Management of perforation after endoscopic retrograde cholangiopancreatography.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP)-related perforation is an infrequent complication. It is associated with significant morbidity and mortality. The present study is an evaluation of experience with management and outcomes of ERCP-related perforations and a review of relevant literature. METHODS: Between January 2008 and January 2015, a total of 9383 ERCPs were performed in endoscopy unit. A total of 29 perforations (0.33%) were identified and retrospectively reviewed. RESULTS: Of the 29 patients, 18 were female and 11 patients were male, with mean age of 70.5 years (range 33-99 years). According to Stapfer's classification, the 29 patients with ERCP related perforations included 5 type 1 perforations, 14 type 2 perforations, 7 type 3 perforations, and 3 cases of type 4 perforation. In total, 15 of 29 patients with ERCP perforation were operated on. Nine (60%) of those who underwent surgery were discharged uneventful, but 6 (40%) patients died due to postoperative complications and/or associated comorbidities. Seven (24.1%) of 29 patients had undergone endoscopic treatment and 5 of the 7 were discharged from the hospital without any problems; however, peritonitis occurred in 2 patients whose initial endoscopic treatment failed. The first of these 2 patients underwent surgery and was discharged uneventfully, but second patient, who refused surgery, died due to sepsis. Six patients were successfully treated with conservative management. Surgery could not be performed in the remaining 2 patients, who died of sepsis following peritonitis; 1 refused surgery, the other had sudden cardiopulmonary arrest during induction of general anesthesia. Mean hospital stay was 13.2 days (range: 2-57 days). In all, 9 (31%) patients died during period of the study. CONCLUSION: ERCP-related perforation is uncommon complication, but an extremely serious condition. Early diagnosis and prompt management are most important to reduce associated significant morbidity and mortality rates. The most appropriate treatment course should be determined on case-by-case basis.

Case Report of the Descending Colon Located Completely in the Right Extraperitoneal Cavity and Sigmoid Colon Located in the Right Quadrant in a Patient with a Splenic Flexure Tumor: a Rare Anomaly.

Cases in which congenital anomalies of the colon and colon tumors are observed together are very rare. The aim of this article is to present a splenic flexure tumor case, which possessed the anomaly of the descending colon in the right extraperitoneal space and the sigmoid colon located in the right quadrant. Similar findings have previously been reported in two cases in cadaveric studies.

How to approach phyllodes tumors of the breast?

OBJECTIVE: Phyllodes tumor of the breast is a rare fibroepithelial breast tumor that comprise 0.3-0.9% of primary breast neoplasms. In this study, we aimed to present clinicopathologic symptoms of our patients along with their treatment modality. MATERIAL AND METHODS: Clinicopathologic properties and treatment modality of 20 phyllodes tumor patients who underwent surgery between January 2008 and January 2013 were retrospectively evaluated. RESULTS: Median patient age was 47 years (22-75). Fine-needle aspiration biopsy was applied to 19 patients. Biopsy results were reported as suspicious in four, malignant in three, benign in 11, and as non-diagnostic in one patient. Final histopathology reports revealed two benign, one malignant and one borderline tumor out of the four patients with suspicious findings on fine needle aspiration biopsy; all patients with malignant cytology had malignancy. There were two borderline and nine benign lesions within the benign biopsy group. Sixteen patients underwent segmental mastectomy, four patients underwent mastectomy with/without axillary dissection. The median tumor size was 6 (1-13) cm. Histopathologically, 11 (55%) tumors were benign, 5 (25%) were borderline, and 4 (20%) were malignant. Two of the four patients with malignancy underwent radiotherapy and chemotherapy, and one patient only received chemotherapy as adjuvant treatment. CONCLUSION: Phyllodes tumors are rare, mix-type breast tumors. Due to high rates of local recurrence and potential for malignancy, preoperative diagnosis and accurate management are important.

Use of a vacuum-assisted closure system for the management of enteroatmospheric fistulae.

PURPOSE: The aim of this study was to analyze the management of enteroatmospheric fistulae (EAF) in an open abdomen using vacuum-assisted closure (VAC) therapy. METHODS: Eighteen patients (ten male/eight female) were treated in our surgical department for the management of EAF. VAC therapy was used to manage both complex and open abdominal wounds and for effluent control in all patients except one until definitive surgery could be performed or spontaneous closure of the EAF occurred. RESULTS: The median age of the patients was 61.1 years (range 29-84 years). Their average hospital stay was 88.89 days (range 22-129 days). The median number of VAC applications was 22.5, and the median duration of VAC applications was 43.6 days (range 14-114 days). Non-surgical spontaneous closure of the fistulae with negative pressure wound therapy could be achieved in four patients. In the other six patients, after the EAF were controlled with VAC therapy, definitive surgery was performed. Primary fascial repair was performed in two patients, and the component separation technique was synchronously performed in another two patients. Ventral hernia repair using polypropylene mesh was performed in a patient 1 year after discharge from the hospital. One patient was discharged with skin grafting plus ileostomy after the EAF was managed with VAC therapy. Eight patients (44.4%) died due to intraabdominal infections and sepsis, which could not be controlled despite all precautions. No VAC-related complications were observed in this study. CONCLUSION: A VAC system can be successfully used for wound management in the control of fistula effluent in patients with an EAF in an open abdomen until spontaneous fistula closure occurs or definitive fistula surgery can be performed.

