Sarcoidosis incidentally diagnosed: a case report.

Sarcoidosis is a chronic, granulomatous condition with unknown cause. Because most of the patients are free of clinical symptoms, sarcoidosis should be considered in differential diagnosis if noncaseous granuloma is noted in biopsies, performed for other reasons. With no clinical symptoms, our patient was diagnosed with sarcoidosis upon identifying noncaseous granuloma in the lymph node biopsy material collected during the laparoscopic operation, performed for gallbladder polyp.

Evaluation of diagnostic findings and scoring systems in outcome prediction in acute pancreatitis.

AIM: To determine factors related to disease severity, mortality and morbidity in acute pancreatitis. METHODS: One hundred and ninety-nine consecutive patients were admitted with the diagnosis of acute pancreatitis (AP) in a 5-year period (1998-2002). In a prospective design, demographic data, etiology, mean hospital admission time, clinical, radiological, biochemical findings, treatment modalities, mortality and morbidity were recorded. Endocrine insufficiency was investigated with oral glucose tolerance test. The relations between these parameters, scoring systems (Ranson, Imrie and APACHE II) and patients' outcome were determined by using invariable tests and the receiver operating characteristics curve. RESULTS: One hundred patients were men and 99 were women; the mean age was 55 years. Biliary pancreatitis was the most common form, followed by idiopathic pancreatitis (53% and 26%, respectively). Sixty-three patients had severe pancreatitis and 136 had mild disease. Respiratory rate > 20/min, pulse rate > 90/min, increased C-reactive protein (CRP), lactate dehydrogenase (LDH) and aspartate aminotransferase (AST) levels, organ necrosis > 30% on computed tomography (CT) and leukocytosis were associated with severe disease. The rate of glucose intolerance, morbidity and mortality were 24.1%, 24.8% and 13.6%, respectively. CRP > 142 mg/L, BUN > 22 mg/dL, LDH > 667 U/L, base excess > -5, CT severity index > 3 and APACHE score > 8 were related to morbidity and mortality. CONCLUSION: APACHE II score, LDH, base excess and CT severity index have prognostic value and CRP is a reliable marker for predicting both mortality and morbidity.

[A case of cat scratch disease]. / Kedi tirmigi hastaligi olgusu.

Cat scratch disease (CSD) which is usually seen in children and young adults and characterized by self limited lymphadenopathy, is caused by Bartonella henselae. In this report, a 30-year-old male patient who was admitted to the outpatient clinic with the complaint of lymphadenopathy, was presented. Erythrocyte sedimentation rate and C reactive protein values of the patient were normal, and anti-HIV, Brucella agglutination and anti-toxoplasma IgM and IgG tests were negative. No bacterial growth was detected in the cultures of repetetive blood samples and biopsy specimens taken from the right axillar lymph node. This might probably be due to the prior antibiotic therapy (ciprofloxacin and cefazolin) given by another health center. Polymerase chain reaction performed with biopsy specimen by using 27f and 1525r primers, also yielded negative result. CSD was diagnosed depending on the history of direct contact with a cat (being scratched and bitten), together with the clinical features and histopathologic findings (necrotizing granulomatous inflammation concordant with CSD). Lymphadenopathies of patient had completely resolved after five-days oral azithromycin therapy. Since CSD is a rare infection of adults, it should be taken into consideration in the patients who suffer from silent lymphadenopathy and present with the history of direct contact with cats.

Risk factors for and effect of a one-year surveillance program on surgical site infection at a university hospital in Turkey.

