An Alternative Method for Percutaneous Treatment Of Hydatid Cysts: PAI Technique.

OBJECTIVE: Surgery is still the first choice in complicated cystic echinococcosis. However, percutaneous methods have performed increasingly in recent years. The Puncture, Aspiration, Injection, Reaspiration (PAIR) technique is mostly the preferred percutaneous method. The Puncture, Aspiration, Injection (PAI) technique is the new modified method, which is differentiated from PAIR technique by its applicability to all types of hydatid cysts (types 1-5) and unperforming of reaspiration. METHODS: The 52 hydatid cysts were prospectively examined in the study. Thirty-four of them were Types I and II, 13 of them were Type III, and 5 of them were Types IV and V. The technique was performed using the 20 G Chiba needle under the guidance of ultrasonography. Maximum cyst contents were aspirated immediately after the puncture to reduce the intracystic pressure. After confirming that aspirated liquid does not contain bile and that cyst has no cystobiliary connection, 95% alcohol was injected into the cavity, safely. Reaspiration of alcohol was not performed. RESULTS: The cyst sizes were reduced after PAI on ultrasonographic evaluations in all cases. The liquid component disappeared and the cyst got solid characteristic three months after the procedure. CONCLUSION: All hydatid cyst types can be treated safely and effectively with PAI technique without considering dimensions and whether.

Effects of carbon dioxide pneumoperitoneum on postoperative adhesion formation and oxidative stress in a rat cecal abrasion model.

INTRODUCTION: It is claimed that CO2 pneumoperitoneum (CP) is less adhesiogenic than laparotomy. Our aim in this study was to investigate the local oxidative stress responses and related adhesion formation resulting from exposure to CP. METHODS: Forty-five rats were randomised into six groups. Group 1 underwent laparotomy only; in group 2, 6 mmHg CP was performed for 60 min; in group 3, the same procedure was carried out using 12 mmHg CP; in group 4, laparotomy and cecal-peritoneal abrasion were performed; in group 5, 6 mmHg CP was performed for 60 min, followed by laparotomy and cecal-peritoneal abrasion; in group 6, the same procedure was carried out using 12 mmHg CP. Groups 1, 2 and 3 were sacrificed immediately and used only for biochemical examination. The other groups were sacrificed on the 14th postoperative day. RESULTS: The total adhesion scores, thickness, quantity, extent and type of adhesions decreased steadily in groups 4, 5 and 6 (p < 0.05). The median values for neutrophil and monocyte infiltration, and for capillary and fibroblast proliferation decreased steadily in groups 4, 5 and 6 (p < 0.05). CAT, SOD and GSHPx levels decreased significantly in line with increasing pressure in groups 1, 2 and 3. SOD and GSHPx levels were similar in groups 4, 5 and 6, while CAT levels decreased with increasing pressure in groups 4, 5 and 6. CONCLUSION: It was found that CP is associated with less adhesion formation than laparotomy in the presence of similar antioxidant levels. The reduced adhesion formation is probably caused by a decreased inflammatory response.

Is non-operative management feasible for splenic injury due to colonoscopy?

Colonoscopy is a widely used diagnostic and therapeutic procedure. While it is a relatively safe procedure, there is a risk of some complications. Splenic injury after colonoscopy is a very rare but a life-threatening complication; around 105 cases have been reported in the literature so far. Owing to the rarity of this complication, no management standards were defined. In the literature, most of the patients were managed with operative intervention and less frequently with observation. We report a case of splenic injury and massive hemoperitoneum due to colonoscopy treated non-operatively.

Limberg flap versus Bascom cleft lift techniques for sacrococcygeal pilonidal sinus: prospective, randomized trial.

BACKGROUND: Although various methods have been described for surgical treatment of pilonidal sinus disease, which is best is under debate. Tension-free techniques seem to be most ideal. We aimed to evaluate the effects of two tension-free methods in terms of patient satisfaction, postoperative complications, and early recurrence. METHODS: A group of 122 patients were prospectively included in the study. Patients were divided into two groups based on the operative method used: Limberg flap or Bascom cleft lift. Quality of life scores, pain scores, length of time for healing, hospital stay, surgical area-related complications, excised tissue weight, and early recurrence information were evaluated. RESULTS: Follow-up of patients in each group was completed. Patients in the Bascom cleft lift group had shorter operation duration, less excised tissue weight, better bodily pain score, and less role limitation due to physical problems score on postoperative day 10. There was no statistically significant difference between groups for the other criteria. CONCLUSIONS: Although both techniques provided good results during the early period, the Bascom cleft lift procedure is a reliable technique that provides shorter operation duration and better quality of life during the early postoperative period.

