Intussusception of the bowel in adults: two different cases.

Intussusception in adults is considered an unusual condition accounting for 5% of all cases of intussusceptions and almost 1%-5% of all cases of bowel obstruction. We present two cases of patients with a complaint of abdominal discomfort and concomitant vomiting who are 43 and 44 years old. Ileocecal intussusception was diagnosed by computed tomography. One patient underwent open whereas the other underwent laparoscopic right hemicolectomy and ileotransversostomy. A histopathological study revealed lipoma in the first case and adenocarcinoma in the second. We described the diagnosis and treatment of intestinal intussusception in adults.

Factors Associated with Mammographic Density in Postmenopausal Women.

OBJECTIVES: Breast density increases the risk of breast cancer, but also in the interpretation of mammography is also important. This study examine the risk factors affecting breast density in postmenopausal women. METHODS: Between January 2013 and January 2014, 215 patients admitted to The Clinics of Gynecology and Obstetrics with complaints of menopause were taken. According to the results of mammography, Group I (non-dense, n = 175) and Group II (dense, n = 40) were created. The informations of the caseswere analyzed retrospectively. RESULTS: In Group I, body mass index (BMI), number of pregnancies, parity were significantly higher than group II (P < 0.05). In group II, the withdrawal period of menstruation and progesterone levels were significantly higher (P < 0.05). In logistic regression analysis, BMI for dense breasts and number of pregnancies were found to be an independent risk factor (P < 0.05). CONCLUSION: Increased BMI, pregnancy and parity, result of reduction in density , but longer duration of menopause and increased progesterone cause an increase in density. BMI and the number of pregnancy was found to be independent risk factors for reducing breast density.

Effects of oleuropein on serum inflammatory cytokines and histopathological changes in rats with pancreatitis.

OBJECTIVES: Acute pancreatitis is a severe debilitating disease with high morbidity and mortality. The severity of the disease is largely due to the actions of various inflammatory mediators. No specific therapy is indicated for AP and its treatment remains largely supportive. This study investigated the effect of oleuropein on serum inflammatory cytokines and distant organ injury in rats with acute pancreatitis induced by bile-pancreatic duct obstruction. MATERIAL AND METHODS: Thirty adult male Wistar rats were randomly assigned to 3 groups of 10 rats each: group I: sham, group II: pancreatitis and group III: pancreatitis+oleuropein. Rats in Group III received oleuropein 20 mg/kg intragastrically during 10 days before surgery. The rats were sacrificed at 24 h after surgery and venous blood, pancreatic and lung tissue samples were obtained for analysis. RESULTS: A statistically significant difference was found between groups regarding serum amylase, LDH, lipase, pancreatic amylase, IL-6, IL-10 and TNF-α values with a Kruskal-Wallis test (p<0.05). No statistically significant difference was found between Group II and III regarding pairwise comparison of amylase, LDH, lipase, pancreatic amylase, IL-6, IL-10 and TNF-α value by using pairwise comparisons with a Mann-Whitney U test (p>0.01). A statistically significant difference between groups was found regarding edema, inflammation, hemorrhage and acinar cell necrosis in histopathological examination of the pancreas (p<0.05). No difference was found between group II and III (p>0.01). A difference was found between the groups in terms of lung tissue edema (p<0.05) but no difference was found regarding hemorrhage and inflammation (p>0.05). No statistically significant difference was found between group II and III with pairwise comparison (p>0.01). CONCLUSIONS: The experimental model used in this study showed to be appropriate for creation of acute pancreatitis. It was concluded that oleuropein as a prophylactic treatment has no protective effect on serum proinflammatory and anti-inflammatory cytokines as well as pancreatic tissue.

Intestinal malrotation: a rare cause of small intestinal obstruction.

Background. The diagnosis of intestinal malrotation is established by the age of 1 year in most cases, and the condition is seldom seen in adults. In this paper, a patient with small intestinal malrotation-type intraperitoneal hernia who underwent surgery at an older age because of intestinal obstruction is presented. Case. A 73-year-old patient who presented with acute intestinal obstruction underwent surgery as treatment. Distended jejunum and ileum loops surrounded by a peritoneal sac and located between the stomach and transverse colon were determined. The terminal ileum had entered into the transverse mesocolon from the right lower part, resulting in kinking and subsequent segmentary obstruction. The obstruction was relieved, and the small intestines were placed into their normal position in the abdominal cavity. Conclusion. Small intestinal malrotations are rare causes of intestinal obstructions in adults. The appropriate treatment in these patients is placement of the intestines in their normal positions.

