two patients.

CONCLUSION

Colonoscopy, US, and CT are useful tools in diagnosing mucocele and synchronous cancer. However, diagnosis is usually made intraoperatively or postoperatively on histopathological examination. Appendectomy is the standard of care for mucinous cystadenoma. Furthermore, it is important to prevent spillage of the mucocele content.

Treatment of multiple primary hydatid cysts

Hydatid disease, which is caused by the parasite Echinococcus granulosis, is endemic in certain parts of the world in which humans and sheep live in proximity. Hydatid cysts occur most often in the liver, and affliction with multiple cysts is rare. We present the case of a 48-year-old woman with 55 hydatid cysts (47 in the liver, 5 in the right lung, and 3 in the left lung). The cysts in the right lung were intact, and those in the left lung had ruptured. A partial cystectomy was performed to excise 34 cysts through a right thoracoabdominal incision. The remaining deeply seated cysts were treated by needle aspiration and the ultrasonographically guided injection of hypertonic saline. This case report indicates that open surgery accompanied by ultrasonographically guided aspiration can effectively treat multiple hydatid cysts in a single laparotomy session.

Adhesion molecules as prognostic markers in pancreatic adenocarcinoma

BACKGROUND AND OBJECTIVES

Pancreatic adenocarcinoma is a highly aggressive cancer with high metastatic potential and therefore, a high mortality rate. Ezrin, radixin, moesin, and E-cadherin are transmembrane glycoproteins that regulate cell motility, migration, and metastasis. In this study, we investigated the relationship of ezrin, moesin, and E-cadherin expression with the clinicopathological features of pancreatic ductal adenocarcinoma.

METHODS

Data including demographic features, size and grade of tumor, presence of perineural and lymphovascular invasion, and survival were obtained retrospectively from 46 patient records.

RESULTS

No significant correlation was found among ezrin, moesin, and E-cadherin. Significant correlations were found between ezrin and the tomographic size of the tumor (P = 0.034) and resectability (P = 0.052). Moesin-stained tumors were found to have high lymphovascular (P = 0.030) and perineural (P = 0.036) invasion rates and a high histopathologic grade (P = 0.053). E-cadherin staining was correlated with perineural invasion (P = 0.003) but not with lymphovascular invasion (P = 0.334). Only moesin was correlated with survival in resected pancreatic adenocarcinomas and moesin-negative patients had longer survivals compared with moesin-positive patients (P = 0.021).

CONCLUSIONS

We could not demonstrate a relation between ezrin and E-cadherin staining with survival. However, we found ezrin to be related to local tumor behavior, and moesin to be a potential prognostic molecule.

The adequacy of laparoscopy for continuous ambulatory peritoneal dialysis procedures

The aim of this study was to determine the safety and efficacy of diagnostic/therapeutic laparoscopy in the management of peritoneal Tenchoff catheter placement in end-stage renal disease patients who had previous abdominal surgery and malfunctioning peritoneal dialysis catheters. From 1999 to 2004, 16 videolaparoscopic procedures were performed in 16 patients who had previous laparotomies. Laparoscopy was performed before peritoneal catheter placement in seven (group 1) and in 9 patients with peritoneal dialysis catheters in place, laparoscopy was performed for the management of catheter dysfunction (group 2). All laparoscopic procedures were performed under general anesthesia. The mean follow-up was 31.5 (range, 11 to 60) months. In group 1, six patients (85.7%), and in group 2, seven patients (77.7%) are still on peritoneal dialysis. Laparoscopy resulted in the placement/salvage of peritoneal dialysis catheter dysfunction. Placement of catheter was accomplished in patients who would have been previously designated as unsuitable candidates. Laparoscopy is a useful tool in every step of a peritoneal dialysis program.

Laparoscopic management of gallbladder duplication

Gallbladder duplication is a rare condition. Because laparoscopic cholecystectomy is the primary treatment modality for the diseased single gallbladders, it should be the choice of treatment for double gallbladders. However, preoperative imaging methods may be unsatisfactory for the correct diagnosis. As a result, incomplete resections may be performed. Intraoperative cholangiography should be performed in suspected cases to prevent inadvertent injury to the biliary system. In this report, we present a symptomatic patient with double gallbladders with separate cystic ducts in whom the gallbladders were successfully resected as a single specimen by laparoscopic means. The pitfalls of diagnostic modalities and surgical strategy are discussed in the context of the available literature.