A rare and forgotten diagnosis of gastrointestinal bleeding: primary aortoduodenal fistula.

Upper gastrointestinal (UGI) bleeding is a common medical condition among adults. Bleeding is mainly caused by the gastric or proximal duodenum, but rarely by the distal duodenum. Aortoduodenal fistula is one of the causes of UGI bleeding that results in a life-threatening condition if not treated properly. It is commonly observed in patients who have undergone previous aortic surgery and rarely occurs in patients without a history of aortic surgery. Diagnosis of aortoenteric fistula is difficult unless there is a high level of clinical suspicion. In this article, we aim to present a patient with aortoduodenal fistula and discuss the clinical presentation, as well as the diagnostic and therapeutic options of this disease.

The effects of different mechanisms on the development of post-ERCP pancreatitis in an ERCP model in rats.

BACKGROUND/AIMS: To investigate the effects of different mechanisms on the development of pancreatitis after endoscopic retrograde cholangiopancreatography. MATERIAL AND METHODS: 40 male rats were randomly divided into four groups. After laparotomy, in Group 1, only duodenum was reached by a 24G cannula without performing any other procedure. In Groups 2, 3, and 4, biliopancreatic duct was cannulated transduodenally. Group 2 received no additional intervention after the cannulation. Group 3 received saline, whereas Group 4 received contrast agent into the duct. After a period of 24 hours, all rats were sacrificed. Laboratorytests for blood samples were performed and pancreatic tissue was also evaluated histopathologically. RESULTS: Leukocyte, blood sugar, serum glutamic oxaloacetic transaminase, lactate dehydrogenase, amylase, C-reactive protein, and base excess parameters were evaluated. The values in Groups 2, 3, and 4 were found to be significantly higher than those in the control group, except for leukocyte count and base excess (p=0.551, p=0.031, p=0.0001, p=0.0001, p=0.0001, p=0.0001, p=0.683, respectively). Histopathological results demonstrated significant differences between the groups. Highest pathological damage scores were observed in Groups 3 and 4. CONCLUSION: Among different theories for the pathogenesis of post-endoscopic retrograde cholangiopancreatography pancreatitis, elevated intraductal hydrostatic pressure was observed to be the main underlying cause.

A rare cause of small bowel obstruction in adults: persistent omphalomesenteric duct.

Previous abdominal surgery is the most common cause of mechanical small bowel obstruction. However, in patients with no abdominal surgery history, it is difficult to diagnose and treat. Omphalomesenteric duct is a primitive embryonic structure of fetal development between the midgut and yolk sac. In some cases, it may persist and result in several complications, particularly in childhood. In adults, intestinal obstruction due to persistent omphalomesenteric duct is an extremely rare circumstance. We report a 42-year-old male patient presenting with omphalomesenteric duct remnant causing small bowel obstruction.

Transabdominal migration of retained surgical sponge.

Retained surgical sponge (RSS) is a rare surgical complication. The RSSs are mostly located intra-abdominally but they can also be left in the thorax, spine, extremity, cranium, and breast. RSS is often difficult to diagnose because of the nonspecific clinical symptoms and radiologic findings. Clinically, RSS may present as an exudative reaction in the early postoperative period or may also cause an aseptic fibrous tissue response. A foreign body may remain asymptomatically silent for a long time, and it may later present with obstruction, fistulization, or mass formation. In this report, we present a case in which an RSS has migrated through the abdominal wall and caused an anterior abdominal wall abscess.

Transstomal small bowel evisceration after colonic perforation secondary to ischemic colitis.

Intestinal stomas are commonly used in a temporary or permanent fashion in gastrointestinal surgeries. The complication rate of stomas has been reported to vary between 23 and 50%. There is only one case in the literature involving transstomal small bowel evisceration following colonic perforation. In this paper, we aimed to present a patient with a perforated colon secondary to ischemic colitis, which resulted in small bowel evisceration through this perforation site.

Gastric outlet obstruction due to duodenal bezoar: A case report.