BACKGROUND: Surveillance of surgical site infection (SSI) is one of the most effective methods for decreasing the incidence. We determined the risk factors for SSI and the effect of a one-year surveillance program on the rate at a tertiary-care center. METHODS: The annual SSI rate before the study period was determined in a preliminary study. Risk factors related to SSI, the bacteria cultured from infected sites, and the effect of surveillance were then analyzed prospectively. Risk factors were determined by logistic regression analysis, and 95% confidence intervals were calculated. RESULTS: The incidence of SSI decreased from 12.8% before the study to 8.8% at the end of the surveillance period. There were 90 SSIs (8.8%) in 1,017 procedures during the study period, most of which (77; 69%) were detected during the hospital stay. The distribution of superficial incisional, deep incisional, and organ/space SSI was 61.1%, 33.4%, and 5.5%, respectively. Prolonged preoperative hospital stay (>8 days), abdominal incision, early preoperative hair removal, inappropriate antimicrobial prophylaxis, whole blood transfusion, famotidine treatment, repair with mesh, age >75 years, wound contamination, high American Society of Anesthesiologists score, malnutrition, diabetes mellitus, emergency surgery, obesity, and coexistent infection proved to be independent risk factors for SSI, whereas the skin closure technique, patient sex, presence of malignancy, smoking history, and duration of operation were not. Staphylococcus aureus and Escherichia coli were the bacteria isolated most frequently. Six infected patients (5.4%) died, four because of SSI. Development of SSI increased hospital expenses by around 600 US dollars per patient. CONCLUSION: Surveillance even for one year decreases the incidence of SSI.

Videolaparoscopic treatment of hepatic hydatid cyst.

BACKGROUND/AIMS: Unroofing, cystopericystectomy, or cystic evaluation and omentoplasty have been used in videolaparoscopic treatment in hepatic hydatidosis since 1992. Currently it is shown that videolaparoscopic treatment has been carried out successfully in selected cases. METHODOLOGY: Fifteen hepatic hydatid cysts in 12 cases were treated by videolaparoscopic methods. Formerly in the 5 cases, the cysts were aspirated with a needle designed for a 5-mm trocar, leaving a cystic cavity that was tension-free, then scolicidal solution was injected and aspirated. In the last 7 patients an aspirator-grinder apparatus was used. Intraoperative ultrasonography was applied in all patients. RESULTS: All the cysts were treated by drainage and omentoplasty. In one case cystic cavity infection was diagnosed in the 2nd postoperative month (morbidity rate 8.33%). Another patient died due to cerebral hydatid cyst and multiple organ failure after the postoperative first month (mortality rate 8.33%). Operative mortality was not seen. CONCLUSIONS: Videolaparoscopic treatments of hepatic hydatid cysts may be carried out successfully in selected cases.

Results of alcohol and albendazole injections in hepatic hydatidosis: experimental study.

BACKGROUND: Percutaneous drainage with alcohol injection for hydatid cysts has been commonly used in the last two decades. Albendazole is the drug of choice in the medical treatment of hydatidosis, and has also been used as an intraoperative scolicidal solution. The side-effects of its local application are not well known and have not been investigated. The purpose of the present study was to investigate the effects of the intracystic injections of alcohol and albendazole solutions on the hydatid cysts and hepatobiliary system of rabbits. METHODS: There were three groups of eight rabbits: a control group, an alcohol group and an albendazole group. In all groups hepatic hydatidosis was obtained. The control group received no therapeutic procedure. Cyst liquid was aspirated, and alcohol or albendazole solutions were injected in the other two study groups. alanine aminotransferase (ALT), aspartate aminotransferase (AST) and gamma-glutamyl transferase (GGT) levels, echinococcus indirect hemagglutination (IHA) tests, and the size and volume of the residual cysts were investigated. Liver was histopathologically evaluated. RESULTS: The ALT, AST, GGT, and alkaline phosphatase (ALP) levels were significantly higher in the alcohol group, whereas echinococcus IHA level was highest in the control group than in the study groups. Albendazole had similar effects but of a lesser degree (P < 0.01). After therapy, the cyst volume was greater in the control than in the albendazole group (P < 0.01). In histopathological evaluation hepatocellular necrosis, portal inflammation and fibrosis were most severe in the alcohol group (P < 0.01). CONCLUSIONS: Alcohol and albendazole solutions are effective as scolicidal solutions. Higher scolicidal effect and lesser side-effects on hepatobiliary system are the advantages of albendazole solution.