Giant hepatic hydatid cyst: A case report

Large type 1 cysts are prone to perforation. Furthermore, insufficient drainage with subsequent abscess is a frequent problem of large cysts. We report here a case of a 19-year old man who was admitted to the hospital with pain in the right upper quadrant and epigastric region. An asymmetrical right upper quadrant enlargement was detected on physical examination. Ultrasonography and computerized tomography revealed a type 1 giant hydatid cyst in the right hepatic lobe, measuring 16 cm in diameter. During operation, partial cystectomy and drainage were done. The large dead space was obliterated by the ‘sandwich’ method. Omentum and gelatin sponges were used to fill the cavity. The postoperative period was uneventful and the patient was discharged on the 5^th postoperative day.

The effect of metoclopramide on gastric emptying in traumatic brain injury

OBJECTIVE

Gastric paresis in traumatic brain injury (TBI) hinders the effectiveness of enteral support in this patient group. In this study we have investigated the effect of metoclopramide on gastric emptying in TBI patients.

METHOD

In this prospective, randomized, controlled, double-blind study, 19 TBI patients with Glasgow Coma Scale scores of 3-11 were included. In all patients, enteral nutrition was commenced with a nasogastric feeding tube within 48 hours of trauma. Patients were randomized into two groups. In the metoclopramide (M) group, 10 mg metoclopramide was delivered intravenously three times daily for 5 days. In the control (C) group, an equal volume of saline was administered. Besides demographics, gastric emptying according to a paracetamol absorption test at days 0 and 5, time to reach target nutritional requirements, gastric residues, intolerance to feeding, nutritional complications, and clinical outcomes were recorded for each patient.

RESULTS

The gastric residue rates were 2.7+/-7.4 mL and 8.1+/-17.7 mL per 100 patient days for groups C and M respectively (p=0.408). Similarly, feeding intolerance and complication rates did not significantly differ between groups C and M, (respectively p=0.543 and 0.930). Gastric emptying parameters also were similar between the study groups.

CONCLUSION

We were unable to document any advantage to using metoclopramide in TBI patients. Simple intragastric enteral feeding with close monitoring of the possible complications seems to be sufficient with acceptable morbidity rates.

The effect of preoperative blood transfusion on morbidity and survival in colorectal malignancy

BACKGROUND/AIMS

It is believed that blood transfusions adversely affect colorectal cancer surgery. However, intra- and postoperative blood transfusions represent urgent interventions, and immeasurable confounding factors may affect the shortand long-term outcome. Therefore, we compared colorectal cancer patients who had received preoperative blood transfusion with patients who did not receive transfusions with regard to postoperative complications and long-term outcome.

METHODS

The records of 333 patients who were operated for colorectal malignancy between 1980 and 1995 were evaluated.

RESULTS

Sixty-one patients (18.3%) received preoperative blood transfusions. Wound infection rate was higher (14.2% vs 1.9%) in the no-transfusion group. Disease-free survival was not different between the groups (p=0.134). Cumulative survival was adversely affected in the preoperative transfusion group (p=0.012). However, preoperative blood transfusion did not emerge to be an independent factor for wound infection or for death on follow-up when the confounding factors were corrected.

CONCLUSION

Preoperative transfusion during surgery for colorectal malignancy does not result in an increase in postoperative complications, long-term failure or death rates.

Microvessel density, VEGF expression, and tumor-associated macrophages in breast tumors: correlations with prognostic parameters

Angiogenesis plays an important role in tumor growth, metastasis, and prognosis. Vascular endothelial growth factor (VEGF) is a potent endothelial mitogen and acts on the angiogenic stimulation of human neoplasias. In infiltrative ductal carcinoma (IDC), VEGF expression is correlated with high vascularity. Tumor-associated macrophages (TAMs) contribute to tumor proliferation, progression and angiogenesis and have a complex role in tumor biology. In this study, the correlations between microvessel density (MVD), VEGF expression, and TAMs and their relations to clinicopathological parameters such as tumor size, metastatic lymph node, mitotic activity index (MAI) and tumor grade were investigated in 48 cases of IDC and 30 infiltrative lobular carcinoma (ILC) cases. MVD showed a significant positive correlation with TAMs, VEGF, metastatic lymph nodes, tumor size and grade in IDC (P < 0.001). In ILC, MVD and tumor size were positively correlated (P = 0.003), while MVD was not correlated with VEGF, TAMs, MAI, metastatic lymph nodes, and grade. These findings are suggestive of angiogenesis stimulation in IDCs by VEGF, driving the macrophages into the tumor area. MVD and TAMs were found to be important prognostic factors in IDCs. On the other hand, however, VEGF did not contribute to angiogenesis in ILCs, and MVD and TAMs did not have any prognostic significance. These results suggest the involvement of factors not related to VEGF in the angiogenesis of lobular carcinoma.