Protective effect of ethyl pyruvate on ischemia-reperfusion injury in rat ovary: biochemical and histopathological evaluation.

BACKGROUND: To investigate the protective effect of ethyl pyruvate (EP), an anti-oxidant agent, against ischemia-reperfusion injury in a rat model of ovarian torsion, considering biochemical and histopathological aspects. METHODS: Forty Wistar Albino rats were divided into five groups: Group I, sham operation; Group II, ischemia alone, Group III, ischemia-reperfusion; Group IV, ischemia-reperfusion+50 mg/kg EP; and Group V, ischemia-reperfusion+100 mg/kg EP. Through laparotomy, 360° torsion was performed and maintained for 3 h, and detorsion was maintained for a further 3 h. Intraperitoneal EP was given 30 min before the surgical procedure. Ovarian tissues and blood samples were obtained after surgery. Malondialdehyde (MDA) and asymmetric dimethyl arginine (ADMA) levels were measured in both plasma and tissue samples. Tissue sections were evaluated histopatologically. Analysis of variance was used for statistical analyses. RESULTS: In both serum and tissue samples, ADMA and MDA levels were found to be significantly lower in the EP groups compared with the ischemia alone and ischemia-reperfusion groups (p=0.0001). However, no significant difference was found between groups treated with 50 mg/kg or 100 mg/kg EP. On histopathological evaluation, the total tissue injury score was found to be lower in rats treated with EP. No significant difference was detected between groups treated with 50 mg/kg or 100 mg/kg EP. CONCLUSION: Ethyl pyruvate may exert positive effects in ischemia-reperfusion injury in cases of ovarian torsion. However, no difference was detected between 50 mg/kg and 100 mg/kg EP.

Preventing intraperitoneal adhesions with linezolid and hyaluronic acid/carboxymethylcellulose: a comparative study in cecal abrasion model.

BACKGROUND: We aimed to compare the effectiveness of linezolid in preventing intraperitoneal adhesions with hyaluronic acid + carboxymethylcellulose (Seprafilm). METHODS: Thirty rats were divided randomly into 3 groups: Group I (control), untreated; Group II (Seprafilm); and Group III (linezolid). All rats were sacrificed on the 14th day after surgery. Macroscopic adhesion, inflammation, and fibrosis were evaluated. RESULTS: The multiple comparisons between groups showed a statistically significant difference for adhesion. There were statistically significant differences between Group I and II and I and III, but no statistically significant difference between Group II and III. The multiple comparisons between the groups showed a statistically significant difference for inflammation and fibrosis. For inflammation and fibrosis, there was a statistically significant difference between Group I and II and I and III, but no statistically significant difference between Group II and III. CONCLUSION: The efficiency of linezolid in reducing the formation of intraperitoneal adhesions was statistically significant compared with the control group.

Comparison of lovastatin and hyaluronic acid/carboxymethyl cellulose on experimental created peritoneal adhesion model in rats.

OBJECTIVES: The aim of this experimental study was to compare the effectiveness and reliability of lovastatin and hyaluronic acid + carboxymethyl cellulose (Seprafilm). MATERIALS AND METHODS: Thirty two female Wistar-Albino rats weighing between 250 and 300 g were used in the study. The rats were divided into four groups as sham, control, lovastatin and Seprafilm each of which contained 8 rats. All rats were sacrificed on the 14th day after surgery. Macroscopic adhesion, microscopic adhesion and tPA, MDA and NO values were evaluated. RESULTS: Macroscopic adhesion formation was significantly lower in the sham and study groups than in the control group (p < 0.05). Microscopic classification adhesion formation was significantly lower in the sham and study groups than in the control group (p < 0.05), and the tPA, MDA and NO values showed statistically significant differences among the groups. CONCLUSION: Lovastatin and Seprafilm were equally effective in preventing postoperative intra abdominal adhesions. The study groups were showed significant superiority to the control group.