Acute pancreatitis caused by leptospirosis: report of two cases.

Two cases of acute pancreatitis with leptospirosis are reported in this article. CASE 1: A 68-year-old woman, presented initially with abdominal pain, nausea, vomiting, and jaundice. She was in poor general condition, and had acute abdominal signs and symptoms on physical examination. Emergency laparotomy was performed, acute pancreatitis and leptospirosis were diagnosed on the basis of surgical findings and serological tests. The patient died on postoperative d 6. CASE 2: A 62-year-old man, presented with fever, jaundice, nausea, vomiting, and malaise. Acute pancreatitis associated with leptospirosis was diagnosed, according to abdominal CT scanning and serological tests. The patient recovered fully with antibiotic treatment and nutritional support within 19 d.

Reconstruction of a wide abdominal defect using an extended groin flap.

We present reconstruction of a wide anterior abdominal defect measuring 30 x 45 cm(2), the result of necrotising pancreatitis. After serial debridements and reconstruction of the peritoneum using a Prolene mesh support, a delayed extended groin flap was transposed. No complications were encountered afterwards. An extended groin flap can be used safely to cover a full-thickness defect of the abdominal wall encompassing all of the anatomic subunits.

Umbilical hernia repair with the prolene hernia system.

BACKGROUND: Despite its extensive application for the repair of inguinal hernias, the use of the Prolene Hernia System (PHS; Ethicon, West Somerville, NJ) for the repair of umbilical hernias has been sparse. The purpose of this prospective study was to assess, in comparison with currently available techniques, the effectiveness of the PHS in repairing umbilical hernias. METHODS: Fifty consecutive patients diagnosed with a primary umbilical hernia were enrolled for the study. They were randomized and underwent elective repair of umbilical hernia using either the PHS (n = 17), Mayo repair (n = 18), or onlay repair with mesh (n = 15). Data for the time required for the surgical repair method, length of hospital stay, postoperative pain, analgesic necessity, and return to work, and early and late complications were recorded, and compared with respect to the repair procedure. RESULTS: The mean operating time and the mean length of hospital stay were the longest in the onlay repair with mesh group (P < .05). Those patients operated on using the PHS described minimum pain on the postoperative first , second, and seventh days (P < .05) and also the necessity of analgesic was significantly lower in this group (P < .05). There were 2 recurrences in Mayo repair group. The mean follow-up duration was 22 months (range 6 to 44 months). CONCLUSION: The PHS seemed to be useful for umbilical hernia repairs in selected patients as it caused minimal postoperative pain and less analgesic necessity.

Is pneumoperitoneum harmful during intra-abdominal hemorrhage in rats?

BACKGROUND: Laparoscopic surgical interventions are being used in trauma patients for diagnostic and therapeutic purposes, but there are limited studies on this subject. The effect of pneumoperitoneum during intra-abdominal hemorrhage has not been elucidated. The aim of this study was to investigate the hemodynamic, respiratory, and renal effects of pneumoperitoneum in the splenic injury/ hemorrhagic shock model in rats. MATERIAL AND METHODS: In this study, 80 anesthetized Wistar male rats (294.5 +/- 31.2 g) were randomized into 2 main groups: nontraumatized (group A) and traumatized (group B). After initial preparation and monitoring, each group was divided according to the degree of pneumoperitoneum. The nontraumatized subgroups were A1, sham-operated; A2, 4-8 mm Hg; A3, 9-13 mm Hg; and A4, 14-18 mm Hg. The traumatized subgroups were B1, splenic injury without pneumoperitoneum; B2, B3, and B4, splenic injury with pneumoperitoneum at 4-8 mm Hg, 9-13 mm Hg, and 14-18 mm Hg, respectively. Mean arterial pressure, heart rate, and respiratory rate were monitored continuously. Blood samples were obtained for hemoglobin, hematocrit, arterial blood gases, and biochemical analyses. Twenty-four hour urine output was collected. RESULTS: In group B4, pH, pCO2, and HCO3 levels were lower than in all other groups, while pCO2 and base deficit levels were significantly higher (P < 0.05). Both blood and urine analysis results showed that 24-hour urine output and the glomerular filtration rate of groups A4 and B4 were significantly lower (P < 0.05), while urinary osmolarity and fractional sodium excretion levels were significantly higher (P < 0.05). CONCLUSION: High-pressure pneumoperitoneum in splenically traumatized rats amplifies acidosis, decreases urine output, decreases glomerular filtration rate, and increases urinary osmolarity and fractional sodium excretion significantly.