Effects of a static magnetic field on wound healing: results in experimental rat colon anastomoses

BACKGROUND

Research has shown that pulsed electromagnetic fields (EMFs) promote wound healing in experimental colonic anastomosis; however, the effects of static EMFs in this setting have not been investigated to date.

METHODS

Fifty male Wistar rats were used. Ten served as controls for mechanical strength testing, and the other 40 underwent descending colon resection and anastomosis. Twenty of these 40 animals (M group) had NeFeB magnets placed in contact with the anastomosis site (magnetic field strength at the site 390 to 420 G). The other 20 animals (sham [S] group) had non-magnetized NeFeB bars of the same dimensions and weight implanted. Half of the animals in each group were killed and assessed for healing parameters on postoperative day 3 (M3 and S3 groups) and the other half on postoperative day 7 (M7 and S7 groups). Four types of assessment were done: gross healing, mechanical strength, hydroxyproline deposition, and histopathology.

RESULTS

There were no differences between the M and S animals with respect to gross healing parameters. The mechanical strength was also not different between groups (23.8 +/- 12.7 and 24.7 +/- 9.6 mm Hg for M3 and S3, respectively; P = .863 and 91.3 +/- 65.4 and 94.8 +/- 55.9 mm Hg for M7 and S7, respectively; P = .902). Similarly, hydroxyproline deposition was not different between groups on postoperative day 3 or day 7. On postoperative day 3, the M group had significantly higher scores than the S group for fibroblast infiltration (2.4 +/- 0.7 vs 1.4 +/- 0.7, respectively; P = .008) and capillary formation (2.5 +/- 0.7 vs 0.9 +/- 0.4, respectively; P <.001). However, these effects were reversed and did not endure by day 7.

CONCLUSIONS

The study results suggest that static EMF has no effect on experimental colonic wound healing in the rat.

Thoracic epidural anesthesia and analgesia for gastric resection at 26 week pregnant woman

Anesthesia and surgery are required in up to 1.5% to 2% of all pregnancies. Alterations in maternal anatomy and physiology create potential risks for both mother and fetus. The anesthetic considerations for any surgery during pregnancy must take both patients into account. Gastric adenocarcinoma presenting during pregnancy is a rare condition and has a poor prognosis. This report describes anaesthetic management of a woman who was diagnosed with gastric adenocarcinoma at 26 weeks' gestation. Distal subtotal gastrectomy was planned in an attempt to maximize the mother's life expectancy while maintaining the pregnancy until the fetus reached viable gestation. A combination of general anesthesia and thoracic epidural anesthesia was used. The goal was to reduce physiological stress and minimize anesthesia risk for both mother and fetus and also diminish the neuroendocrine response during the surgery. The patient was discharged from the hospital 10 days after the surgery and was then readmitted at 30 weeks' gestation for an elective cesarean section.

Hydrodissection with adrenaline–lidocaine–saline solution in laparoscopic cholecystectomy

AIM

This investigation examined the effects of a solution injected to the gallbladder bed on operative time, bleeding, incidence of gallbladder perforation, and postoperative pain.

METHODS

One hundred sixty-four consecutive patients with cholelithiasis were randomized into two clinically comparable groups. In group 1 (84 patients), 40 ml of saline-adrenaline-lidocaine solution was injected between the gallbladder and liver. In group 2 (80 patients), laparoscopic cholecystectomy was performed without hydrodissection. The time taken to dissect the gallbladder from the liver, bleeding from the liver bed, incidence of gallbladder perforation and spillage of bile and stones, duration of operation, amount of gas used for the laparoscopic cholecystectomy, conversion to open cholecystectomy, postoperative pain and pain localization were recorded.

RESULTS

The mean dissection time, amount of gas used, incidence of gallbladder perforation, spillage of stones, and liver bed bleeding were not significantly different between the groups. There also was no significant difference between the groups regarding postoperative pain and pain localization.

CONCLUSION

Hydrodissection did not reduce time to dissect the gallbladder from the liver or risk of gallbladder perforation. Similarly, adrenaline and lidocaine injection between the gallbladder and the liver did not effect bleeding from the dissection area and did not alter postoperative pain or pain localization.

