Multiple pelvic cysts in a patient with familial Mediterranean fever: Benign cystic mesothelioma.

Benign cystic mesothelioma (BCM) is a rare tumor arising from endothelial cells of the pelvic visceral or parietal peritoneum. It is a clinically and histopathologically benign disease. Etiology and pathogenesis of BCM remain unclear. Familial Mediterranean fever (FMF) is an inherited disorder characterized by episodes of fever, and abdominal, chest and/or joint inflammation. Association between malignant mesothelioma and FMF has been reported previously; however, co-existence of FMF and BCM is rare. Here, we report a case of BCM in a 43-year-old male patient with FMF.

Does Sacrococcygeal Angle Play a Role on Pilonidal Sinus Etiology?

The predisposing factors for the development of sacrococcygeal pilonidal disease (SPD) still remain undetermined. Here, we investigate the sacrococcygeal angle as a possible predisposing factor for the development of disease. Consecutive male patients admitted to our clinic with the diagnosis of SPD were included. Sex, age and BMI matched healthy controls without SPD were enrolled to the study. The predefined sacrococcygeal angles of patients and controls were measured on lateral pelvic radiographs by a single experienced radiologist. Thirty patients were included in each group. Sacrococcygeal angles of patients and control group were measured as 37.3±14.5 and 36.81±10.23 in patients and controls, respectively. The difference with respect to sacrococcygeal angle was not statistically significant between two groups. Sacrococcygeal angle which is the main skeletal determinant of intergluteal sulcus is not a predisposing factor for the development of sacrococcygeal pilonidal disease.

The role of n-butyl-2-cyanoacrylate in the repair of traumatic diaphragmatic injuries.

Diaphragmatic injuries either by blunt or penetrating trauma require prompt surgical intervention and are often exigent to repair. N-butyl-2-cyanoacrylate (n-butyl-2-CA) is a tissue adhesive which has gained wide application in many areas of surgery including emergency. To repair the extensive injuries of the diaphragm it may be necessary the use of synthetic mesh by fixing it with sutures or staples. The use of tissue adhesives may circumvent the potential problems associated with mesh fixation. This study aimed to evaluate the efficacy and safety of tissue adhesives usage for mesh fixation in diaphragmatic injury repair. Twenty-four rats were divided into 3 groups each of them containing 8 rats. A 1- cm diaphragmatic defect was created in all rats. The defect was repaired by polypropylene suture in Group I, by mesh fixed with sutures in group II and by mesh fixed with n-butyl-2-CA in group III. The rats were sacrificed after 1 month. The episode of hernia and the adhesions were assessed by adhesion density score. Also, the abscess and inflammation in the repaired tissue were evaluated microscopically. The Kruskal-Wallis test was performed for the histopathological analysis. No diaphragmatic hernia was detected in any group. While Group III had higher adhesion density scores than group I (P: 0.027), there were no differences between group III and II (P: 0.317) and group II and I (P = 0.095) regarding adhesion density scores. The inflammation grade was higher in group III than group I and II (P < 0.001) and was higher in group II than group I (P < 0.05). There was no differences between each groups, concerning microabcsess formation (P > 0.05). Repair of traumatic diaphragmatic injury in penetrating wound, with polypropylene mesh fixed by n-butyl-2-CA in rats appears to be as efficacious and safe as conventional methods in early period. However, further experimental and clinical study are needed to compare the long-term results of adhesive mesh repair with those of the traditional sutured techniques.

The use of fibrin glue without surgery in the treatment of pilonidal sinus disease.

Pilonidal sinus disease is a common disabling condition affecting the natal clefts of the buttocks. We analyze the role of fibrin glue in the treatment of selected patients with pilonidal sinus disease. Forty patients diagnosed with pilonidal sinus disease at Vakif Gureba Training and Research Hospital were treated between December 2007 and December 2011. Recurrence was noted in four patients (10%). Ninety percent of patients had no recurrence one year later (95% confidence interval: 0.85-0.95). This procedure is suggested as a first line of treatment for patients with no prior history of infection and who have only one sinus orifice.

The effect of serosal suture reinforcement on burst pressure in sleeve gastrectomy specimens.

