Effect of Genetic Factors on the Etiopathogenesis of Thrombosed Hemorrhoidal Disease.

OBJECTIVE: The aim of this study is to investigate whether genetic factors known to increase thrombosis risk play a role in the etiopathogenesis of thrombosed hemorrhoidal disease. Methods: Genomic DNA from patients with thrombosed hemorrhoidal disease was analyzed for the presence of factor V Leiden, prothrombin G20210A, methylenetetrahydrofolate reductase C677T, and methylenetetrahydrofolate reductase A1298C mutations. Results: No significant differences were found in the allele frequencies of factor V Leiden, prothrombin G20210A, methylenetetrahydrofolate reductase C677T, and methylenetetrahydrofolate reductase A1298C mutations between patients with thrombosed hemorrhoidal disease and controls (p 0.05). Moreover, there were no significant differences in the genotype (heterozygous and homozygous mutations) of factor V Leiden, prothrombin G20210A, methylenetetrahydrofolate reductase C677T and A1298C mutations between patients with thrombosed hemorrhoidal disease and controls (p 0.05). Conclusions: Our findings indicate that mutations associated with venous thromboembolism do not play a role in the etiopathogenesis of thrombosed hemorrhoidal disease; however, several environmental, mechanical, and hemodynamic factors may contribute to the etiopathogenesis of hemorrhoidal disease.

A New Protocol for Venous Thromboembolism Prophylaxis in Bariatric Surgery.

BACKGROUND: Morbidly obese patients are at high risk for developing venous thromboembolism (VTE). The aim of this study was to evaluate the effect of a new VTE prophylaxis protocol (low dosage, low-molecular-weight heparin [LMWH]) with a pneumatic compression device (PCD) in patients undergoing bariatric surgery. MATERIALS AND METHODS: Between November 2015 and December 2017, 368 patients underwent surgery due to obesity. The patients received 0.2 ml of nadroparin (Fraxiparine, GlaxoSmithKline) 12 h before the operation. A PCD (Kendall SCD Compression System) was applied to the patient during the operation and left on the patient during the subsequent 24 h. Nadroparin 0.4 ml was started subcutaneously after the PCD was removed from the patient and the same dosage of nadroparin was given daily for 15 days following the bariatric operation. Ambulation within 2 h of surgery was encouraged and was performed frequently. RESULTS: A total of 368 patients underwent laparoscopic bariatric surgery. The median age was 34.1 years (range, 18-61), the median weight was 128 kg (range, 90-182), and the median body mass index (BMI) was 47.2 kg/m2 (range, 36-72). No thrombotic events were observed postoperatively or at the 1-, 3-, and 6-month follow-up visits. Four bleedings occurred requiring transfusions. None of these patients required a re-laparotomy for hemorrhage control. The mortality rate was 0% at 30 and 90 days and during the hospitalization. CONCLUSION: Low dosage LMWH with PCD is very effective for VTE prophylaxis in bariatric surgery.

Perforated duodenal diverticulum: A case report.

Duodenum is the second most frequent location for diverticulum in the digestive tract, surpassed only by the colon. Perforation is rare, but it is the most serious complication of duodenum diverticula. Presently described is case of 22-year-old male patient who presented at emergency department with abdominal pain and vomiting. Surgery was performed with prediagnosis of perforated duodenum diverticula based on results of computed tomography.

Diagnostic Value of Frozen Section in Patients with Non-Palpable Breast Lesions.

