Challenges in Diagnosis and Treatment of Fasciola hepatica Infection.

A 57-year-old female patient presented with fever, nausea, vomiting, loss of appetite, and weight loss within the last two months. Ceftriaxone and metronidazole therapy was started upon discovery of a liver abscess but provided no benefit. Following the of abscess biopsy, the patient developed fever, itching, anemia, acute renal failure, hyperbilirubinemia, and eosinophilia that required intensive care unit (ICU) admission. The Fasciola hepatica antibodies were detected by enzyme-linked immunosorbent assay (ELISA). Triclabendazole was started, after which the symptoms and magnetic resonance imaging (MRI) findings regressed. Even without eosinophilia, F. hepatica should be considered in cases with a liver abscess that does not respond to antibiotics.

Successful pregnancy after presurgical uterine artery embolization in the management of a very large cervical myoma: A case report.

Although fibroids are the most common benign tumors of the uterus in women of reproductive age, cervical fibroids are rarely seen. Since cervical fibroids are located deep in the pelvis, the incidence of complications in surgery is high. Among these complications bleeding is the most common, due to poor access to myoma, difficulty in suturing and repair, and distortion of vital neighboring structures. Each case should be managed individually to minimize bleeding. To decrease bleeding in patients who wish to retain their fertility, intraoperative interventions include vasoconstrictors such as vasopressin and adrenaline, uterotonics such as oxytocin, misoprostol or ergometrines, uterine artery clamping, internal iliac artery balloon occlusion catheters, and tourniquets; preoperative interventions include gonadotropin releasing-hormone analogues and uterine artery embolization. We present a case of a 40-year-old woman who had a large cervical myoma and a desire for future fertility. To overcome technical difficulties and reduce intraoperative bleeding during myomectomy, presurgical uterine artery embolization was performed. The patient conceived spontaneously after the operation and a healthy baby was delivered by cesarean section.

In-bore MRI-guided prostate biopsy in a patient group with PI-RADS 4 and 5 targets: A single center experience.

PURPOSE: To determine the diagnostic yield of magnetic resonance imaging (MRI) guided in-bore biopsy in patients with high likelihood multiparametric MRI (mpMRI) findings, regarding overall and clinically significant prostate cancer (csPCa) detection rates and concordance of biopsy and radical prostatectomy (RP) Gleason scores (GS). METHODS: This retrospective study consisted of 277 Prostate Imaging Reporting and Data System (PI-RADS) assessment category 4 and 5 targets in 246 patients (mean age, 65.7 years; median prostate specific antigen value, 7.75 ng/mL) who had undergone in-bore biopsy at our institution between 2012 and 2020. Eighty-one patients who underwent RP were eligible for the concordance analysis of biopsy and RP specimen GS. RESULTS: Overall PCa detection rates were 80.5 % per patient (198/246) and 78 % per target (216/277) and 83.5 % and 67.4 % in primary (biopsy naive) and secondary (at least one negative prior biopsy) settings. csPCa was found in 63 % overall, 66 % of patients (132/200) in the primary, and 50 % of patients (23/46) in the secondary biopsy settings (p < 0.001). The prostate cancer detection rate was 68 % and 92 % in PI-RADS 4 and 5, respectively (p < 0.001). In the radical prostatectomy subcohort, 27.2 % of patients were upgraded, 8.6 % of patients were downgraded from needle biopsy. Significant complications occurred in 1.2 % of patients. CONCLUSIONS: MRI-guided in-bore prostate biopsy has a high detection rate of csPCa in primary and secondary biopsy cohorts. Biopsy results were satisfactory in terms of the number of positive cores, cancer percentage in positive cores, and concordance of GS in needle biopsy and RP specimen.

Dealing with the gray zones in the management of gastric cancer: The consensus statement of the Istanbul Group.

The geographical location and differences in tumor biology significantly change the management of gastric cancer. The prevalence of gastric cancer ranks fifth and sixth among men and women, respectively, in Turkey. The international guidelines from the Eastern and Western countries fail to manage a considerable amount of inconclusive issues in the management of gastric cancer. The uncertainties lead to significant heterogeneities in clinical practice, lack of homogeneous data collection, and subsequently, diverse outcomes. The physicians who are professionally involved in the management of gastric cancer at two institutions in Istanbul, Turkey, organized a consensus meeting to address current problems and plan feasible, logical, measurable, and collective solutions in their clinical practice for this challenging disease. The evidence-based data and current guidelines were reviewed. The gray zones in the management of gastric cancer were determined in the first session of this consensus meeting. The second session was constructed to discuss, vote, and ratify the ultimate decisions. The identification of the T stage, the esophagogastric area, imaging algorithm for proper staging and follow-up, timing and patient selection for neoadjuvant treatment, and management of advanced and metastatic disease have been accepted as the major issues in the management of gastric cancer. The recommendations are presented with the percentage of supporting votes in the results section with related data.