PURPOSE: Staple-line leak is a life-threatening complication of laparoscopic sleeve gastrectomy. Reinforcement materials have been reported to lower the risk of staple-line bleeding, but their effects on leak risk have not been elucidated. The aim of this study was to compare the effects of 2 supportive techniques on burst pressures in sleeved gastrectomy specimens. METHODS: A total of 30 patients who underwent laparoscopic sleeve gastrectomy were evaluated. The resected sleeve gastrectomy specimens were categorized into 3 groups: group 1 had no extra support in the staple-line, group 2 had interrupted serosal suture on the staple-line, and group 3 had serosal suture on staple-line junction points. The endpoint was the first detectable leakage, at which point the leak pressure and anatomic site of the leakage were recorded. RESULTS: A total of 30 sleeved gastrectomy specimens were included (each group included 10 specimens). There were no differences between groups in terms of age, sex, and body mass index. The leak pressure was significantly higher (56.2±6.4 mm Hg) in group 2 (P<0.01). Leaks occurred significantly more frequently in the staple-line than in the staple-line junction points (P<0.01). CONCLUSIONS: Interrupted serosal suture significantly increased the burst pressure. Increases in intraluminal pressure are known to be significant in leak etiology. Thus, we concluded that interrupted serosal suture may be beneficial in the prevention of leaks.

A pilot study investigating early postoperative changes of plasma polyunsaturated fatty acids after laparoscopic sleeve gastrectomy.

BACKGROUND: This study aimed to determine early postoperative changes of plasma polyunsaturated fatty acids (PUFAs) following laparoscopic sleeve gastrectomy (LSG). METHODS: Ten obese patients (mean BMI: 51.10 ± 11.59 kg/m²) underwent LSG and eleven normal weight control patients (mean BMI: 24.37 ± 2.33 kg/m²) underwent laparoscopic abdominal surgery. Fasting blood samples were collected prior to surgery, at day 1 after surgery and after postoperation oral feeding. Plasma levels of arachidonic acid (AA, C20:4n6), dihomo-gamma-linolenic acid (DGLA, C20:3n6), eicosapentaenoic acid (EPA, C20:5n3) and docosahexaenoic acid (DHA, C22:6n3) were determined by an optimized multiple reaction monitoring (MRM) method using ultra fast-liquid chromatography (UFLC) coupled with tandem mass spectrometry (MS/MS). Prostaglandin E2 (PGE2) was measured in serum samples by enzyme immunoassay. RESULTS: A significant decrease was observed in insulin and HOMA IR levels in sleeve gastrectomy patients after postoperation oral feeding compared to preoperation. Plasma AA levels and AA/EPA ratio were significantly increased in sleeve gastrectomy patients after postoperation oral feeding compared to postoperation day 1. Serum PGE2 levels and AA/DHA ratio was significantly higher in sleeve gastrectomy patients at preoperation, postoperation day 1 and after postoperation oral feeding when compared to control group patients. CONCLUSION: Increased peripheral insulin sensitivity associated with LSG may play a role in the significant increase of plasma AA levels in sleeve gastrectomy patients following postoperation oral feeding. The significant increase in PGE2 levels and AA/DHA ratio in sleeve gastrectomy group patients also confirms the presence of a proinflammatory state in obesity.

SILS hepatectomy for hepatic hydatid disease: a case report.

Single-incision laparoscopic surgery (SILS) is being used with increasing frequency in the treatment of many conditions requiring surgery. Experience with SILS for hepatectomy is limited. This is one of the first reports of SILS hepatectomy in the treatment of hepatic hydatid disease. A 17-years-old female who has 89 × 59-mm cystic mass in the left lobe of the liver was admitted with abdominal pain persisting for several months. For treatment of the mass, SILS hepatectomy performed. Although complexity of the liver structure and the technical difficulties of SILS restrict its applications in hepatic surgery, the treatment of liver hydatid disease with SILS in selected patients is safe and efficient. Moreover, it allows a better cosmetic result and rapid recovery.

Recurrent squamous cell carcinoma arising in a neglected pilonidal sinus: report of a case and literature review.

Squamous cell carcinoma (SCC) is a rare complication observed mainly in chronic, recurrent and untreated primary pilonidal disease. It is associated with poor prognosis, and its recurrence rate after surgery is high. Here we present a patient diagnosed with SCC arising from a neglected pilonidal sinus. A 44-year-old male, who is a heavy truck driver, applied to the hospital with chronic discharge from sacrococcygeal region. He had symptoms of the disease with multiple recurrent abscesses and spontaneous drainage for 10 years. The patient underwent cyst excision and the defect was left open for secondary healing. One year later, the patient was admitted to the hospital with a mass of 3 x 3 cm in the same area. Re-excision and a sigmoid colostomy were performed. The patient died after two years. This case study illustrates that since SCC is a fatal complication of recurrent and long-standing pilonidal sinus, the proper treatment of this disease should be carried out as soon as the diagnosis is established. To this end, we believe, that all pilonidal sinus lesions should be sent for pathologic examination.