Scalding in Turkish children: comparison of burns caused by hot water and hot milk

INTRODUCTION

Our aim in this study was to compare the clinical differences and etiologic risk factors for hot water and hot milk scald burns in Turkish children.

METHODS

The retrospective study examined the cases of 140 children aged 0.1-7 years who had scald burns treated in three burn units of a Turkish hospital network between March 2000 and December 2004. The patients were categorized in two groups: hot water burns or hot milk burns.

RESULTS

Ninety-five (67.9%) patients had hot water burns and 45 (47.1%) had hot milk burns. The proportion of patients with hot milk burns who lived in rural areas was significantly higher than the corresponding proportion for the hot water cases (75.6% versus 52.6%, respectively; p<0.01). In 20 (44%) of the hot milk cases, the burn was caused by milk being boiled in large pots outdoors for cheese production. The other 25 hot milk cases were caused by milk being boiled in the kitchen. The mean (+/-S.D.) percentage total body surface area burned in the hot milk cases was higher than that in the hot water cases (33.6+/-2.24% versus 21.42+/-1.43%, respectively; p<0.001), and the corresponding mean percentages of TBSA with full-thickness burns were 9.2+/-2.52% versus 3.13+/-0.83%, respectively; (p=0.083). The mean percentages of TBSA with second-degree burns showed the same trend (29.0+/-12.39% versus 18.8+/-1.47%, respectively; p<0.001) higher percentage of the children with hot milk burns required antibiotics (78% versus 52.8%, respectively; p<0.006). Seven (7.4%) of the hot water burn patients and 15 (33.3%) of the hot milk burn patients died during the study period (p=0.025; overall mortality rate 15.7%).

CONCLUSION

Children scalded with hot milk tend to have more extensive burns, and thus have higher mortality, than those scalded with hot water. To create effective programs for preventing scald injuries in Turkey and elsewhere, it is essential to consider ethnic and cultural issues based on these characteristics. Simple precautions should be explained and methods of using liquids such as hot milk should be researched in different geographic locations in order to formulate good prevention strategies.

Surgical treatment of liver hydatid cysts

BACKGROUND

The surgical treatment technique for liver hydatic cyst (LHC) cannot be standardized, and the surgical technique should be tailored according to the extent of the cyst and any adjunct complications of hydatid disease.

PATIENTS AND METHODS

All patients were treated with albendazole (10 mg/kg/day) for 15 days preoperatively. Total pericystectomy was performed in three patients (7%). Partial cystectomy and its modifications were performed in the remaining 41 patients (93%).

RESULTS

A total of 44 patients were operated on for LHC between December 1998 and October 2004 in our center. Patients were evaluated with ultrasonography and computed tomography scan to determine the extent of the disease and preoperative staging. Twenty-four (53%) of these patients were women and 20 were men (median age, 52.5 years; range, 19-81 years). The majority of patients (n=27) had 1 cyst, and the remaining 17 patients had multiple cysts. In four patients (9.1%), daughter cysts were found in the biliary system, and abscesses were present in three patients (7%). Biliary fistula was the most frequent complication (n=5). Three patients had wound infections. Follow-up was complete for 33 patients (75%). The mean postoperative follow-up was 11.9+/-10.8 months; there were four recurrences during this time.

DISCUSSION

The aim should be to provide complete drainage and obliteration of the cavity. Bile leak and biliary obstruction may complicate the postoperative course if bile leakage into the peritoneal cavity and obstruction in the biliary system are missed.

Epidemiology of Pediatric Burn Injuries in Southern Turkey

The aim of this study was to identify the epidemiological features of pediatric burn injuries in southern part of Turkey. In this retrospective study, 137 hospitalized pediatric patients (85 men and 52 women) who were admitted to our burn unit during a period of 3 years were analyzed. Pediatric patients were categorized into three groups: the infants and toddlers (0-2 years), early childhood (3-6 years), and late childhood (7-15 years). Epidemiological data included age, sex, location, the cause and type, and place of burn. In the first two groups, scalding (95.1% and 86.7%, respectively) was the predominant cause of burn whereas in late childhood electric burns (51.4%) were a more common occurrence. No differences were found between the groups with respect to mean TBSA and full-thickness burns. A total of 15 (10.1%) patients died during the study period. A total of 74.4% of burn injuries occurred at home, and almost all were preventable, with 16 % of the burns occurring in the autumn; however, 42% occurred in the summer. These findings will be used as a basis for developing targeted preventive programs to protect children from burns. We also consider it is necessary to educate children and their parents about the prevention of burn injuries.