Multiparametric MRI guidance in first-time prostate biopsies: what is the real benefit?

PURPOSE: With the increased recognition of the capabilities of prostate multiparametric (mp) magnetic resonance imaging (MRI), attempts are being made to incorporate MRI into routine prostate biopsies. In this study, we aimed to analyze the diagnostic yield via cognitive fusion, transrectal ultrasound (TRUS)-guided, and in-bore MRI-guided biopsies in biopsy-naive patients with positive findings for prostate cancer screening. METHODS: Charts of 140 patients, who underwent transrectal prostate biopsy after the adaptation of mp-MRI into our routine clinical practice, were reviewed retrospectively. Patients with previous negative biopsies (n=24) and digital rectal examination findings suspicious for ≥cT3 prostate cancer (n=16) were excluded. T2-weighted imaging, diffusion-weighted imaging, and dynamic contrast-enhanced imaging were included in mp-MRI. Cognitive fusion biopsies were performed after a review of mp-MRI data, whereas TRUS-guided biopsies were performed blinded to MRI information. In-bore biopsies were conducted by means of real-time targeting under MRI guidance. RESULTS: Between January 2012 and February 2014, a total of 100 patients fulfilling the inclusion criteria underwent TRUS-guided (n=37), cognitive fusion (n=49), and in-bore (n=14) biopsies. Mean age, serum prostate specific antigen level, and prostate size did not differ significantly among the study groups. In TRUS-guided biopsy group, 51.3% were diagnosed with prostate cancer, while the same ratio was 55.1% and 71.4% in cognitive fusion and in-bore biopsy groups, respectively (P = 0.429). Clinically significant prostate cancer detection rate was 69.1%, 70.3%, and 90% in TRUS-guided, cognitive fusion, and in-bore biopsy groups, respectively (P = 0.31). According to histopathologic variables in the prostatectomy specimen, significant prostate cancer was detected in 85.7%, 93.3%, and 100% of patients in TRUS-guided, cognitive fusion, and in-bore biopsy groups, respectively. CONCLUSION: In the first set of transrectal prostate biopsies, mp-MRI guidance did not increase the diagnostic yield significantly.

Adrenal cortex-sparing surgery for bilateral multiple pheochromocytomas in a patient with von hippel-lindau disease.

Pheochromocytomas can be a part of familial neoplastic syndromes, in which case they tend to be multiple and involve both adrenal glands. Therefore, sparing adrenocortical function represents a major concern while dealing with these hereditary lesions. Herein, we describe the clinical characteristics and the management strategy of a patient with von Hippel-Lindau (VHL) disease who had multiple, bilateral pheochromocytomas as well as bilateral renal masses, pancreatic masses, and a paracaval mass. Only a portion of the left adrenal gland has remained in situ after two consecutive open surgeries and a percutaneous radiofrequency ablation which have been performed to treat the various components of this syndrome. No adrenal or extra-adrenal pheochromocytoma recurrences have been detected during a follow-up period of more than 2 years. Pancreatic and adrenal functions were normal throughout the postoperative period and never necessitated any replacement therapy. Adrenal cortex-sparing surgery is a valid option for VHL disease patients who present with synchronous bilateral adrenal pheochromocytomas.

Aorta after stent grafting for mycotic aneurysm.

Endovascular stent grafting is applied for the treatment of different aortic pathologies in the current medical era. It may be lifesaving in patients with comorbidities and virtually inoperable when adopting conventional techniques. This manuscript reports on a 40-year-old patient, who was previously treated for a mycotic saccular aneurysm at the aortic arch and who presented with a descending aortic rupture at the mid-term follow-up. The descending aortic rupture was also managed successfully by endovascular measures.

Aorta após endoprótese para aneurisma micótico / Aorta after stent grafting for mycotic aneurysm / Aorta después de endoprótesis para aneurisma micótico

Endopróteses vasculares são atualmente utilizadas no tratamento de diferentes patologias da aorta. Podem salvar a vida de pacientes com comorbidades e virtualmente inoperáveis quando da utilização de técnicas convencionais. Esse manuscrito relata o caso de um paciente de 40 anos, que havia sido previamente tratado de um aneurisma micótico sacular no arco aórtico e que apresentou ruptura da aorta descendente no seguimento de médio prazo. O tratamento da ruptura da aorta descendente também foi realizado através de medidas endovasculares, com sucesso.