Comparison of four different methods in staple line reinforcement during laparascopic sleeve gastrectomy.

The main early complications of Laparascopic Sleeve Gastrectomy are bleeding and gastric leakage. Many reinforcement methods are performed in order to reduce these complications. In this prospective, randomized study, we compared four different techniques to evaluate staple line reinforcement in Laparascopic Sleeve Gastrectomy. Between January 2012 and May 2013, 65 patients were prospectively randomized into four groups in which different techniques were used in handling the staple line during Laparascopic Sleeve Gastrectomy. Of the four groups, there wasn't any reinforcement used on 15 patients during LSG (group 1), continuous serosal 3-0 prolene sutures were used on 16 patients for staple line reinforcement (group 2), staple line was supported with v-loc suture in 16 patients (group 3), and 18 patients had Tisseel fibrin sealant applied throughout the staple line (group 4). 40 of 65 patients were females, the mean age was 36.8 years (20-58 years), and the mean BMI was 49.2 (41-60 kg/m²). Characteristics of patients among groups were similar. There wasn't any significant difference found between groups for BMI. Gastric leakage was detected from the staple line in 2 patients of the v-loc group. According to our results, we demonstrated that good results can be obtained without any reinforcement. Reinforcement with propylene suture only prolongs the operation time, and tissue fibrin sealent increases the cost. In conclusion, we should be more careful using v-loc sutures, and further series with larger numbers are needed to test v-loc.

Early postoperative changes of HDL subfraction profile and HDL-associated enzymes after laparoscopic sleeve gastrectomy.

This study aimed to determine early postoperative changes of LDL/HDL subfraction profile and HDL-associated enzymes following laparoscopic sleeve gastrectomy (LSG). Thirteen obese patients (mean body mass index (BMI) 52.74 ± 10.97 kg/m(2)) underwent LSG and normal weight control patients (mean BMI 23.56 ± 1.92 kg/m(2)) underwent laparoscopic abdominal surgery. Fasting blood samples were collected prior to surgery, at day 1 after surgery, and after postoperation oral feeding. LDL and HDL subfraction analysis was done by continuous disk polyacrylamide gel electrophoresis. Plasma levels of cholesteryl ester transfer protein (CETP), lecithin-cholesterol acyltransferase (LCAT), and apolipoprotein A-1 (apoA-I) were determined by enzyme-linked immunosorbent assay. Measurement of CETP and LCAT activity was performed via fluorometric analysis. LDL subfraction profile showed no change in both LSG and control group patients. No significant difference was observed in HDL cholesterol, HDL-subfraction distribution, and apoA-I levels in the control group. LSG patients showed a significant increase in HDL-large and a significant decrease in HDL-small fractions at postoperation day 1 compared to preoperation. HDL cholesterol significantly decreased and apoA-I significantly increased in LSG patients after postoperation oral feeding compared to both preoperation and postoperation day 1. Changes in HDL subfraction profile at postoperation day 1 after LSG were accompanied by a significant decrease in CETP protein, LCAT protein, and LCAT activity as compared to preoperation levels. Early changes in HDL subfraction profile and HDL-associated enzymes following LSG suggest that the surgical procedure, irrespective of changes in body weight, affects reverse cholesterol transport.

Delayed presentation of posttraumatic diaphragmatic hernia.

BACKGROUND: Missed diaphragmatic injuries after trauma may present with herniation of intraabdominal organs into the thoracic cavity. We aimed to review our patients who presented with delayed posttraumatic diaphragmatic hernia. METHODS: A retrospective review of the medical records of patients with delayed diagnosis of posttraumatic diaphragmatic hernia between 2001 and 2009 was performed. RESULTS: Ten patients with a mean age of 44.3 years were included. Six patients were female. Blunt injuries (n: 7) were more common. Mean duration between trauma and presentation to the hospital was 5.9 years (4 months - 19 years). Nine patients had left-sided diaphragmatic hernia. All patients had chest X-ray and most were diagnostic (n: 8). Additional diagnostic imaging with computerized tomography (CT) and magnetic resonance (MR) was used in seven patients. For the repair, laparotomy incision was chosen for seven patients and thoracotomy incision for two patients. One patient underwent left thoracoabdominal approach. Mesh repair was used in seven patients. Postoperative mean hospitalization was 10.6 days. Empyema and atelectasis were the morbidities in one patient. No postoperative mortality was detected. CONCLUSION: Delayed presentation of posttraumatic diaphragmatic hernia is a serious challenge for trauma surgeons. Prompt diagnosis and treatment prevent serious morbidity and mortality associated with complications such as gangrene and/or perforation of the herniated organ.