Simple two-part tool for screening of malnutrition

OBJECTIVE

Malnutrition in hospitalized patients is a major problem that is underdiagnosed. Early recognition of malnutrition is important for nutritional support to be effective. Our aims were to determine the malnutrition rate at our center and to devise an effective screening tool for identifying patients at risk for malnutrition.

METHODS

This prospective study included 2211 patients. Each subject was assessed for malnutrition by the Subjective Global Assessment (SGA), and combination criteria (CC), which included anthropometric measurements and laboratory testing. Findings based on these methods were compared with findings in a series of malnutrition screening tests (malnutrition screening tool, self-assessment portion of a mini-nutritional assessment, a question about unintentional weight loss, evaluation of loss of subcutaneous fat, and various combinations of these).

RESULTS

The SGA and CC methods identified 242 (11.0%) and 345 (15.6%) patients as malnourished, respectively. Of the screening methods that were tested, the combination of unintentional weight loss and loss of subcutaneous fat proved to be the most valuable, with 93% accuracy for predicting malnutrition according to the SGA, and 82.9% accuracy for predicting malnutrition according to CC. The corresponding negative predictive values were 95.5% and 87.3%.

CONCLUSIONS

The results show that this simple two-part nutritional screening tool (unintentional weight loss and loss of subcutaneous fat) is valuable for identifying malnutrition according to the SGA and CC at our institution; however, its validity must be confirmed at other centers.

A New weighted scoring system for Subjective Global Assessment

OBJECTIVE

Subjective Global Assessment (SGA) is a widely used and validated method for identifying and classifying malnutrition. Recently, in effort to assess nutritional status more accurately, quantitative systems have been devised in which scores are assigned for items or components of the SGA. In addition to validation of conventional SGA in our patient population, this prospective study investigated the association of a recently devised quantitative SGA (Q-SGA) method and an invented modified Q-SGA (MQ-SGA) scoring system with conventional SGA.

METHODS

A total of 2197 patients was evaluated. Each subject was assessed for malnutrition by SGA, anthropometric measurements, and laboratory testing. The items of SGA were scored by assigning 1 point for each increasing severity level to obtain the Q-SGA score. In the invented MQ-SGA system, the items were entered into the logistic regression model and weighted scores were calculated according to the weighted effect of the SGA items. The efficiencies of Q-SGA and MQ-SGA were compared to predict malnutrition according to SGA.

RESULTS

Eighty-nine percent of patients were classified as well nourished according to conventional SGA, whereas 27 patients (1.2%) were classified as severely malnourished. When patients were grouped according to binary SGA outcome (well nourished versus malnourished), receiver operating characteristics curve areas for the Q-SGA and MQ-SGA scores were 0.897 (95% confidence interval = 0.875-0.919) and 0.952 (95% confidence interval = 0.939-0.964), respectively. The cutoff points for Q-SGA and MQ-SGA were identified as 10 and 18, respectively. Although the sensitivity of these systems in identifying malnutrition were similar (90.0% and 90.9%, respectively), the specificity of MQ-SGA was greater than that of Q-SGA (85.6% versus 67.0%).

CONCLUSIONS

The findings suggest that MQ-SGA outperforms Q-SGA in identifying malnutrition according to SGA. Future nutrition scoring studies need to take into account the weighted effects of items on outcome.

Radiological findings of primary retroperitoneal synovial sarcoma

Synovial sarcomas are most commonly localized in the extremities, especially the lower thigh and knee areas. Retroperitoneal synovial sarcoma is very rare. We describe the radiological and pathological findings of an adult retroperitoneal synovial sarcoma.

Transurethral prostatectomy and inguinal hernia repair in a single session

INTRODUCTION

We aimed at evaluating the outcomes of transurethral prostatectomy and inguinal hernia repair performed in a single session.

PATIENTS AND METHODS

Fifty-six patients (mean age 68+/-8.3 years) in whom transurethral prostatectomy was performed combined with an inguinal hernia repair were included into the study. Type of anesthesia, technique of inguinal hernia repair, hospitalization time, and the complications encountered were recorded. Cost comparisons were made using the official price-lists of the Turkish Medical Association. All patients were asked whether they were satisfied with the outcome of both operations performed in one session. The data obtained from the patients who underwent both operations in one session were compared with those obtained from 56 patients who underwent transurethral prostatectomy only (control group). Statistical analysis was performed using the chi-square test corrected for continuity according to the Yates or the Fisher exact test.