The effect of scrubbing hands with iodine-containing solutions on urinary iodine concentrations of the operating room staff.

BACKGROUND: Excessive iodine exposure is associated with thyroid dysfunction and thyroid autoimmunity. Most surgical hand-scrub solutions contain large amounts of iodine, and transcutaneous and mucosal absorption of iodine from these antiseptic solutions has been demonstrated. In this study we determined the effect of hand scrubbing with iodine-containing surgical hand-scrub solutions on urinary iodine concentrations (UICs) in operating room staff. METHODS: The study included 117 surgeons and surgical nurses from two different hospitals who often used surgical hand-scrub solutions as the iodine exposure group and 92 age-matched hospital staff from nonsurgical units of the same hospitals as the controls. In the iodine exposure group, 39 subjects (from hospital 1) used iodine-containing hand scrub solutions intermittently, and the remaining 78 in the surgical staff (from hospital 2) used only iodine-containing hand-scrub solutions. Morning spot urine specimens were collected from all participants for the analysis of UIC. RESULTS: The operating room staff had significantly higher UICs compared to the control group (142 µg/L [12-822 µg/L] vs. 89 µg/L [10-429 µg/L], p<0.001). UICs from 39% of the subjects from hospital 2 were found to reach levels higher than 300 µg/L. CONCLUSION: Scrubbing with iodine-containing solutions might lead to iodine excess among surgical staff. Further studies investigating the effects of hand scrubbing with iodine-containing products on thyroid function and on thyroid antibodies of the operating room staff are needed to determine the consequences of this high iodine exposure.

Comparison of results of laparoscopic gastric banding and consecutive intragastric balloon application at 18 months: a clinical prospective study.

BACKGROUND: Obesity is a serious health problem that leads to serious physical and psychological problems. The methods used in treating obesity include diet and behavioral changes, pharmacotherapy, and surgery. Laparoscopic adjustable gastric banding (LAGB) and intragastric balloon (IGB) applications are two of the methods used to treat obesity. The aim of this study was to compare the effects of LAGB with those of two consecutive IGB applications in weight loss management of obese patients. METHODS: Thirty-two patients (F/M:24/8) admitted in the study were divided into two groups. In the first group of 16 patients, LAGB was performed, and in the other group two consecutive IGBs were applied. Total weight loss, body mass index (BMI), excess weight loss percent (EWL %), and excess body mass index loss percent (EBMIL %) were recorded at months 6, 12, and 18 for both groups. RESULTS: At the end of the 6th month, BMI values of LAGB and IGB groups were 36.0 and 30.6 kg/m(2), EWL % were 32.3% and 39.3%, and EBMIL % were 36.3% and 47.1%, respectively. The results were similar. At the end of 12 months, median BMI was 36.6 kg/m(2) for LAGB and 27.5 kg/m(2) for IGB (P<.05). The EWL % and EBMIL % at the end of the 12th month were 57% and 70%, which is significant in favor of IGB. The last evaluation was made at the 18th month of applications, and the three parameters for two applications were found to be similar. CONCLUSIONS: The achieved weight losses at the 6th month were similar for both groups. However, at the 12th month, two consecutive IGB applications were more effective. At the end of the 18th month, the results were again similar. Two consecutive IGB applications may be offered to obese patients who do not feel ready for surgery.

Jejunogastric intussusception, a rare complication of gastric surgery: report of two cases.

Jejunogastric intussusception is a rare complication of gastric surgery. It usually presents with abdominal pain, nausea, vomiting, and hematemesis. A history of gastric surgery can help in making an accurate diagnosis. An early diagnosis and urgent surgical intervention is mandatory. We herein report two cases of patients with jejunogastric intussusception who presented with acute abdomen and hematemesis.

[Our experience in the cases with penetrating colonic injuries]. / Penetran kolon yaralanmali olgulardaki deneyimlerimiz.

BACKGROUND: In this study, the factors that effect the morbidity and mortality in patients with penetrating colonic injuries were evaluated. METHODS: Fourty-two patients (37 males, 5 females; mean age 30,1; range 14 to 63 years) with penetrating colonic trauma were evaluated according to age, gender, type of penetrating trauma, location and severity of the colonic injury, associated injury, interval between the trauma and the definitive operation, hemodynamic status, blood transfusion requirement, fecal contamination, surgical procedure, postoperative complication and mortality. RESULTS: Type of the penetrating trauma was stab injury in twenty-eight (67%) patients, and gunshot injury in fourteen (33%) patients. The mean Colon Injury Severity Score was 2,1. The mean Abdominal Trauma Index (ATI) was 17,2 and it was over than 25 in eight (19%) patients. The symptoms of shock were present in eleven (26%) patients at admission. Blood transfusions were applied in sixteen (38%) patients. In twenty-one patients intraabdominal bleeding was observed and it was more than 500 mL in eleven (26%) patients. Primary repair was performed in 36 (86%) of the 42 patients and colostomy was performed in six (14%) patients. Morbidity and mortality rates were 41% and 10% respectively. CONCLUSION: It was found that morbidity rates were increased in patients with ATI score higher than 25, and mortality rates were increased in patients presenting shock at admission, with the amount of intraabdominal blood more than 500 mL, and who needed three or more units of blood transfusion. The primary repair of the penetrating colon trauma can be performed confidently in the hemodynamically stable patients with ATI score less than 25.