INTRODUCTION: Gastric outlet obstruction (GOO) is a clinical syndrome characterized by abdominal pain and postprandial vomiting. Causes of GOO include both benign and malignant disease. Bezoars, concretions of undigested or partially digested material in the gastrointestinal tract, are a rare entity and GOO due to duodenal bezoar is an uncommon presentation. PRESENTATION OF CASE: We report the case of a 56-year-old woman who presented to the emergency department acutely with a 3-day history of epigastric pain, weakness and postprandial nonbilious vomiting. Initially, an upper gastrointestinal endoscopy (UGE) was performed to evaluate the cause of the GOO. A solid impacted bezoar was detected in the first portion of the duodenum with complete obstruction of the pyloric canal. In spite of multiple attempts for fragmentation using different devices, the extraction attempts failed. We administered acetylcysteine and cola per os. Abdominal computerized tomography was obtained and showed a solid mass in the duodenum. UGE was performed once more however, the mass was not suitable for fragmentation and removal. Thus, surgical treatment was decided. The bezoar was extracted via gastrotomy. The postoperative period was uneventful. DISCUSSION: Even if a duodenal bezoar is small, because of its location it may cause GOO with abruptly clinical features. The diagnostic approach is similar to the other causes of the GOO. However, therapeutic options differ for each patient. CONCLUSION: We should remember all the therapeutic and diagnostic options for a patient with upper gastrointestinal bezoars who present at the hospital whether or not there is a predisposing risk factor.

Small Bowel Intussusception due to Metastasized Sarcomatoid Carcinoma of the Lung: A Rare Cause of Intestinal Obstruction in Adults.

Although small bowel intussusception is one of the most common abdominal emergencies in childhood, it is rare in adults and usually occurs as a result of an underlying pathology. Sarcomatoid carcinoma, a very rare subtype of lung cancer, rarely metastasizes to small bowel and causes complications. In this paper, we aim to describe a patient with small bowel intussusception caused by an isolated small bowel metastasis of the sarcomatoid carcinoma of the lung by reviewing the literature.

Delayed enterothorax and hepatothorax due to missed right-sided traumatic diaphragmatic rupture.

Traumatic diaphragma ruptures (DRs) are an unusual condition after blunt thoracoabdominal trauma, and there are some difficulties in the diagnosis, in the absence of the additional life-threatening injuries. Right-sided injuries are less frequent than left-sided injuries and may be missed easily. Intrathoracic herniation of abdominal organs is an uncommon condition for right-sided DR. Particularly, to our knowledge, progressive hepatothorax and enterothorax that develop over years are a very rare presentation of DR. Herein, we present a case of progressive thoracic herniation of the abdominal organs, diagnosed 22 years after the initial trauma.

Management of delayed presentation of a right-side traumatic diaphragmatic rupture.

BACKGROUND: Right-side diaphragmatic rupture is an unusual condition after blunt trauma. The diagnosis may be missed during the early period of trauma and may lead to progressive herniation of intraabdominal contents into the thorax. In this study, we aimed to evaluate the diagnosis and treatment options for the late diagnosis of cases of right-side traumatic diaphragmatic rupture. METHODS: We evaluated the patients with diaphragmatic hernia who were admitted to the hospital during an 8-year period. Only patients with a right-side diaphragmatic hernia and a history of high-energy trauma were included in the study. Patients with left-side diaphragmatic hernia or those who were subjected to emergency operation due to diaphragmatic rupture were excluded from the study. Patient characteristics, clinical presentations, diagnostic tools, and treatment options were evaluated. RESULTS: Eight patients (five men, three women) were enrolled in the study. The most common trauma type was a traffic accident, and the average interval between the trauma and diagnosis was 10 years. Thoracoabdominal computed tomography had high sensitivity and specificity for visualizing the diaphragmatic hernia. No predisposing factor was found to add laparotomy to thoracotomy. There was no postoperative mortality, and no late complications were observed at the assessments during the 45-month follow-up. CONCLUSIONS: Clinical presentation of late diagnosed diaphragmatic hernia, which is encountered only rarely on the right side, requires diagnostic and therapeutic approaches different from those associated with acute diaphragmatic rupture. It should not be forgotten during the differential diagnosis in patients with a history of trauma.

New therapeutic option with N-acetylcysteine for primary sclerosing cholangitis: two case reports.

Primary sclerosing cholangitis is a progressive, cholestatic hepatic disease of unknown etiology. It is characterized by progressive inflammation, destruction, and fibrosis of the intrahepatic and extrahepatic bile ducts. Several medical therapies have been tried such as penicilamin, colchicine, methatraxate, cyclosporine, tacrolimus, and ursodeoxycholic acid. Treatment with mucolytic agents in excessively high viscosity conditions appears to have an important role. N-acetylcysteine (NAC), as a mucolytic agent, may fascilitate the drainage in partial obstructions by decreasing the mucous viscosity. We suggest that NAC and ursodeoxycholic acid have markedly positive effects on the clinical course of cholangitis and cholestasis when used together by affecting bile viscosity. Here, we present two cases treated with NAC. NAC capsul therapies at 800 mg/day were administered to two patients with primary sclerosing cholangitis. Clinical and laboratory parameters of patients saw significant improvement.