Factors that affect the false-negative outcomes of fine-needle aspiration biopsy in thyroid nodules.

Background. The purpose of this study was to assess the factors that affect the false-negative outcomes of fine-needle aspiration biopsies (FNABs) in thyroid nodules. Methods. Thyroid nodules that underwent FNAB and surgery between August 2005 and January 2012 were analyzed. FNABs were taken from the suspicious nodules regardless of nodule size. Results. Nodules were analyzed in 2 different groups: Group 1 was the false-negatives (n = 81) and Group 2 was the remaining true-positives, true-negatives, and false-positives (n = 649). A cytopathologist attended in 559 (77%) of FNAB procedures. There was a positive correlation between the nodule size and false-negative rates, and the absence of an interpreting cytopathologist for the examination of the FNAB procedure was the most significant parameter with a 76-fold increased risk of false-negative results. Conclusion. The contribution of cytopathologists extends the time of the procedure, and this could be a difficult practice in centres with high patient turnovers. We currently request the contribution of a cytopathologist for selected patients whom should be followed up without surgery.

Effect of Beta-glucan on intestinal anastomoses in a rat model.

OBJECTIVES: The authors aimed to investigate the effect of ß-Glucan on healing of an experimental left-sided colon anastomosis model. MATERIAL AND METHODS: Twenty adult male Wistar albino rats were randomized into two groups which had colonic transection and end-to-end anastomosis. Group I (Control): anastomosis group, received no treatment (n = 10); group II, anastomosis + ß-Glucan (50 mg/kg/day within seven days after surgical procedure). Bursting pressure, hydroxyproline levels and histopathological characteristics of the anastomosis were analyzed. RESULTS: The average burst pressure of Groups I and II were 106.67 ± 5.00 and 148.00 ± 11.35 mmHg and hydroxyproline levels were 0.85 ± 0.14 and 1.45 ± 0.46 µg/mg, respectively. Both the burst pressure and hydroxyproline levels in group II were statistically significantly higher (p < 0.05). Histopathological examination revealed less epithelial damage in group II (p < 0.05). Though not statistically significant, less edema and damage to the submucosal-muscular layer was seen in Group II (p = 0079). CONCLUSIONS: Due to significant increases in anastomotic bursting pressures and tissue hydroxyproline levels and considering the inhibitory effect of ß-Glucan on epithelial damage, edema, and submucosal-muscular layer damage, ß-Glucan was thought to contribute to the healing of the anastomosis.

Nonfunctional adrenal lesions without loss of signal intensity on MRI: whose problem is it? The patient's? The surgeon's?

BACKGROUND: Current indications for adrenalectomy include functional adrenal tumors and potentially malignant tumors based on imaging studies. We evaluated the effectiveness of magnetic resonance imaging (MRI) in obtaining a correct preoperative diagnosis. METHOD: Fifty-three patients with nonfunctional adrenal lesions were analyzed. Indications for adrenalectomy of nonfunctional adrenal lesions included >6 cm in size and ≤6 cm in size with atypical characteristics on MRI. Lesions with a size of >6 cm, local invasion, irregular margins, and chemical-shift imaging that demonstrated no loss of signal intensity on out-of-phase images were considered suspected of malignancy. RESULTS: Adrenal lesions of >6 cm in size exhibited an 80-fold increased prediction of malignancy (OR: 80; 95% CI 7.8-813), whereas irregular margins and local invasion exhibited a 45-fold (OR: 45; 95% CI 6.4-312.5) and a 12-fold (OR: 12; 95% CI 4.6-30.6) increased occurrence of malignancy, respectively. The loss of signal intensity did not affect the prediction of malignancy. CONCLUSION: The rate of unnecessary tumor resections that are <6 cm in size can be decreased by performing adrenal biopsies in selected cases or by short-term follow-up to prevent the insufficiency of imaging techniques.

The "forgotten" goiter after total thyroidectomy.