Intrabiliary rupture: an algorithm in the treatment of controversial complication of hepatic hydatidosis.

AIM: Intrabiliary rupture (IBR) is a common and serious complication of hepatic hydatid cyst. The incidence varies from 1% to 25%. The treatment of IBR is still controversial. We aimed to design an algorithm for the treatment of hepatic hydatidosis with IBR by reviewing our cases. METHODS: Eight cases of IBR were analyzed retrospectively. Patients were evaluated according to age, sex, clinical findings, cyst number and stage, abdominal ultrasonography and CT-scan, surgical methods, complications, results and coincidental diseases. RESULTS: Female/male ratio was 1/7. Mean age was 52.12+/-18.26 years (range 24-69 years). Right upper quadrant pain, flatulence, palpable hepatic mass were symptoms common in all patients. Cholestatic jaundice was found in four cases. In all patients, cyst evacuation and omentoplasty were performed, followed by either choledochoduodenostomy, T-tube drainage, intracavitary suturing of the orifice, two cases in each. Whereas in two patients diagnosed post-operatively percutaneous drainage of biliary collection or ERCP and sphincteroplasty were added. Morbidity and hospital stay were higher in these cases. CONCLUSION: When the diagnosis of IBR can be done pre- or intra-operatively, morbidity decreases. If a biliary fistula is seen post-operatively, endoscopic procedures such as ERCP, sphincteroplasty or nasobiliary drainage can be applied.

Gastrointestinal bezoars: a retrospective analysis of 34 cases.

AIM: Bezoars (BZ) are the most common foreign bodies of gastrointestinal tract. Clinical manifestations vary depending on the location of BZ from no symptoms to acute abdominal syndrome. When located in small bowel, they frequently cause small bowel obstruction (SBO). We aimed to present our experience by reviewing literature. METHODS: Thirty-four patients with gastrointestinal BZ were presented. The data were collected from hospital records and analyzed retrospectively. Morbidity and mortality rates were statistically analyzed between the subgroups according to SBO and endoscopic or surgical treatment modalities. RESULTS: The 34 patients had phytobezoars (PBZ). Two patients with mental retardation and trichotillomania had trichobezoars (TBZ). More than half of them (55.88%) had previous gastric surgery. Also most of them had small bowel bezoars resulting in obstruction. Surgical and endoscopic morbidity rates were 32.14% and 14.28% respectively. The total morbidity rate of this study was 29.41%. Four patients in surgically treated group died. There was no death in endoscopically treated group. The total and surgical mortality rates were 11.76% and 14.28% respectively. The differences in morbidity and mortality rates between the subgroups were not statistically significant. CONCLUSION: BZ are commonly seen in stomach and small intestine. SBO is the most common complication. When uncomplicated, endoscopic or surgical removal can be applied easily.

Dual treatment of albendazole in hepatic hydatidosis: New therapeutic modality in 52 cases.