Successful endoscopic therapy of postoperative duodenal fistula by lipiodol injection: a new therapeutic approach.

Postoperative upper gastrointestinal fistulas or anastomotic leaks with peritonitis are rare but serious clinical conditions. Due to severe fluid and electrolyte imbalance and risk of development of sepsis implementation of efficient and timely management is crucial. Various endoscopic interventions have been performed to date for postoperative upper gastrointestinal fistulas. We herein describe a new therapeutical approach involving lipiodol injection, which we performed to treat a patient who had unsuccessfully undergone surgery for a posttraumatic duodenal fistula. The fistula was then successfully managed by endoscopic lipiodol injection. We present this case due to its interesting nature of a postsurgical duodenal fistula without evident fistula tract, and a successful therapy by a new approach, lipiodol injection. We conclude that this new method offers an option for patients with high operation risk or for those with failed surgery, and this new method may decrease morbidity, mortality and the time required for the closure of duodenal fistulas.

Endoscopic alcohol injection therapy of giant gastric leiomyomas: an alternative method to surgery.

Leiomyomas are the most common benign mesenchymal tumours of the upper gastrointestinal tract. They rarely cause symptoms when they are smaller than 5 cm in diameter. Observation with repeated endoscopies is recommended in asymptomatic patients with small lesions. Surgical resection remains the main therapy option for symptomatic and complicated patients. The treatment of esophageal leiomyoma has been enhanced by improvements in diagnostic and therapeutic endoscopic techniques; however, the same cannot be said for gastric leiomyoma management. The present article describes the management of two cases involving giant gastric leiomyomas that were  successfully treated using endoscopic injection of alcohol. To the authors' knowledge, the present study is the first report of the treatment of such hemorrhagic gastric tumours using this alternative and low-cost technique. Endoscopic local ethanol injection may be the treatment of choice in carefully selected patients with hemorrhagic leiomyomas of the upper gastrointestinal tract.

The Diagnostic Value of Endoscopic Balloon Catheter Usage for Detecting Early-Stage Primary Sclerosing Cholangitis in Endoscopic Retrograde Cholangiopancreatography: A Case Report.

A 34-year-old woman was admitted to our clinic with abdominal pain, jaundice and pruritus. Endoscopic retrograde cholangiopancreatography was performed for cholestasis. Endoscopic retrograde cholangiopancreatography (ERCP) was judged as normal, after a standard ERCP cannula was used for the cholangiogram. However, marked canalicular irregularities were identified in cholangiography when pressurized contrast agent was administrated via balloon catheter. This cholangiographic view was thought to reveal an early-stage alteration of sclerosing cholangitis. Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease characterized by destruction and fibrosis of the bile ducts. The diagnosis of PSC is based on typical cholangiographic findings, supported by nonspecific clinical signs and symptoms, cholestatic liver biochemical tests, and liver biopsy. Cholangiography is considered to be the gold standard for the diagnosis of PSC. The diagnosis is easy when diffuse multifocal biliary strictures, the hallmarks of the disease, resulting in a 'beaded' appearance on ERCP is detected. However, it may reveal a normal image in an early stage of the disease when bile duct changings are not prominent. We think that balloon catheter ERCP appears to facilitate the diagnosis of early-stage primary sclerosing cholangitis.

Current Diagnosis and Management of Gastrojejunocolic Fistula.

We herein report the case of a 51-year-old man with gastrojejunocolic fistula. It is one of the late severe complications of gastrectomy and gastrojejunostomy and is considered to be induced by a stomal ulcer due to inadequate resection of the stomach and incompleteness of vagotomy. The main clinical presentation of this condition is chronic abdominal pain, weight loss, diarrhea, gastrointestinal bleeding and fecal vomiting. The diagnostic workup should include barium enema, gastroscopy and sometimes colonoscopy and abdominal tomography for excluding and ruling out the possibility of malignant extraluminal disease. The historical approach of the treatment of this rare entity was 2-3-phased operations which included colostomy. However today, medical management has recently been recommended as the first-line therapy, with parenteral and enteral support treatments. The preferred surgical approach is single-stage gastrocolic resection and anastomosis and this has been favored to minimize mortality.