RESULTS

The operations were performed in 19 patients under general, in 20 patients under epidural, and in 14 patients under spinal anesthesia. Three patients were given general anesthesia and spinal anesthesia combined. In 6 patients bilateral and in 50 patients unilateral hernia repair was performed. In 11 repairs, polyprolene mesh grafts were utilized; in 2 repairs, a laparoscopic method was used, and in the remaining 49 repairs, one of the conventional techniques (McVay, Bassini, or Shouldice) was employed. There were no significant differences with regard to early and late postoperative complications and satisfaction between study group and control group (p>0.05). Combined prostatectomy and hernia repair allows approximately 30% cost profit.

CONCLUSIONS

Performing transurethral prostatectomy and inguinal hernia repair in one session decreased the number of the operations and anesthesias, hospital stay, and thus health costs and did not cause an increase in operative and postoperative morbidity.

Giant adrenal hemangioma: a case report

Although adrenal masses are relatively common, hemangiomas occurring in adrenal glands are rare. This entity creates problems in the differential diagnosis. We report a patient with a giant cavernous hemangioma with a diameter of 13 cm, which was pre-operatively diagnosed as an adenoma or a malignant tumour. Clues to the correct diagnosis and therapeutic alternatives are discussed in the context of the available literature.

Laparoscopic Repair of Bilateral Morgagni Hernia

Morgagni hernias are rare and comprise approximately 3% of the congenital diaphragmatic hernias that are observed in 1 in 4800 live births. A 50-year-old female patient who complained of nonspecific chest pain radiating to the right arm for approximately 1 year presented. Chest x-ray revealed a right-sided paracardiac mass diagnosed Morgagni hernia by computerized tomography of the thorax. Laparoscopic exploration showed that the retrosternal hernia was actually a bilateral one. After reducing the contents of the hernial sacs, the defects were closed as a single defect with hernia stapler starting from each end and an appropriate sized polyprolene mesh was closed over the repair site. The patient did not have any symptoms of recurrence after 3 months. Recent advances in video-endoscopic surgery made it possible to perform repairs of these hernias less traumatic and more comfortable to the patients than the conventional transabdominal or transthoracic methods.

Expression of survivin, bcl-2, P53 and bax in breast carcinoma and ductal intraepithelial neoplasia (DIN 1a)

Survivin is a recently discovered member of the family of proteins that inhibits apoptosis. This anti-apoptotic compound can be detected in most types of cancer and expression is associated with a poor prognosis. We, immunohistochemically, investigated the expression of survivin in breast carcinomas and intraductal epithelial neoplasia of the breast to determine whether expression of this protein is associated with clinicopathological parameters such as grade, stage, mitotic rate. In 34 out of 43 cases (79.1%) of breast carcinoma and 22 out of 62 cases (35.4%) of intraductal epithelial neoplasia with mild, moderate and severe ductal epithelial, cell hyperplasia stained positively for survivin. None of the histological parameters analyzed were significantly correlated with survivin expression in breast carcinomas. In the carcinoma cases, survivin expression was positively correlated with expression of bcl-2, but was not correlated with expression of p53, bax, c-erbB-2 and estrogen, or progesterone. Some of the intraductal epithelial neoplasia cases with moderate or severe ductal epithelial hyperplasia stained positively for both survivin and p53. Breast carcinomas exhibited a significant expression of survivin, p53, and bcl-2 compared to breast with intraductal epithelial neoplasia. Survivin was not correlated with any of the clinicopathological parameters studied, however it could be a useful tool in early carcinomas and florid, severe ductal epithelial hyperplasia.

The effect of tissue adhesive, octyl-cyanoacrylate, on the healing of experimental high-risk and normal colonic anastomoses

BACKGROUND

Tissue adhesives may be advantageous over sutures in colonic anastomoses because they do not result in potentially dangerous tight tissue approximation.

METHODS

Ninety male Wistar-albino rats were used in the study. Excluding the 10 animals that constituted the control, the rest of the animals were divided in two groups: normal (N) and high-risk (HR). Only resection and anastomosis were done on half of the animals in each group. Octyl-cyanoacrylate was applied on the anastomosis of the other half of the groups. Anastomotic assessment was done at the third and seventh postoperative days. Gross anastomotic healing, mechanical strength, hydroxyproline deposition, and histopathological healing indices were used for the assessment.

