Clinicopathological analysis of patients operated for appendiceal mucocele.

BACKGROUND: The term mucocele refers to the dilatation of the appendix due to mucus, and it is an uncommon disorder with an estimated incidence of 0.2%-0.3% of all appendectomies performed and 8%-10% of all appendiceal tumors. It is often asymptomatic, but may manifest appendicitis-like symptoms. METHODS: Twenty-six patients (14 females and 12 males) were operated on due to mucocele of the appendix. Sixteen patients exhibiting the characteristics of clinically acute appendicitis required an emergency operation. Appendectomy was performed on 14 patients, and right hemicolectomy was carried out on 2 patients. Of the remaining 10 patients who received surgery under elective conditions, 4 underwent a right hemicolectomy and 6 underwent an appendectomy. RESULTS: The patients' age ranged from 27 to 81 years. Sixteen open and 4 laparoscopic appendectomies were performed. An incidental appendiceal mucocele was identified in 2 patients who had undergone colonoscopy. According to the histopathological examination, the incidence rate of mucosal hyperplasia, mucinous cystadenoma, and mucinous cystadenocarcinoma was found to be 23.1%, 61.4%, and 15.5%, respectively. CONCLUSION: In patients with long-term pain in the right lower quadrant of the abdomen, appendiceal mucocele should be considered, and the results of radiological imaging tests should be carefully analyzed before 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.

The fate of suboptimal anastomosis after colon resection: An experimental study.

BACKGROUND: The fate of suboptimal anastomosis is unknown and early detection of anastomotic leakage after colon resection is crucial for the proper management of patients. METHODS: Twenty-six rats were assigned to "Control", "Leakage" and "Suboptimal anastomosis" groups where they underwent either sham laparotomy, cecal ligation, and puncture or anastomosis with four sutures following colon resection, respectively. At the fifth hour and on the third and ninth days; peripheral blood and peritoneal washing samples through relaparotomy were obtained. The abdomen was inspected macroscopically for anastomotic healing. Polymerase chain reaction (PCR) with 16s rRNA and E.coli-specific primers were run on all samples along with aerobic and anaerobic cultures. RESULTS: The sensitivity and specificity of PCR on different bodily fluids with 16s rRNA and E.coli-specific primers were 100% and 78%, respectively. All samples of peritoneal washing fluids on the third and ninth days showed presence of bacteria in both PCR and culture. The inspection of the abdomen revealed signs of anastomotic leakage in eight rats (80%), whereas mortality related with anastomosis was detected in two (20%). CONCLUSION: Anastomotic leakage with suboptimal anastomosis after colon resection is high and the early detection is possible by running PCR on peritoneal samples as early as 72 hours.

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.

Effect of orally administered simvastatin on prevention of postoperative adhesion in rats.

AIM: Formation of adhesions in the abdominal region appearing after abdominal pelvic surgery lead to infertility, chronic pelvic pain, intestinal obstructions, difficulty and morbidity at the following operations, and increased morbidity. The aim of our study is to examine the effectiveness of orally administered simvastatin on preventing the postoperative adhesion. MATERIALS AND METHODS: 20 male Wistar Albino rats weighing 230-250 gr were used. The rats were housed for 12 hours day and 12 hours night cycles in cages and were divided into two groups, namely study and control group. Microscopic evaluation of adhesion was assessed under 5 main topics which are the signs of inflammatory response; inflammation, activation, fibroblast activity, vascularity, presence of giant cell. Activation was scored as follows: (0) no activation, (1) while activation was accepted as present the score for other parameters was evaluated between 0 to 3 according to the increased severity. After evaluating all topics separately, the average of all scores has been assessed in both groups. RESULTS: As a result of the macroscopic evaluation of postoperative intra-abdominal adhesions, the percentage of adhesion in simvastatin applied group was found to be 0.8 ± 0.17. This value was calculated as 0.6 ± 0.2 in the control group. Regarding the severity of adhesion, while in the simvastatin applied group the value was found to be 9.1 ± 4, in the control group it was 6.8 ± 3. The general adhesion score was found to be 7.7 ± 4.2 in simvastatin applied group and 5.1 ± 3.7 in control group. CONCLUSION: In this experimental study it was showed that orally administered simvastatin has no significant effect on preventing formation of postoperative adhesions.

An unusual presentation of perforated appendicitis in epigastric region.