AIM: We analyzed wire-marking, frozen section (FS) and surgical approach in malignancy-suspicious non-palpable lesions detected on mammography (MG) and ultrasonography (US) as breast mass, microcalcifications and distorsions. Material and Methods: A hundred patients in whom wiremarking and frozen section analysis was performed because of non-palpable, malignancy-suspected breast lesions at General Surgery Department, Goztepe Training and Research Hospital, Istanbul were analyzed retrospectively. Results: Seventy-six % of the cases was in BIRADS 4, 21% in BIRADS 3 and 3% BIRADS 5, according to Breast Imaging Reporting and Data System (BIRADS) classification. There was a statistically significant correlation between paraffin block (PB) and frozen section analyses (kappa statistics: 0.872; p 0.01). In BIRADS 4 group of the patients, there was a significant correlation between PB and FS results (Correlation ratio was 85.3% and kappa statistics: 0.853; p 0.01). CONCLUSION: In early stage breast cancer wire-marking and resection method is an important diagnostic tool. In BIRADS 4 patients with non-palpable breast lesions, wire marking, resection under general anesthesia and FS can be used trustfully. In patients with early breast cancer, breast-conserving surgery and sentinel lymphnode biopsy may avoid unnecessary axillary lymph node dissection.

Role of human neutrophil gelatinase associated lipocalin (NGAL) and Matrix Metalloproteinase-9 (MMP-9) overexpression in neoplastic colon polyps.

To explore the role of Human neutrophil gelatinase associated lipocalin (NGAL) and Matrix Metalloproteinase-9 (MMP-9) overexpression in neoplastic polyps and might used as a marker to separate those from non-noeplastic polyps. The study was performed on total 65 cases, 40% (n = 26) of them females and 60% (n = 39) of them males, in Haydarpasa Numune Education and Research Hospital between March 2012 and June 2012. The assessment of immunostained sections was performed by a random principle by one experinced pathologists to the clinico-pathological data. NGAL expression was based on the presence of cytoplasmic and membranous staining. The NGAL intensities of the cases show highly statistically significantly difference according to the pathological results (p < 0.01). The NGAL prevalences of the cases show highly statistically significantly difference according to the pathological results (p < 0.01). The NGAL ID scores of the cases show highly statistically significantly difference according to the pathological results (p < 0.01). We could hypothesize that NGAL and MMP-9 overexpression in neoplastic polyps might be used as a marker to separate those from non-noeplastic polyps. However, in this study, we determined that NGAL overexpression could not distinguish dysplasia from adenocancer. Finally, we suggest NGAL and MMP-9 as an immunohistochemical marker for colonic dysplasia. To determine dysplasia in early steps of colorectal adenoma-carcinoma sequence, it could help to determine new targets in preventive cancer therapy for colorectal cancer. We suggest development of standards for study method, introduction to routine practice by investigating in future studies including many patients.

Long-term effects of forgotten biliary stents: a case series and literature review.

There are many studies about the biliary stents, however there is a little information about the long-term stayed forgotten biliary stents except a few case reports. We have reported the results of a number of cases with biliary stents that were forgotten or omitted by the patient and the endoscopist. During February 2010 to May 2013, five patients were referred to the general surgery clinic of Haydarpasa Numune Training and Research Hospital, Istanbul Turkey. Past history and medical documents submitted by the patient did not indicate a replacement of the biliary stent in 3 patients. Two patients knew that they had biliary stents. We also conducted a literature review via the PubMed and Google Scholar databases of English language studies published until March 2014 on forgotten biliary stent. There were 3 men and 2 women ranging in age from 22 to 68 years (mean age 41.6 years). Patients presented with pain in the upper abdomen, jaundice, fever, abnormal liver function tests or dilatation of the biliary tract alone or in combination. Patients' demographic findings are presented in Table 1. A review of three cases reported in the English medical literature also discussed. The mean duration of the patency of the stent is about 12 months. The biliary stenting is performed either with plastic or metal stents, studies recommending their replacement after 3-6 months. Patients with long stayed forgotten biliary stents are inevitably treated with surgical intervention. We recommend for all endoscopic retrograde cholangiopancreatography units provide a stent registry system that the stents placed for various therapeutic procedures are not forgotten both by the patient as well as the physician. There should be a deadline for biliary stents in the registry system for each patient.

Use of stapling devices for safe cholecystectomy in acute cholecystitis.