RESULTS

There was no difference in the third day and the seventh day groups regarding the gross healing parameters and hydroxyproline concentration. Similarly there was no difference between the third day groups in terms of mechanical healing (P = 0.669). However, the mechanical strength of the anastomosis assessed the seventh postoperative day was lower in groups in which octyl-cyanoacrylate was applied (P <0.001). Furthermore, inflammatory reaction, presence of necrosis, peritonitis, and exudate was pronounced in groups in which octyl-cyanoacrylate was applied.

CONCLUSIONS

Application of octyl-cyanoacrylate to both normal and high-risk colonic anastomosis does not provide any benefit over conventional suturing at the early phase of the healing. However, octyl-cyanoacrylate seems to be detrimental at the late phase of the healing probably due to the ongoing intense inflammatory reaction.

Burns in Southern Turkey: Electrical Burns Remain a Major Problem

In Turkey, burns represent a relatively small number of injuries overall, but they continue to be a major public health problem. Our aim in this study was to identify risk factors that affect outcome in burn patients hospitalized in the southern part of our country, with special emphasis on electrical burns. The database for 109 burn patients who were admitted to our burn center from April, 2000, through August, 2001, was retrospectively analyzed. Electrical injury was the cause of burn in 23 (21%) of the 109 cases. The burn causes differed among age groups and between the sexes, with males constituting 95% of the electrical burn patients. The mortality rate for the electrical burn group was lower than the rate for the rest of the burn patients (1/23 vs 17/86, respectively; P <.001); however, the opposite was true for complication rate (10/23 vs 5/86, respectively; P <.001), cost of treatment (8351 US dollars vs 5122 US dollars, respectively; P =.009), and length of hospital stay (39.9 vs 26.2 days, respectively; P < 0.001). The rate of electrical burn injury in Turkey has changed very little in the past two decades. This underlines the need for stronger efforts aimed at prevention, such as better public education and strict regulations regarding the distribution and use of electricity.

Sporadic hereditary pancreatic desmoid tumor: a new entity?

Deeply seated aggressive fibromatosis also termed as desmoid tumors are rare tumors that invade surrounding structures. Although they never metastasize mortality rate may be as high as 10% due to their aggressive local behavior. Intraabdominal desmoid tumors are usually associated with familial poliposis coli and have a high recurrence rate regardless of the therapy instituted. Sporadic cases are very rare and generous surgical excision may be of benefit. We hereby report 2 siblings with sporadic pancreatic desmoid tumors who also harbor additional fibrotic masses in the pelvis. Although in previously reported cases there is usually a triggering event such as trauma, in the present cases there was no inciting event. Furthermore, the cases are without an associated FAP history, which provides the first clinical clue of a possible genetic determinant in this rare disorder.

Effect of drainage on postoperative nausea, vomiting, and pain after laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy is associated with a high incidence of postoperative pain, nausea, and vomiting. Pneumoperitoneum created during the operation and residual gas after the operation are two of the factors in postoperative pain and nausea. We studied the effects of a subdiaphragmatic gas drain, which is intended to decrease the residual gas, on postoperative pain, nausea, and vomiting after laparoscopic cholecystectomy.

PATIENTS AND METHODS

Seventy patients were randomized into two demographically and clinically comparable groups: drainage and control. Postoperative pain, nausea, and vomiting were measured by verbal grading and visual analog scale 2-72 h postoperatively. Analgesic and antiemetic use and incidence of retching, vomiting and other complaints were also recorded.

RESULTS

Subdiaphragmatic drain effectively reduced the incidence and amount of subdiaphragmatic gas bubble. The incidence and severity of nausea was lower in the drainage group at 72 h. Although severity of pain was lower at 8 and 12 h in the drainage group, the difference was not significant. There was also no difference between the groups in regard to analgesic and antiemetic use.

CONCLUSIONS

Subdiaphragmatic drain offers only minor, if any, benefit on postoperative pain, nausea, and vomiting after laparoscopic cholecystectomy, and this effect is probably clinically irrelevant.

[Intraabdominal and intramural hemorrhage due to warfarin therapy]

BACKGROUND

The study investigated clinical, radiological findings and treatment methods used in patients who developed intraabdominal hemorrhage due to chronic warfarin use.

PATIENTS AND METHODS

Eight patients receiving warfarin for cardiac valve replacement, pulmonary thromboemboli, and atrial fibrillation were admitted to our hospital. The patients had abdominal pain, nausea, and vomiting although there was no hematemesis and melena.

RESULTS

Abdominal ultrasonography and computerized tomography identified the individuals' problems as intraabdominal hemorrhage (n=2), intestinal intramural and intraabdominal hemorrhage (n=2), bleeding into the sheath of the rectus abdominus muscle (n=1), subcapsular splenic hemorrhage (n=1), and bleeding due to ruptured ovarian cyst (n=2).

