Intraabdominal gossypiboma: Report of two cases.

Gossypiboma which cause medico-legal implications is a heritage of previous surgery. In this study, we present two cases of gossypiboma mimicking intraabdominal malignancy. Case 1: A 28-year-old woman presented with an epigastric mass measuring 10 cm in diameter and a history of open cholecystectomy performed three years ago. Radiological exams revealed a cystic mass at the lesser sac and suggested serous cystadenocarcinoma. Case 2: A 36-year-old female patient with a history of two caesarean sections had a mass in the left lower quadrant. Radiological imaging showed tumoral mass near the left ovary. The exact diagnosis of gossypiboma were achieved by laparotomy and pathological examination in both cases. Gossypibomas usually present with nonspecific symptoms and appear many years after surgery. Therefore, its preoperative diagnosis is very difficult. High degree of suspicion is essential and it should be considered in the differential diagnosis of intraabdominal masses in patients who have previously undergone surgery.

Synchronous Occurrence of Primary Breast Carcinoma and Primary Colon Adenocarcinoma.

A 65-year-old female patient presented to the emergency clinic with abdominal pain, meteorism, and intermittent rectal bleeding. Colonoscopy was performed, and a hepatic flexure tumor was detected. Histopathological examination of biopsy revealed adenocarcinoma. Thoracoabdominal CT was performed for staging, and a spiculated contour mass was found incidentally on the left breast. Mammography and ultrasonography were performed for the cause of these findings, and suspicious lesions of malignancy were seen in the left breast. Invasive ductal carcinoma was detected in core needle biopsy samples from lesions. In the multidisciplinary council consisting of oncologist, pathologist, radiologist, and general surgery specialist, it was decided to perform breast operation first and then colon operation, followed by adjuvant chemotherapy. In the first operation, left total mastectomy and sentinel lymph node biopsy were performed. One week after her initial operation, the patient underwent right hemicolectomy. After operations, the patient did not develop postoperative complications and was sent to medical oncology department for adjuvant chemotherapy.

Extralaryngeal division of the recurrent laryngeal nerve: A common and asymmetric anatomical variant.

OBJECTIVE: Recognition of extralaryngeal branching of the recurrent laryngeal nerve is crucial because prevention of vocal cord paralysis requires preservation of all branches of the recurrent laryngeal nerve. We assessed the prevalence of extralaryngeal branching of the recurrent laryngeal nerve and the median branching distance from the point of bifurcation to the entry point of the nerve into the larynx. MATERIAL AND METHODS: Prospective operative data on recurrent laryngeal nerve branching were collected from 94 patients who underwent thyroid or parathyroid surgery between September 2011 and May 2012. RESULTS: A total of 161 recurrent laryngeal nerves were examined (82 right, 79 left). Overall, 77 (47.8%) of 161 recurrent laryngeal nerves were bifurcated before entering the larynx. There were 36 (43.9%) branching nerves on the right and 41 (51.9%) branching nerves on the left, and there was no significant difference between the sides in terms of branching (p=0.471). Among 67 patients who underwent bilateral exploration, 28.4% were found to have bilateral branching, 40.3% had unilateral branching, and the remaining 31.3% had no branching. The median branching distance was 15 mm (5-60mm). CONCLUSION: Extralaryngeal division of recurrent laryngeal nerve is a common and asymmetric anatomical variant. These variations can be easily recognized if the recurrent laryngeal nerve is identified at the level of the inferior thyroid artery and then dissected totally to the entry point of the larynx. Inadvertent division of a branch may lead to vocal cord palsy postoperatively, even when the surgeon believes the integrity of the nerve has been preserved.

The risk of hypocalcemia in patients with parathyroid autotransplantation during thyroidectomy.