INTRODUCTION: "Forgotten" goiter is an extremely rare disease which is defined as a mediastinal thyroid mass found after total thyroidectomy. PRESENTATION OF CASE: We report two cases with forgotten goiter. One underwent total thyroidectomy due to thyroid papillary cancer and TSH level was in normal range one month after surgery. The thyroid scintigraphy scan revealed mediastinal thyroid mass. The second case underwent total thyroidectomy due to Graves' disease and TSH level was low after surgery. At postoperative seventh year, patients were admitted to our Endocrinology Division due to persistent hyperthyroidism and CT scan revealed forgotten thyroid at mediastinum. Both patients underwent median sternotomy and mass excision, there was no morbidity detected after second surgical procedures. DISCUSSION: In the majority of cases forgotten goiter is the consequence of the incomplete removal of a plunging goiter. Although in some cases, it may be attributed to a concomitant, unrecognized mediastinal goiter which is not connected to the thyroid with a thin fibrous band or vessels. Absence of signs like mediastinal mass or tracheal deviation in preoperative chest X-ray do not excluded the substernal goiter. CONCLUSION: Retrosternal goiter should be suspected if the lower poles could not be palpated on physical examination and when postoperative TSH levels remained unchanged.

Spigelian hernia: our experience and review of the literature.

BACKGROUND: Spigelian hernia is an uncommon and rare abdominal wall defect. We present our series of patients with Spigelian hernia and a literature review. METHODS: We carried out a retrospective review of patients operated on from 2005 to 2011 at Ondokuz Mayis University Medical Faculty Department of General Surgery. Epidemiological aspects, diagnostic methods, surgical techniques, morbidity, hospital stay, recurrences and follow up were analyzed. RESULTS: We have treated 9 patients, 7 female and 2 male, with a mean age of 64 (range 47-81) years. Right side was the most frequent location. Risk factors were present in 77.8% of patients. Diagnosis was made clinically in 7 of 9 cases but preoperative imaging was made in all patients for obtain detailed information about the defect. Open hernioplasty with polypropylene mesh placed over the external oblique aponeurosis constitutes the most frequent technique (44.5%) used by repair with a primary suturation (33.3%). The remaining 22.2% of cases were laparoscopic hernioplasty placing intraperitoneal position a mesh (22.2%). Mean hospital stay was 5.1 days (range 2-9), however if we look the laparoscopic cases the time decreased to 2.5 days. One recurrence was noted during the 15th month of follow-up, which has already been operated on. The mean follow-up period of this study was 58 months. No mortality was observed among patients. CONCLUSIONS: Spigelian hernia is rare and requires a high index of suspicion given the lack of consistent symptoms and signs. The physician should secure the diagnosis combining a proper history and physical examination with the preoperative imaging. Surgical technique depends on patient characteristics, type of hernia and surgeon experience.

Large animal-related injuries in a rural population in northeastern Turkey.

Animal-related injury is a serious health problem for people living in rural areas. This type of injury could be of great consequence and life-threatening. There are insufficient data regarding this issue. The purpose of this study was to evaluate the causes and treatment outcomes of large animal injuries. We reviewed the medical records of 157 patients with large animal-related injuries in a State Hospital in Northeastern Turkey, between September 2004 and April 2007. Demographic and etiological characteristics of patients and injury and outcome data were analyzed. A total of 157 patients were included in the study. One hundred and thirty-two (84.1 %) of them were male and 25 (15.9 %) female. The mean age of patients was 29.1 years (range 3-83 years). One hundred and twelve patients (71.3 %) had horse-related injuries and 45 patients (28.7 %) had bovine-related injuries (P = 0.096). Twenty-one (13.4 %) patients were referred to a tertiary center due to their need for intensive care, whereas 1 (0.6 %) patient died. Large animal-related injuries constitute an important health problem for people living in rural areas. This type of injury could be serious and mortality could be observed.

The impact of preoperative immunonutrition and other nutrition models on tumor infiltrative lymphocytes in colorectal cancer patients.

