Surgical intervention may not always be required in gossypiboma with intraluminal migration.

Gossypiboma is the technical term for a retained surgical sponge. Because of legal-ethical concerns, there have not been many publications on this topic. Delays in diagnosis and treatment might increase mortality and morbidity. Radiological imaging is used in diagnosis. We present a case of gossypiboma that had fistulized to bulbous following hydatic cyst surgery. We established the diagnosis with endoscopy and followed its migration endoscopically.

The effects of desferrioxamin and vitamin E as supplements to antibiotics in the treatment of peritonitis in rats.

AIM: The aim of the study was to determine the effects of vitamin E and the iron chelating agent desferrioxamin (Dfx), supplemented by clindamycin and gentamycin therapy, on peritonitis caused by caecal ligation of a puncture wound in an experimental model. MATERIALS AND METHODS: One hundred and twenty Spraque Dawley rats were divided into eight groups. Three groups were used as controls; intraperitoneal (i.p.), subcutaneous (s.c.) and i.p. and s.c., respectively. Group 4 was treated with Dfx, Group 5 with vitamin E and Group 6 with antibiotics. Group 7 was treated with vitamin E in combination with antibiotics, and Group 8 with a combination of antibiotics and Dfx. The rats were studied for 14 days following treatment, and survivors then humanely dispatched. Post-mortem examination was undertaken on all the rats studied. RESULTS: In the control groups, mortality at 14 days was 66%. Rats treated with antibiotics alone (Group 5) had a mortality rate of 40%. Those treated with a combination of antibiotics and vitamin E (Group 7), however, had a mortality rate of only 14%, and those treated with antibiotics and Dfx had a mortality rate of only 7%. CONCLUSION: This study suggests that treatment of peritonitis in rats with a combination of Dfx and antibiotics has a significant beneficial effect on survival, in comparison with treatment with antibiotics alone.

Endoscopic sphincterotomy in the management of postoperative biliary fistula A complication of hepatic hydatid disease.

BACKGROUND: Intrabiliary rupture is the most common complication of hepatic hydatid disease (HHD), and persistent biliary leakage is the most frequent complication after surgery for HHD. In this study, we evaluated the outcome of endoscopic sphincterotomy (ES) performed in the management of postoperative biliary fistula in 33 patients with HHD and investigated the effects of the daily output of the fistula and the timing of the ES on the duration of the fistula. METHODS: Between January 1994 and April 2000, 33 patients (20 female, 13 male; median age, 44 years; range, 17-72) underwent ES at our clinics. The daily output of the biliary fistula ranged from 100 ml to 1000 ml (mean, 430 ml; in 18 patients < or = 400 ml; in 15 patients, >400 ml). The interval between the occurrence of the fistula and the performance of the ES ranged from 7 days to 5 months (median, 20 days; in 12 patients, < or = 2 weeks; in 21 patients >2 weeks). RESULTS: In patients with fistula output 400 ml (n = 18) and >400 ml (n = 15), the average closure times for the fistula after ES were 10.7 +/- 4.5 and 10.4 +/- 4.9 days, respectively (t-test: p = 0.847, t = 0.195). In patients (n = 2) with a short interval between the occurrence of the fistula and ES (<2 weeks), the average closure time for the fistula was 11.6 +/- 5.6 days, whereas for the patients (n = 15) with longer intervals (>2 weeks) it was 9.4 +/- 3.9 days (t = test: p = 0.254, t = 1.180). The drainage from the fistula stopped after an average of 9.88 +/- 4.83 days in all patients who underwent ES, and there were no any complications. Pearson's correlation test (PC) showed no significant relationship between the time for the complete closure time of the fistula after ES and the fistula output (PC=-0.253, p=0.155) or for the duration of the fistula before endoscopic retrograde cholangio pancreatography (ERCP) (PC = -0.333, p = 0.058). CONCLUSIONS: Endoscopic sphincterotomy is safe and effective and should be considered the minimally invasive procedure of choice for the management of postoperative biliary fistula due to HHD because it obviates the need for reoperation. If the sphincterotomy is successful, neither the daily output not the duration of the fistula has any influence on the time required for complete closure of the fistula.

Biological considerations in locally advanced breast cancer treated with anthracycline-based neoadjuvant chemotherapy: thymidine labelling index is an independent indicator of clinical outcome.