Spontaneous biloma managed with endoscopic retrograde cholangiopancreatography and percutaneous drainage: a case report.

INTRODUCTION: Spontaneous biloma formation is a very rare condition, which mandates immediate treatment. CASE PRESENTATION: An 80-year-old Caucasian man was referred to our department with a diagnosis of intra-abdominal collection located in his right upper quadrant. Further radiological examination demonstrated multiple calculi in his gallbladder and common bile duct. Our patient underwent endoscopic retrograde cholangiopancreatography and the stones in the common bile duct were extracted. Percutaneous drainage of the abdominal collection revealed a spontaneous biloma formation. Continuous drainage of bile persisted for one week, so endoscopic retrograde cholangiopancreatography was repeated and a 10Fr stent was placed; subsequently the biliary leak ceased and our patient was discharged. A control abdominal computed tomography did not show any residual fluid collection. CONCLUSION: Spontaneous biloma formation is a very rare incidence; awareness is necessary for prompt recognition and treatment.

Coronary vasospasm secondary to 5-Fluorouracil and its management: case report.

Although rare, 5-fluorouracil (5-FU) may lead to cardiotoxicity that presents with angina, elevated cardiac enzymes and electrocardiogram (ECG) changes. Coronary vasospasm related to 5-FU is a rare clinical entity in oncological practice and may be seen during both bolus and protracted infusional administration. This toxicity is generally reversible and responds well to conventional anti-angina treatment following discontinuation of infusion. We propose that parenteral diltiazem is an effective and safe approach for the treatment of coronary vasospasm secondary to 5-FU infusion. We present clinical findings and management of a case in which coronary vasospasm occurred during the infusion of the 5-FU component of FOLFIRI-bevacizumab chemotherapy (CT) regimen given for treatment of metastatic rectal cancer.

Surgical treatment of complicated pilonidal sinus with a fasciocutaneous V-Y advancement flap.

PURPOSE: In this study, we investigated the value of fasciocutaneous V-Y advancement flap reconstruction in the treatment of complicated or recurrent sacrococcygeal pilonidal sinus. METHODS: Patients with complicated pilonidal sinus treated with a V-Y advancement flap from July 2002 through December 2005 were studied. The duration of inpatient stay, early wound complications, time of return to active work, recurrence, and patient satisfaction with the operation were recorded. RESULTS: Forty-three patients were treated for recurrent or complicated sacrococcygeal pilonidal disease. All flaps remained viable without necrosis. However, 4 patients (9.3%) had wound infections, and 3 patients (7%) had hematoma. The mean hospital stay was 3 (range, 2-5) days, and time to return to active life was 17 (range, 13-25) days. The mean duration of follow-up was 48 (range, 27 to 69) months. Recurrence was detected in only one patient in the early period. Seven patients (16.3%), including 4 bilateral repairs, had numbness over the operative site. Thirty-nine patients (90.7%) were not satisfied with scars; 4 reported that the scar was not important. CONCLUSIONS: In selected patients, V-Y advancement flaps provide tension-free repair with minimal recurrence rates and reliable skin coverage while flattening the natal cleft that predisposes to recurrence. Because patient dissatisfaction with cosmetic results is high, potential treatment outcomes should be discussed with patients in detail before the operation.

Venous air embolism during laparoscopic cholecystectomy.

Vascular air embolism is a rare and potentially life-threatening event. In this study, a case of venous air embolism during laparoscopic cholecystectomy due to an injured inferior vena cava is presented. Anesthesiologists and surgeons must be aware of this dangerous complication. Emphasis is given to the prevention and prompt recognition of this event and to the use of all available tools in the management of cardiovascular complications.

Recurrent laryngeal nerve palsy after thyroid surgery.