AIM: The importance of the alteration of tumor infiltrative lymphocytes (CD4(+), CD8(+), CD16(+), and CD56(+)) in colorectal cancer prognosis is well known. In this study, we analyzed the effect of preoperative immunonutrition and different nutritional models on the clinical condition of colorectal cancer patients. METHODS: Twenty-eight colorectal cancer patients were grouped into 4 groups according to their nutrition regimens randomly and were given immunonutrition (IMN), standard enteral (SE), total parental nutrition (TPN), and normal nutrition (NN) regimens, all of which contained the same calorie-nitrogen content within a 7-day preoperative period. All patients had an endoscopic biopsy before and after the regimen, and the lymphocyte population infiltrating mucosal parts of the resected tumor tissue were evaluated. Immunohistochemical analysis of the tissue specimens was performed by staining with antihuman CD4(+), CD8(+), CD16(+), and CD56(+) antibodies. RESULTS: After nutrition, there were significant increases in each of the 4 groups of CD4(+) and CD8(+) cells within the tumor. Comparing the rates of augmentation, the increased rates of the CD8(+) cells infiltrating the tumor after nutrition in the patients who were fed with IMN were significantly more than the ones in other groups (P = .01). CD16(+) cell infiltration was significantly higher in all groups except the SE and IMN groups. The SE group had increased CD56(+) cell infiltration compared with the other groups. CONCLUSIONS: In the colorectal cancer patients who had nutrition in the 7-day preoperative period, except for the SE nutrition group, there were significant increases of infiltration of CD56(+) cells at the mucosal part of the tumor tissue within the CD4(+) and CD8(+) cell population. When postnutrition values were compared, there was a marked increase of CD8(+) cells in the IMN group.

An unusual cause of right lower quadrant pain: the caecum diverticulitis.

Purpose. In the study presented, preoperative examinations and surgical methods were discussed along with literature, regarding two cases who were operated with the prediagnosis of acute appendicitis and for whom caecum diverticulitis was determined. Case 1. 21 years old male patient who had applied to hospital with complaint of abdominal pain, underwent an operation with a prediagnosis of acute appendicitis. Right hemicolectomy was performed with mass perioperatively determined in caecum. Histopathological examination revealed necrosis and inflammation in diverticulum wall. Case 2. 36 years old female patient applied to emergency department with abdominal pain and underwent an operation with a prediagnosis of acute appendicitis. Appendectomy and diverticulectomy were performed for whom inflame diverticula in caecum was determined perioperatively. Histopathological examination was revealed acute inflammation in diverticulum wall. Conclusion. Although solitary caecum diverticulitis is a rarely encountered disease, it must be considered in the differential diagnosis of right lower abdomen pain.

The predictivity of serum biochemical markers in acute biliary pancreatitis.

Background and Aim. There are no accurate methods of differentiating acute biliary pancreatitis. Obstructions of biliary ducts, idiopathic pancreatitis may be related with biliary origin which needs identification for acute treatment. We searched for the predictivity of biochemical markers in early acute biliary pancreatitis. Patients and Methods. Serum levels of AST (Aspartate Transaminase),ALT (Alanine Transaminase), ALP (Alkaline Phosphatase), GGT (Gamma Glutamyl Transferase), total bilirubin, direct bilirubin, LDH (Lactate Dehydrogenase), amylase, lipase, CRP (C-Reactive Protein) and WBC (White Blood Cell) were measured in 157 patients with acute pancreatitis. Biliary and nonbiliary pancreatitis were differentiated by Magnetic Resonance Cholangiopancreatography (MRCP), Endoscopic Retrograde Cholangiopancreatography (ERCP), Intraoperative Cholangiopancreatography (IOC). Cut-off points of admission biochemical markers with sensitivity, specifity, positive predictive value and negative predictive value were determined after identification of significant variables. Receiver Operator Curves were plotted for each biochemical marker. Results. Serum Alkaline Phosphatase, total bilirubin, direct bilirubin, amylase and lipase levels were significantly higher in biliary pancreatitis with a positive predictive value of 80.8%, 83.9%, 81.6%, 78.8%, 79.7%. Conclusion. Increased Alkaline Phosphatase,total bilirubin, direct bilirubin, amylase and lipase levels may be used in prediction of biliary pancreatitis.

Left gastric and right hepatic artery anomalies in a patient with gastric cancer: images for surgeons.