Many techniques are described for the ligation of a difficult cystic duct (CD). The aim of this study is to assess the effectiveness and safety of stapling of a difficult CD in acute cholecystitis using Endo-GIA. From January 2008 to June 2012, 1441 patients with cholelithiasis underwent laparoscopic cholecystectomy (LC) at the Department of General Surgery, Haydarpasa Numune Education and Research Hospital. Of these, 19 (0.62%) were identified as having a difficult CD and were ligated using an Endo-GIA stapler. All patients were successfully treated with a laparoscopic approach. The length of hospital stay was 3.4 days. There were umbilical wound infections in 4 patients (21%). The length of follow-up ranged from 1.0 to 50.4 months. In conclusion, Endo-GIA is a safe and easy treatment method for patients with a dilated and difficult CD. The cystic artery should be isolated and ligated if possible before firing the Endo-GIA stapler. If isolation and stapling are not possible, fibrin sealant can be applied to avoid bleeding. The vascular Endo-GIA can be applied in a large CD, but for acute cholecystitis with an edematous CD, the Endo-GIA roticulator 4.8 or 3.5 stapler is preferred.

Analysis of 120 patients with abdominal stab wound focusing on diagnostic role of fast.

OBJECTIVE: The purpose of this study was to evaluate the managemant results of patients with penetrating abdominal injuries. MATERIAL AND METHODS: One hundred twenty (120) patients who were admitted to the Emergency Department of Haydarpasa Numune Training and Research Hospital between December 2003 and December 2010 with abdominal stab wounds were included to retrospective study. The data of all patients regarding age, gender, FAST and CT results, injured organs, surgical procedures, length of hospital stay, follow-up were examined. USG findings were classified as follows: true positive (TP), in cases of positive USG findings, and positive laparotomy; true negative (TN), in cases of negative USG findings, and negative physical examination and follow-up findings; false negative (FN), in cases of negative USG findings, and positive laparotomy; and false positive (FP), in cases of positive USG findings, and negative physical examination and follow-up findings. Abdominopelvic CT extended from the lower chest to the symphysis pubis. CT was performed by administering radiopaque agents via intravenous (i.v.) rectal or oral route. RESULTS: One hundred twenty (120) patients who were admitted to the Emergency Department of Haydarpasa Numune Training and Research Hospital between December 2003 and December 2010 with stab abdominal injuries were hospitalized. According to USG findings, 45.7% were TP, 82.4% were TN, 10.6% were FN, and 34.3% were FP. Thirty-five patients with hemodynamic stability and positive FAST findings and 15 patients with positive hemodynamic stability but negative FAST findings underwent computed tomography. CONCLUSION: Serial FAST and CT help guide treatment for stable patients with penetrating sharp injuries to the abdomen.

Asymptomatic partial splenic infarction in laparoscopic floppy Nissen fundoplication and brief literature review.

Short gastric vessels are divided during the laparoscopic Nissen fundoplication resulting in splenic infarct in some cases. We report a case of laparoscopic floppy Nissen fundoplication with splenic infarct that was recognized during the procedure and provide a brief literature review. The patient underwent a laparoscopic floppy Nissen fundoplication. We observed a partial infarction of the spleen. She reported no pain. A follow-up computed tomography scan showed an infarct, and a 3-month abdominal ultrasound showed complete resolution. Peripheral splenic arterial branches have very little collateral circulation. When these vessels are occluded or injured, an area of infarction will occur immediately. Management strategies included a trial of conservative management and splenectomy for persistent symptoms or complications resulting from splenic infarct. In conclusion, we believe that the real incidence is probably much higher because many cases of SI may have gone undiagnosed during or following an operation, because some patients are asymptomatic. We propose to check spleen carefully for the possibility of splenic infarct.

A modified Rendezvous ERCP technique in duodenal diverticulum.