The present retrospective study aims to determine the clinical value of thymidine labelling index (TLI) together with other established clinical and biological factors in 116 locally advanced breast cancer (LABC) patients treated with anthracycline-based neoadjuvant chemotherapy, surgery, adjuvant chemotherapy and radiotherapy. TLI was determined in 71 LABC patients with a median of 2.62% (0-23.64%) and a mean of 4.71% +/- 5.54. As a result of neoadjuvant chemotherapy, 85 patients (73%) responded to chemotherapy (CT), whereas 31 patients were unresponsive (27%). No relationship has been found between the pretreatment biological variables including TLI, estrogen receptor (ER), progesteron receptor (PgR) status and clinical parameters such as the chemotherapy response rates and axillary lymph node involvement following chemotherapy. Median follow-up was 35 months (18-97 months) and the 3-year overall survival (OS) and disease free survival (DFS) rates were 71.6% and 52.2%, respectively. In univariate analysis, patients with inflammatory breast cancer, high TLI-index (> or = 2.62%), lymph node (LN) positivity or > 3 positive lymph nodes following neoadjuvant chemotherapy and without any response to neoadjuvant chemotherapy were found to have worse DFS and OS-rates and high local and systemic recurrence rates. In multivariate analysis, TLI was estimated as the most powerful independent factor affecting the OS in LABC patients among the other established clinical and biological parameters (p = 0.02). These results suggest that TLI is an important independent indicator of clinical outcome in patients with LABC and these patients with high TLI levels require more effective treatment modalities.

Laparoscopic esophagomyotomy without an antireflux procedure for the treatment of achalasia.

Various gastroenteric surgical procedures have been attempted laparoscopically. Laparoscopic esophagomyotomy (LE) with or without fundoplication, performed for achalasia, has gained popularity. In our clinic, LE (Heller's myotomy) was performed on six patients with achalasia. All patients underwent barium esophagography, endoscopy, and esophageal manometry for diagnosis. Extramucosal myotomy was started 6 cm above the cardioesophageal junction on the left anterolateral aspect of the esophagus and continued 1 cm below this area. Endoscopic control of the distal esophageal mucosa and the stomach was carried out under direct laparoscopic visualization following the completion of myotomy during the operation. LE was completed without complication in five patients. In one patient (16%), mucosal perforation occurred after myotomy during endoscopic control and was repaired with endostitches. There were no postoperative complications. The average hospital stay was 3 days. Three of the six patients agreed to 24-h pH monitoring, the results of which showed no evidence of reflux. All patients were completely symptom free in the postoperative period. The average preoperative lower esophageal sphincter pressure was 44 mm Hg, whereas in the early postoperative period and 6 months later, it was 11 mm Hg. There was no dysphagia or reflux esophagitis during the follow-up period (range 12 to 24 months). LE is associated with low morbidity and a high success rate, comparable with an open procedure, and can be done without an antireflux procedure.

Comparison of fine needle aspiration cytology and excisional biopsy in palpable breast cancers.

It is essential to know the nature of breast lesions before surgery. One of the well-known procedures is the cytologic diagnosis by means of Fine Needle Aspiration (FNA). We planned a prospective comparative study to assess how reliable FNA is for breast masses in our institution. 338 ladies with palpable breast lesions underwent FNA cytology and the results were malignant nature in 89 patients, atypia in 33, atypia suspicion in 24, benign in 171, and insufficient material in 21. Histopathologic examinations of the specimens confirmed that 89 of 89 malignant cytology cases were malignant (100%), 25 of 33 atypia cases were malignant (75%), 9 of 24 atypia suspicion cases were malignant (37%), 12 of 171 benign cases were malignant (7%). Most of the malignant cytology cases consisted of invasive ductal carcinomas (78%). Invasive lobular carcinoma represented suspicious cytology in 42%. FNA is 100% specific and 91% sensitive. Lesions containing rich stroma and fewer cells (lobular, colloidal carcinoma) exhibited mainly suspicious findings. We conclude that FNA is a simple, cheap and safe procedure yielding enough information to diagnose breast masses. It allows possible and accurate treatment options to be explained to the patient before surgery. Suspicious cytology should be confirmed by excisional biopsy because of its high malignant potential. If clinical and mammographic findings supports benign cytology, lesions can be followed up.