BACKGROUND: Surgical resection remains the principal treatment for advanced gastric cancer, but one of the difficulties in a curative or extended gastrectomy is the identification of the vascular supply of the stomach. METHODS: A patient had gastric cancer hospitalized for planning and performing his surgical therapy. A multidetector-row computed tomography scan showed us a large tumor mass and numerous lymph nodes invading perigastric and second tiers of stomach and revealed a left gastric artery and right hepatic artery in which branched directly from aorta. A 3-dimensional construction showed a demonstrative vascular anomaly as well during operation. RESULT: We were able to perform total gastrectomy and D2 lymph node dissection as surgical therapy for patient. The patient's postoperative clinical course was uneventful, and after postoperative 36 months, there was no evidence of recurrence. CONCLUSION: We recommend that a multidetector-row computed tomography scan is very useful for the preoperative staging in gastric cancer patients because of its diagnostic value for showing any vascular anomaly and aiding in decision making on the appropriate surgical strategy.

The role of computerized tomography in the diagnosis of acute appendicitis in patients with negative ultrasonography findings and a low Alvarado score.

BACKGROUND: We aimed to identify the role of computerized tomography (CT) in the differential diagnosis of acute appendicitis in patients with a low Alvarado score and negative ultrasonography findings. METHODS: Fifty-two cases who underwent appendectomy (December 2004-September 2008) were included. All patients had an Alvarado score of 4-6 together with negative ultrasonography findings; preoperative abdominal CT examination results were available in all patients. CT results were compared with intraoperative and pathological findings. RESULTS: The mean age of the cases was 31±4 years (range 11 to 71 years). The mean Alvarado score was 4.9. CT results were in favor of acute appendicitis in 34 of 52 cases. Of these 34 patients, acute appendicitis was confirmed by pathological findings in 31, whereas acute appendicitis could not be confirmed in the remaining three cases (8.2%). In 15 of 18 cases without CT findings of appendicitis, intraoperative and pathological findings were also in agreement; however, the remaining three cases had acute appendicitis. Based on the results of the recent studies, sensitivity and specificity of CT in the diagnosis of acute appendicitis were 91.2% and 83.3%, respectively. CONCLUSION: To avoid unnecessary appendectomies in suspected acute appendicitis cases with a low Alvarado score and negative ultrasonography findings, CT may be used as a complementary diagnostic tool.

Unusual locations of hydatid disease: diagnostic and surgical management of a case series.

BACKGROUND: Hydatid disease is endemic in many areas of the world, where it is an important public health problem. The aim of this study was to describe a series of patients with atypically located primary hydatid disease, accompanied by a literature review. METHODS: Six male and four female patients with atypically located hydatid cysts who presented to the Kars State Hospital between September 2004 and March 2008 were evaluated. The mean age was 42.5 years (range 17-72 years). Hydatid cysts were identified by using a combination of serology tests, ultrasonography, and computed tomography (CT). RESULTS: Six of the patients underwent surgical treatment. Three patients (two with pericardial hydatid involvement and one with pancreatic involvement) were sent to a tertiary medical center for surgery, and one patient died from cardiac and renal failure two days after diagnosis. CONCLUSIONS: Although this disease is seen most often in the liver and lungs, it can be found in any part of the body. Hydatid disease must be considered in the differential diagnosis of cystic lesions, especially in patients who have spent time in endemic areas.

Epidemiological and demographic features of appendicitis and influences of several environmental factors.

BACKGROUND: In this study, we present the demographic features of appendicitis and investigate the influence of several factors (season, temperature, humidity, altitude) on the development of the condition. METHODS: A total of 1871 patients operated between 2004 and 2007 were included and divided into two subgroups as perforated and non-perforated appendicitis. The demographic features and environmental factors were investigated. We compared the effects of environmental conditions with those observed in other countries. RESULTS: Appendicitis was most frequent among males between 10 to 19 years of age. Perforated appendicitis was mostly seen between 0-9 years and after 50 years of age. The frequency of appendicitis was the highest during winter, but the rate of perforation was at its minimum during this season. During the coldest three months of the year, non-perforated appendicitis was mostly seen at temperatures of -8.8 degrees C; however, perforated appendicitis was mostly seen at -11.2 degrees C (p<0.01). CONCLUSION: Our findings show that the frequency of appendicitis and perforation rate are influenced by sex and age. Environmental factors like season, temperature and altitude may also influence the frequency of appendicitis.