INTRODUCTION: Atypical presentations of appendix have been reported including backache, left lower quadrant pain and groin pain from a strangulated femoral hernia containing the appendix. We report a case presenting an epigastric pain that was diagnosed after computed tomography as a perforated appendicitis on intestinal malrotation. PRESENTATION OF CASE: A 27-year-old man was admitted with a three-day history of epigastric pain. Physical examination revealed tenderness and defense on palpation of epigastric region. There was a left subcostal incision with the history of diaphragmatic hernia repair when the patient was 3 days old. He had an intestinal malrotation with the cecum fixed at the epigastric region and the inflamed appendix extending beside the left lobe of liver. DISCUSSION: While appendicitis is the most common abdominal disease requiring surgical intervention seen in the emergency room setting, intestinal malrotation is relatively uncommon. When patients with asymptomatic undiagnosed gastrointestinal malrotation clinically present with abdominal pain, accurate diagnosis and definitive therapy may be delayed, possibly increasing the risk of morbidity and mortality. CONCLUSION: Atypical presentations of acute appendicitis should be kept in mind in patients with abdominal pain in emergency room especially in patients with previous childhood operation for diaphragmatic hernia.

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.

Surgical approach to splenic hydatid cyst: single center experience.

The benefits and risks of surgery for splenic hydatid cyst (SHC) remain controversial. We aimed to share our experience about a surgical approach for SHC. Sixteen consecutive patients with SHC disease who underwent open splenectomy at our hospital between January 2006 and July 2012 were retrospectively evaluated. Data on the patients' demographic features, clinical findings, radiological and serological diagnostic methods, and surgical and medicinal treatment options were collected and used to generate descriptive profiles of diagnosis, treatment course, and outcome. The patient population was composed of 6 females and 10 males, with an age range of 18 to 79 years (mean age: 47.0 ± 18.0). Radiological examinations detected hydatid cysts in spleen alone (n = 7) or both spleen and liver (n = 9). Preoperative serological testing identified 13 of the patients as IHA positive. All except 1 patient received a 10- to 21-day preoperative course of albendazole therapy and all patients received vaccination 1 week prior to surgery. Seven patients underwent splenectomy. The remaining patients underwent splenectomy with partial cystectomy and omentopexy (n = 6), partial cystectomy and unroofing (n = 1), pericystectomy (n = 1), or pericystectomy with partial nephrectomy (n = 1). All except one patient received a 10- to 45-day postoperative course of albendazole. No patients developed serious complications or signs of recurrence during the follow-up. The clinical profile of SHC disease at our hospital includes diagnosis by radiological methods, splenectomy treatment by simple or concomitant procedures according to the patient's symptoms, cyst size, number and localization, and compression of adjacent organs, and adjunct vaccination to decrease risk of postoperative septic complications. This profile is associated with low risk of complications and high therapeutic efficacy.

Splenic artery transposition graft usage for the supply of the right hepatic artery: a case report.

Hepatic artery aneurysms are responsible for 12% to 20% of all visceral arterial aneurysms. Because most patients are asymptomatic, this disease is generally diagnosed incidentally during radiologic examination. Aneurysm rupture develops in 14% to 80% of cases, depending on the aneurysmatic segment's diameter and location, as well as other etiologic factors. Mortality rates associated with rupture range between 20% and 70%. Thus, early diagnosis and timely initiation of medical interventions are critical to improve survival rates. Here, we present a male patient, age 69 years, with a hepatic artery aneurysm that was detected incidentally. The 3-cm aneurysm was detected on contrast-enhanced computed tomography and extended from the common hepatic artery to the hepatic trifurcation. A laparotomy was performed using a right subcostal incision. After dissection of the hepatoduodenal ligament, the common, right, and left hepatic arteries, as well as the gastroduodenal artery, were suspended separately. Then, the aneurysmatic hepatic artery segment was resected, and the gastroduodenal artery stump was ligated. An end-to-end anastomosis was formed between the left and common hepatic arteries, followed by an end-to-end anastomosis formed between the right hepatic artery and splenic artery using a splenic artery transposition graft. Postoperative follow-up examinations showed that both hepatic arterial circulations were good, and no splenic infraction had developed.

The evaluation of a modified Dufourmentel flap after S-type excision for pilonidal sinus disease.

PURPOSE: The use of an S-type oblique excision with a bilateral gluteus maximus advancement flap has recently been described for the surgical treatment of sacrococcygeal pilonidal sinus (SPS). Its use in wide lesions has been limited due to the need for a full-thickness flap. We describe the use of an S-type oblique incision together with the Dufourmentel flap in wide lesions. METHOD: Twenty-one patients were treated using a technique including an S-shaped oblique excision of the sinus tract and a broad-pedicled full-thickness flap resembling a Dufourmentel flap to close the defect. RESULTS: Of the 21 patients, 19 (90.5%) were male and 2 (9.5%) were female. Their mean age was 24.0 ± 6.1 (range 15-36) years. The mean follow-up period was 14.0 ± 5.8 (range 6-23) months. The postoperative complication rate was 4.8% (one patient), and recurrence was seen in one patient (4.8%). The mean return-to-work time was 13.5 ± 1.9 (range 10-18) days. None of the patients reported dissatisfaction with the cosmetic results. CONCLUSIONS: This new technique achieved low morbidity and recurrence rates. We anticipate that this will become an important technique in the surgical treatment of SPS if the observed success is confirmed by randomized prospective trials.