OBJECTIVE: Thyroidectomy is the most common cause of hypocalcemia. Preservation of parathyroid glands in situ is essential in preventing this complication. The aims of our study were to review patients who underwent parathyroid gland autotransplantation during thyroidectomy, and to compare hypocalcemia rates in patients with and without autotransplantation. MATERIAL AND METHODS: Parathyroid gland autotransplantation was performed in 43 (7.9%) of 543 patients who underwent thyroidectomy between 2008 and 2012. RESULTS: Forty-four parathyroid glands were autotransplanted in 43 patients, including 36 women and 7 men. The median age was 55 (range: 30 to 68). The most common cause of autotransplantation was vascular comprise of the parathyroid gland. Early postoperative hypocalcemia developed in 37% of patients with autotransplantation, and none developed permanent hypocalcemia. Transient and permanent hypocalcemia rates were 9.6% and 0.4% in patients without autotransplantation, respectively. The risk of transient hypocalcemia was significantly high in patients with parathyroid autotransplantation (p<0.001). There was no difference between the two groups in terms of permanent hypocalcemia (p=0.156). CONCLUSION: Despite meticulous dissection, parathyroid glands can be devascularized or removed inadvertently during thyroidectomy. Parathyroid autotransplantation is the best method to maintain parathyroid gland function. Although the risk of transient hypocalcemia is increased following parathyroid autotransplantation, long-term results are satisfactory.

Minimal invasive management of anastomosis leakage after colon resection.

The gold standard of surgical treatment of colorectal anastomotic leak is abdominal drainage of collected fluid and stoma formation. Conventional laparotomy has been the preferred approach for treatment. However, both laparoscopic surgical techniquesand endoscopic stenting have gained popularity over the past years as minimal invasive approaches, especially in the management and treatment of perforations of the gastrointestinal system. We present here a successful treatment with a minimal invasive management of anastomosis leak in the early postoperative period after colon resection in a 62-year-old female patient who had undergone urgent laparoscopic intra-abdominal lavage and drainage followed by endoscopic stenting.

A palsied recurrent laryngeal nerve should be explored and evaluated by intraoperative neuromonitoring during secondary thyroidectomy: report of two cases.

INTRODUCTION: Our aim was to evaluate the findings of intraoperative nerve monitoring (IONM) in two cases with preoperative vocal cord palsy. Case 1: a 61-year-old female with recurrent goiter underwent secondary thyroidectomy. The preoperative evaluation of the vocal cords revealed right vocal cord paralyses without atrophy. The right recurrent laryngeal nerve (RLN) was found to be anatomically intact and preserved. The electrical responses of the vocal cords were elicited via IONM. Case 2: a 26-year-old male, who presented with preoperative right vocal cord palsy with atrophy, underwent completion thyroidectomy secondary to papillary carcinoma. The right RLN was explored and found to be tied and interrupted. There was no signal from the RLN with IONM. CONCLUSION: Even in cases with vocal cord palsy detected preoperatively, the nerve should be explored intraoperatively, and should never be sacrificed before an evaluation by nerve monitoring. A palsied RLN which has electrical activity should be protected to maintain the vocal cord's neural tone and to prevent its atrophy.

Jejunal invagination in an adult caused by inflammatory fibroid polyp: a case report.

INTRODUCTION: Invagination is a rare cause of mechanical intestinal obstruction in adults, but half of their causes are malignant. A diagnosis of invagination in an adult patient strongly suggests presence of a malignant pathology. Moreover some benign conditions may resemble malignant disorders like inflammatory fibroid polyp. Inflammatory fibroid polyps are rare benign lesions of uncertain origin that may occur in various parts of the gastrointestinal tract, with gastric antrum being the most common site, followed by the small intestine. CASE PRESENTATION: A 31-year old male patient was admitted to our emergency department few hours after complaints of nausea and vomiting. Abdominal examination revealed distension and clanging intestinal sounds. Computed tomography showed intestinal obstruction without an obvious cause. The patient underwent diagnostic laparotomy. In this process, approximately 10 cm of invaginated mid-jejunal segment was seen. The pathologic segment was resected and end-to-end anastomosis was performed. The patient was discharged without any complication. CONCLUSION: Although IFP is seen very rarely in adults, it is one of the probable diagnoses that should be considered in obstructive tumors of the small intestine causing invagination.