CONCLUSIONS

Clinicians must be alert for intraabdominal bleeding in patients who are prescribed warfarin treatment. Abdominal ultrasonography and computerized tomography should be used to investigate all such cases of suspected hemorrhage. Blood and plasma replacements are first line of supportive treatment and surgery should be avoided if possible.

Laparoscopic resection of patent omphalomesenteric duct in an adult

The omphalomesenteric duct is the embryonic structure connecting the yolk sac to the primitive gut that disappears at 8 to 9 weeks of gestation. Failure of this duct to involute results in various anomalies. Failure of complete closure at different stages results in various anomalies, which occur in approximately 2% of the population. However, complete patency of omphalomesenteric duct is rare, reportedly occurring in approximately 15% omphalomesenteric duct anomalies. Adult presentations are extremely rare. We report the case of a 44-year-old man with a patent omphalomesenteric duct (POMD). He was admitted with a foul-smelling discharge from the umbilicus that he had experienced for 5 years. The condition had been interpreted as an umbilical granuloma at other centers, and multiple unsuccessful sessions of cauterization with silver-nitrate bar had been performed. At laparoscopy through three ports, the POMD was resected with the aid of a laparoscopic linear stapler. To our knowledge, this is the first adult case of POMD resected laparoscopically. The pitfalls of this diagnosis in the adult and the technique of laparoscopic resection is discussed in light of the available literature.

Pinealectomy does not affect the healing of experimental colonic anastomoses

Gastrointestinal system anastomoses, especially colonic anastomoses, have significant morbidity and mortality despite recent technical improvements. Besides regulating the circadian rhythm, the pineal gland and its main neurohormone product melatonin have widespread actions in the organism. The purpose of this study was to investigate the effects of pinealectomy on the healing of colonic anastomoses. One hundred male albino Wistar rats were used in this study. The rats were separated into three groups: control, pinealectomy, and sham groups. In the control group, only colonic resection and anastomoses were performed. Following pinealectomy, colonic anastomosis was performed 2 weeks later on one half and 2 months later on the other half of the pinealectomy group. Only craniotomy was performed on the sham group, and the rats were separated and evaluated like the pinealectomy group. Colonic anastomoses were evaluated on postanastomotic day 3 and 7 by measuring the bursting pressure and the hydroxyproline levels in the anastomotic segments. There was no difference in the bursting pressure measurements between the groups on both postoperative day 3 and 7. Although hydroxyproline levels were different between groups on both postanastomotic days 3 and 7, it has been observed that neither normal nor anastomotic hydroxyproline levels influenced the anastomotic bursting pressure measurements. The percent deviation from the normal values was compared in the anastomotic segments, and no differences were found regarding the bursting pressure and hydroxyproline levels. It was concluded that pinealectomy has no effect on the healing of colonic anastomoses.

Laparoscopic cholecystectomy in a patient with situs inversus totalis

Situs inversus is a rare anomaly characterized by transposition of organs to the opposite side of the body. In this group of patients, cholelithiasis is observed with a frequency similar to the normal population. Herein, we report a patient with situs inversus totalis who underwent a successful laparoscopic cholecystectomy. Diagnostic pitfalls and technical details of the operation are discussed in the context of the available literature.

Traumatic diaphragmatic hernias: a report of 26 cases

Traumatic diaphragmatic hernias, when diagnosed many years after the traumatic event, are observed in about 10% of diaphragmatic injuries. Due to coexisting injuries and the silent nature of diaphragmatic injuries, the diagnosis is easily missed or difficult. The medical records of 26 patients, who were treated for diaphragmatic hernias during the last 20 years, were analysed retrospectively. The patients were divided into acute phase and late-presenting groups, in whom emergency surgery and elective intervention were performed respectively. Chest radiography was diagnostic in 34.6% (n = 9) of patients. 92.3% of the hernias were on the left side, while the most common herniated organs were the stomach (31.8%) and the colon (27.2%). Coexisting injuries were recorded in 38.4% (n = 10) of the patients. Primary repair was predominantly used (92.3%). The hospitalisation period was longer in the late-presenting group (24.1 +/- 18.8 vs. 14.3 +/- 7.7 days). Two deaths occurred in the late-presenting group. Diaphragmatic hernia should be suspected in all blunt abdominal trauma patients. Prompt surgical repair is the treatment of choice in all traumatic diaphragmatic hernias.