The identification of the risk factors associated with the increased incidence of the nerve injury is of paramount importance. Twenty-nine of 581 patients who developed recurrent laryngeal nerve palsy after thyroidectomy were analyzed retrospectively. There were 23 women (79%) and 6 men (21%), with a mean age of 45.6 years (range, 22-66 years). Eleven patients had right vocal cord paralysis, 8 had left vocal cord paralysis, and 10 patients had bilateral involvement. Ten patients underwent near total thyroidectomy (34.4%), eight patients underwent bilateral subtotal thyroidectomy (27.5%), six patients underwent total thyroidectomy (20.7%), and five patients underwent unilateral lobectomy (17.2%). Four of 10 patients with bilateral vocal cord paralysis had a unilateral nerve injury detected with laryngoscopy before surgery. Only five patients developed permanent vocal cord paralysis (17%). Three patients with permanent paralysis underwent reoperative thyroid surgery and had a total lobectomy. One patient required a tracheostomy, and arytenoidectomy was performed in one patient at a later follow-up period. Most recurrent laryngeal nerve palsy after thyroidectomy was transient. Permanent paralysis is associated with reoperative thyroid surgery.

The role of dura mater and free peritoneal graft in the reinforcement of colon anastomosis.

Anastomotic leakage is the most important complication leading to morbidity and mortality in colorectal surgery. To prevent anastomotic leakage, a number of drugs with different mechanisms of action were tested, and autogenic grafts and various synthetic materials were used for reinforcement of the anastomotic region. In this experimental study aimed at preventing anastomotic leakage and dehiscence, we used dehydrated, lyophilized human dura mater and free peritoneal graft for reinforcement of anastomotic region after primary repair in rats, and investigated whether they are superior to primary anastomosis. The rats were sacrificed 3 and 7 days postoperatively. The anastomotic region was observed macroscopically for adhesions, bursting pressure of bowel was measured for tensile strength of the anastomosis, and histopathologic evaluation was performed for anastomotic healing. Compared to the control group, dura mater and free peritoneal graft groups displayed a lower bowel bursting pressure (p < .05), worse anastomotic healing (p < .05), a higher number of adhesions, and presence of anastomotic stricture. In conclusion, both human dura mater and free peritoneal graft reinforcement groups had worse anastomosis healing. The results could be attributed to avascularity of grafts and to aggravated adhesions between anastomosis and intra-abdominal organs, which created a favorable environment for reproduction and dispersion of bacteria and consequently led to decreased anastomosis healing.

Closure of fascial defect at trocar sites after laparoscopic surgery.

As laparoscopic surgery evolves, a growing number of different abdominal operations can now be performed. This necessitates the use of multiple large trocars. Herniation through the fascial defect created by trocar entry in laparoscopic interventions has been reported at a rate of 1-6%. We describe a simple closure technique for fascial defects at trocar sites after laparoscopic surgery. To facilitate the closure of the fascial defects of > or = 10 mm trocar entry sites, the surgeon places the upper end of a dissecting forceps through the fascial defect and tilts it so that the abdominal of the peritoneum comes into contact with its flat surface. The assistant retracts the skin and subcutaneous tissue and the "J" needle with the appropriate suture material is then used to take a stitch through the fascia under direct vision. The sharp end of the needle is prevented from coming into contact with any deeper structure as it slides on the flat surface of the dissecting forceps. The stitch is then pulled up to lift the edge of the fascia and the needle is passed from the opposite edge of the fascia in the same manner and then the suture is ligated. The aforementioned technique is easy to perform and facilitates the closure of the fascial defect at trocar sites, and there is no extra cost for the procedure.

Which repair in umbilical hernia of adults: primary or mesh?

In classic literature, knowing that small defects can be repaired primarily in umbilical hernias of adults, mesh repair should be reserved for larger defects. Conventional repair methods have resulted in high rates of recurrence. Therefore, this prospective study investigated the repair techniques in umbilical hernias of adults. The patients who underwent primary umbilical hernia operation between 1998 and 2003 were reviewed. Primary repair was conducted in defects less than 3 cm, whereas larger defects were repaired with polypropylene mesh. Postoperative complications, the length of hospital stay, and recurrence in follow-up were recorded. Of 111 patients, primary repair was carried out on 63 patients, and 48 underwent polypropylene mesh repair. Recurrence rate was significantly higher in the primary repair group (14%) compared with polypropylene mesh repair group (2%). In conclusion, contrary to the general tendency that small defects can be repaired primarily, polypropylene mesh should be used in all umbilical hernias regardless of the size of the defect.