[Penetrating cardiac injuries]. / Penetran kalp yaralanmalari

BACKGROUND: The aim of this study was to evaluate our clinical findings and results of cardiac injuries. METHODS: We reviewed the records of patients who were admitted to our clinic between 1996 and 2005 and operated due to penetrating cardiac injury. RESULTS: Eighteen patients (17 male, one female; mean age 25.9; range 17-45 years) (all penetrating stab wounds) with cardiac injuries were operated. The clinical aspects were: agonal status in 5 patients (27.8%), profound shock in 7 patients (38.9%). The remaining 6 patients (33.3%) were in mild shock (hypotension 60-90 mmHg) and 3 of them (16.7%) had a diagnosis of cardiac tamponade preoperatively. Emergency room thoracotomy was made in 2 patients (11.1%). Mortality rate was %80 in agonal patients whereas overall mortality was 44.5%. CONCLUSION: Cardiac injuries have high mortality. The mortality rate of the patients, who can arrive to the hospital alive, is closely related to the vital signs and general condition. The mortality can be reduced by quick evaluation and prompt surgical intervention.

[A critical overview of surgical treatment methods of colorectal injuries]. / Kolorektal yaralanmalarda cerrahi tedavi yöntemlerinin irdelenmesi.

BACKGROUND: There is still ongoing debate on therapeutic results of traumatic colorectal perforations. The aim of this study was to evaluate and compare the incidence, management, and outcome of patients with traumatic colonic perforations. METHODS: From January 1997 to December 2002, 85 surgical patients underwent emergency operation for traumatic colonic perforations. Patients were reevaluated by analyzing the relationship between the overall morbidity and mortality and the surgical treatment options. We took into consideration the time interval between perforation and treatment as well as the nature, the site, and the cause of perforation, patients' age, and additional organ injuries. RESULTS: Mean age was 32,1. The most injured segment was transverse segment of the colon. Hartmann's procedure was performed in 3 patients (3.5%); resection, and primary anastomosis in 11 patients (12%); primary repair in 57(67%); primary repair and proximal diverting colostomy in 11(%12) ; colostomy in 5(5.8%); and appendectomy in 1 patient. Four postoperative death and one fecal fistula occurred. Deaths were not related to the surgical therapy applied. CONCLUSION: Our early postoperative results after primary repair, and resection anastomosis were good. We conclude that either primary repair or resection and anastomosis can be performed with acceptable morbidity for perforations of the colon and rectum.

Colonic interposition vs. gastric pull-up after total esophagectomy.

Gastric pull-up is the most frequent reconstruction after esophagectomy. In this report we aimed to compare gastric pull-up with colonic interposition in terms of graft function and patient satisfaction. Of 62 patients undergoing esophagectomy, reconstruction was performed by colonic interposition in 11 and gastric pull-up in 51 (without pyloric drainage in 44 and with pyloric drainage in 7). All esophagectomies were performed transhiatally. Patient follow-up ranged from 6 to 132 months (median 14 months). Follow-up examinations were performed 1, 9, 15, and 24 months postoperatively. The following factors were evaluated: time to the start of oral liquid and solid nutrients without vomiting, frequency of regurgitation, presence of pillow staining (night regurgitation), postprandial fullness, and degree of satisfaction during and after eating compared between groups undergoing colonic interposition and gastric pull-up with or without pyloric drainage. Among patients undergoing gastric pull-up, regurgitation was observed in 22% to 27% during follow-up. None of the patients with colonic interposition had reflux or regurgitation. Twenty-five percent of patients with gastric pull-up without drainage and 66% of patients with gastric pull-up plus drainage had reflux esophagitis at 15 months. No esophagitis was observed in patients with colonic interposition during the same period. Overall satisfaction was superior in patients undergoing colonic interposition followed by gastric pull-up with no drainage. Colonic interposition after esophageal resection is a viable option. Our study suggests that function of the replacement is better in this group of patients.