Gastric outlet obstruction caused by focal nodular hyperplasia of the liver: A case report and literature review.

INTRODUCTION: Here, we present a case of gastric outlet obstruction due to focal nodular hyperplasia of the liver. PRESENTATION OF CASE: A 23-year-old female presented to our emergency clinic with nausea, vomiting, and abdominal pain. Endoscopy showed that the prepyloric region of the stomach was externally compressed by a lesion. Computed tomography and magnetic resonance imaging revealed a 70mm solid mass originating from the liver, extending caudally in an exophytic manner, and compressing the stomach. Laparotomy revealed an irregular and exophytic mass originating from the liver, which caused gastric outlet obstruction. The mass was resected with a 10mm safety margin. The histopathology report of the mass returned as focal nodular hyperplasia. DISCUSSION: Gastric outlet obstruction is a clinical syndrome characterized by abdominal pain, nausea, and postprandial vomiting. This clinical condition frequently develops as a result of peptic ulcer disease, pyloric stenosis, and obstruction of pylorus by foreign bodies including phytobezoars, congenital duodenal webs, malignant disorders, and various lesions externally compressing the stomach. Gastric outlet obstruction due to hepatic lesions is extremely rare; few cases have been reported. CONCLUSION: This is the first reported case of gastric outlet obstruction that developed due to focal nodular hyperplasia of the liver.

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.

Incarcerated abdominal wall hernia surgery: relationship between risk factors and morbidity and mortality rates (a single center emergency surgery experience).

BACKGROUND: The aim of the present study was to investigate morbidity and mortality-related risk factors in patients undergoing surgery due to incarcerated abdominal wall hernia. METHODS: The patients were grouped according to the type of hernia (inguinal, umbilical, incisional, femoral), and these groups were evaluated in terms of risk factors affecting morbidity and mortality such as age, gender, American Society of Anesthesiologists (ASA) score, type of anesthesia, concomitant diseases, and the presence of intestinal strangulation and necrosis. RESULTS: Inguinal hernia was frequent in males, whereas femoral hernia was frequent in females (p<0.001). The rate of intestinal resection due to strangulation and necrosis was found significantly higher among femoral hernias as compared to the other types of hernia (p<0.005 and p<0.001, respectively). Advanced age (≥ 65 years), concomitant disease, strangulation, necrosis, high ASA score (III-IV), time from the onset of symptoms, and time to hospital admission were found to have significant influences on morbidity and mortality. General anesthesia was found to be a risk factor for morbidity as well (p<0.05). CONCLUSION: Incarcerated abdominal wall hernias are surgical problems with high morbidity and mortality rates. Therefore, surgery should be planned under elective conditions when hernia is detected.

Factors affecting mortality and morbidity in emergency abdominal surgery in geriatric patients.

BACKGROUND: The purpose of the present study was to determine the factors affecting morbidity and mortality in geriatric patients undergoing abdominal surgery. METHODS: Ninety-two patients who had undergone acute abdominal surgery at >65 years of age were evaluated in terms of surgical indications, morbidity and mortality rates and the factors affecting morbidity and mortality. Forty-eight patients (52.2%) were males and 44 (47.8%) were females. The mean age was 73.32±6.37 (65-92) years. RESULTS: The most common surgical indication was acute cholecystitis (26.09%). Morbidity was established as 21 (22.82%) and mortality as 14 (15.21%), and the most common cause of mortality was mesenteric vascular occlusion. American Society of Anesthesiology (ASA) IV was noted in 90.05% of the patients admitted to intensive care, and 92.85% of the patients had mortal progression. The mean hospitalization duration was 7.94±7.13 days (median, 7 days). While older age and high ASA scores were significantly correlated with morbidity, mortality and duration of hospitalization, gender was not (p>0.05). CONCLUSION: In order to decrease the postoperative mortality rate in geriatric patients, precaution should be taken beforehand to avoid surgical complications. By carrying out elective surgery in geriatric patients, the likelihood of common causes of acute abdomen, such as acute cholecystitis and incarcerated hernia, can be reduced.