BACKGROUND: Hepatic hydatidosis still remains as a serious problem in general surgery. Recurrence and/or secondary hydatidosis rates are up to 25% in the cases treated with surgery alone. Albendazole is the most commonly used drug in the medical treatment of echinococcosis. The aim of the present study was to evaluate the effect of albendazole using the intraoperative and perioperative periods as dual therapy. METHODS: Fifty-two cases of hepatic hydatidosis were evaluated and treated by dual treatment of albendazole together with surgery. Perioperative albendazole treatment was given in a dose of 12-15 mg/kg per day in four divided doses. The treatment started 2-28 days before the surgery when the diagnosis was established and continued for 2-24 months (4.76 +/- 3.25) postoperatively in a cyclic monthly form. A total of 1.7 microg/mL albendazole solution was used as a protoscolicidal agent in the cystic cavity intraoperatively. In the postoperative period serology, ultrasonography and computed tomography evaluations were done. The follow-up period was 5-92 months (mean: 62.48 months). RESULTS: There was no recurrence in the present study. One patient died in the 6th postoperative week due to cerebral hydatidosis and multiple organ failure. Early and late morbidity rates were 7.69 and 9.61%, respectively. CONCLUSIONS: Dual albendazole treatment is effective in the prevention of recurrences and/or secondary hydatidosis.

Acute pancreatitis caused by afferent loop herniation after Billroth II gastrectomy: report of a case and review of the literature.

We present herein the rare case of a 44-year-old man found to have acute pancreatitis due to afferent limb obstruction caused by internal herniation, twelve years after Billroth II gastrectomy. The patient complained of nausea, vomiting, and epigastric pain in acute onset. Physical examination, laboratory studies and computed tomography imaging revealed acute pancreatitis and peritonitis. The patient had been operated on urgently and afferent limb herniation was observed between the afferent loop's meso and duodenum. The herniated segment was incarcerated and the proximal segment of the afferent limb and duodenum were markedly dilated. Microperforations were also observed in the dilated proximal afferent limb. The herniated segment of the bowel was released and longitudinal plication and serosal patching procedure were performed on the afferent limb. The patient recovered after fifteen days and remained free of acute pancreatitis for two years.

Anticoagulant-induced intramural intestinal hematoma.

Intramural hematoma of the intestine is a rare complication of anticoagulant therapy. We evaluated 7 nontrauma patients with intramural hematoma of the intestine diagnosed at our institution between May 1998 and June 2001. All of the patients were receiving long-term anticoagulant therapy for previous diseases. All 7 patients had abdominal pain, 6 had additional symptoms of nausea and vomiting, and 4 had melanotic stools at admission. Six of the patients had abnormal coagulation parameters. Both abdominal ultrasonography (US) and computerized tomography (CT) showed the exact pathology in all patients. Five of the 7 patients were treated, nonoperatively, and the other patients underwent surgery. All of the patients were followed with abdominal US and CT (mean 12 = months), with complete resolution of their intramural hematomas. Abdominal US and CT evaluation performed together will help the accuracy of diagnosis of intramural hematoma, but nonoperative therapy is the treatment of choice, with surgery indicated if generalized peritonitis or intestinal obstruction develops.

Should intraoperative ultrasonography be used routinely in hepatic hydatidosis?

BACKGROUND/AIMS: Recurrent or secondary hydatidosis are the most important problems of hepatic hydatidosis in the late postoperative period. The spread of cystic liquid, overlooked centrally located or pericystic satellite cysts that are inconspicuous during operation are the basic reasons for the problem. METHODOLOGY: In order to prevent the risk of recurrent or secondary hydatidosis, 22 liver hydatid cystic patients were taken for a prospective study. Beyond the routine investigations and researches, after the completion of conventional surgical procedures, intraoperative ultrasonography was applied to all patients. RESULTS: In three patients the existence of cysts were not found by conventional research (13.63%), in another patient (4.54%) cysto-biliary communication which had been determined clinically but was invisible due to difficulty in anatomic localization was verified by means of intraoperative ultrasonography. CONCLUSIONS: Intraoperative ultrasonography has been thought to be beneficial to find centrally localized cysts which may be inconspicuous especially in cases of multiple cysts.