AIM: To postoperative endoscopic retrograde cholangiopancreatography (ERCP) failure, we describe a modified Rendezvous technique for an ERCP in patients operated on for common bile duct stone (CBDS) having a T-tube with retained CBDSs. METHODS: Five cases operated on for CBDSs and having retained stones with a T-tube were referred from other hospitals located in or around Istanbul city to the ERCP unit at the Haydarpasa Numune Education and Research Hospital. Under sedation anesthesia, a sterile guide-wire was inserted via the T-tube into the common bile duct (CBD) then to the papilla. A guide-wire was held by a loop snare and removed through the mouth. The guide-wire was inserted into the sphincterotome via the duodenoscope from the tip to the handle. The duodenoscope was inserted down to the duodenum with a sphincterotome and a guide-wire in the working channel. With the guidance of a guide-wire, the ERCP and sphincterotomy were successfully performed, the guide-wire was removed from the T-tube, the stones were removed and the CBD was reexamined for retained stones by contrast. RESULTS: An ERCP can be used either preoperatively or postoperatively. Although the success rate in an isolated ERCP treatment ranges from up to 87%-97%, 5%-10% of the patients require two or more ERCP treatments. If a secondary ERCP fails, the clinicians must be ready for a laparoscopic or open exploration. A duodenal diverticulum is one of the most common failures in an ERCP, especially in patients with an intradiverticular papilla. For this small group of patients, an antegrade cannulation via a T-tube can improve the success rate up to nearly 100%. CONCLUSION: The modified Rendezvous technique is a very easy method and increases the success of postoperative ERCP, especially in patients with large duodenal diverticula and with intradiverticular papilla.

Karydakis flap procedure in patients with sacrococcygeal pilonidal sinus disease: experience of a single centre in Istanbul.

BACKGROUND: The aim of this retrospective study was to evaluate the results of patients with sacrococcygeal pilonidal sinus who underwent surgery using the Karydakis technique. METHODS: Two hundred fifty-seven patients with sacrococcygeal pilonidal sinus disease were treated by the Karydakis flap procedure between December 2003 and June 2011. Patients were evaluated with respect to age, gender, preoperative symptoms, duration of preoperative symptoms, history of pilonidal sinus surgery, early postoperative complications, recurrence rates, and cosmetic satisfaction. RESULTS: There were 223 (86.8%) male and 34 (13.2%) female patients. The mean age of the patients was 27.15 ± 7.69 years. The most frequent symptom was seropurulent discharge (57.58%). Postoperative morbidity was noted in 24 patients (9.3%). The mean hospital length of stay was 3.34 ± 1.42 days. The cosmetic satisfaction rate was 91.06%. Recurrences were noted in 6 patients (2.3%). CONCLUSION: The Karydakis flap procedure is a safe treatment alternative for the surgical treatment of sacrococcygeal pilonidal sinus disease owing to the associated low complication rate, short hospital length of stay, rapid healing, and a high patient satisfaction rate.

Symptom-histopathology relation in upper GI endoscopy.

OBJECTIVE: The purpose of this article is to examine the correlation between information obtained from patients before endoscopy and histopathological findings. MATERIAL AND METHODS: One thousand, five hundred and thirty-six patients underwent upper GI endoscopy between January 2011-September 2012, without distinction of age and sex were included in the study. Patients with alarm symptoms, dyspepsia, epigastric pain, gastroesophageal reflux were recorded. Tissue samples taken for histopathological examination and H. pylori screening were evaluated by Giemsa stain. The information given by the patients and histopathological findings were comparatively evaluated. RESULTS: Six hundred and twenty-four patients (40.6%) were male and 912 (59.4%) were female. Mean age was 45 years (18-90). H. pylori was positive in 416 patients with dyspepsia (58.8%), 172 patients with epigastric pain (54.4%), 52 patients with GER symptoms (28.3%) and 128 patients with alarm symptoms (50.8%). Four patients with dyspepsia (0.6%) and 20 patients with alarm symptoms (7.9%) were diagnosed with stomach cancer. CONCLUSION: The main factor should be considered as the presence of at least one of the alarm symptoms when planning an upper GI endoscopy in a patient. In the presence of at least one of the alarm symptoms, an upper GI endoscopy should be performed regardless of age. Under the age of 50 and for patients without alarm symptoms, medical treatment can be tried before performing upper GI endoscopy. Patients with GER symptoms but not diagnosed as reflux esophagitis, should be treated long-term even when symptoms decline with initial treatment.