Endovascular stent grafting is applied for the treatment of different aortic pathologies in the current medical era. It may be lifesaving in patients with comorbidities and virtually inoperable when adopting conventional techniques. This manuscript reports on a 40-year-old patient, who was previously treated for a mycotic saccular aneurysm at the aortic arch and who presented with a descending aortic rupture at the mid-term follow-up. The descending aortic rupture was also managed successfully by endovascular measures.

Endoprótesis vasculares son actualmente utilizadas en el tratamiento de diferentes patologías de la aorta. Pueden salvar la vida de pacientes con comorbilidades y virtualmente inoperables con la utilización de técnicas convencionales. Este manuscrito relata el caso de un paciente de 40 años, que había sido previamente tratado de un aneurisma micótico sacular en el arco aórtico y que presentó ruptura de la aorta descendente en el seguimiento de medio plazo. El tratamiento de la ruptura de la aorta descendente también fue realizado a través de medidas endovasculares, con éxito.

Cutting-balloon angioplasty in transplant renal artery stenosis as first-line treatment in the early postoperative period.

Percutaneous transluminal angioplasty has been successfully used for the treatment of transplant renal artery stenosis (RAS). Cutting-balloon angioplasty (CBA) is being used as a second option in pressure-resistant stenosis. It is thought that CBA is less traumatic and therefore restenosis occurs less frequently than in conventional angioplasty. This case report describes the unusual use of a cutting balloon in transplant RAS as a first option in the early postoperative period. Long-term follow-up data are also presented.

Diffusion weighted MR imaging of pancreatic islet cell tumors.

PURPOSE: The aim of our study is to demonstrate the feasibility of body diffusion weighted (DW) MR imaging in the evaluation of pancreatic islet cell tumors (ICTs) and to define apparent diffusion coefficient (ADC) values for these tumors. MATERIALS AND METHODS: 12 normal volunteers and 12 patients with histopathologically proven pancreatic ICT by surgery were included in the study. DW MR images were obtained by a body-phased array coil using a multisection single-shot echo planar sequence on the axial plane without breath holding. In addition, the routine abdominal imaging protocol for pancreas was applied in the patient group. We measured the ADC value within the normal pancreas in control group, pancreatic ICT, and surrounding pancreas parenchyma. Mann-Whitney U-test has been used to compare ADC values between tumoral tissues and normal pancreatic tissues of the volunteers. Wilcoxon Signed Ranks Test was preferred to compare ADC values between tumoral tissues and surrounding pancreatic parenchyma of the patients. RESULTS: In 11 patients out of 12, conventional MR sequences were able to demonstrate ICTs succesfully. In 1 patient an indistinct suspicious lesion was noted at the pancreatic tail. DW sequence was able to demonstrate the lesions in all of the 12 patients. On the DW images, all ICTs demonstrated high signal intensity relative to the surrounding pancreatic parenchyma. The mean and standard deviations of the ADC values (x10(-3)mm(2)/s) were as follows: ICT (n=12), 1.51+/-0.35 (0.91-2.11), surrounding parenchyma (n=11) 0.76+/-0.15 (0.51-1.01) and normal pancreas in normal volunteers (n=12), 0.80+/-0.06 (0.72-0.90). ADC values of the ICT were significantly higher compared with those of surrounding parenchyma (p<0.01) and normal pancreas (p<0.001). CONCLUSION: DW MR imaging does not appear to provide significant contribution to routine MR imaging protocol in the evaluation of pancreatic islet cell tumors. But it can be added to MR imaging protocol to detect the lesion in a limited number of patients with clinical suspicion for pancreatic ICT with negative or suspicious imaging findings.

Pushable springcoil embolization of pseudoaneurysms caused by gluteal stab injuries.

PURPOSE: To retrospectively review the outcomes of 21 patients with stab wounds to the gluteal region who underwent embolization for pseudoaneurysms causing active bleeding. MATERIALS AND METHODS: Between 1997 and 2007, 3 superior gluteal artery, 2 inferior gluteal artery and 16 deep femoral artery muscular branch pseudoaneurysms detected by digital subtraction angiography were selectively catheterized with diagnostic catheters with hydrophilic coating and embolized with pushable springcoils. 17 of the 21 pseudoaneurysms were located in a distal end of an artery where outflow vessels could not be depicted. The other 4 lesions were side wall injuries which required the placement of coils distal and proximal to the injury site. RESULTS: Embolization was successful in controlling the bleeding in all of the patients. 16 patients required 1 or 2 coils, 4 patients required 3 coils and 1 patient required 5 coils. 2 patients had femoral puncture site hematomas which resolved spontaneously. 2 patients required surgical evacuation of large gluteal hematomas following the embolization because of symptoms second to mass effect. There were no procedure related major complications or mortality. CONCLUSIONS: Our experience demonstrates that pushable coil embolization is a relatively simple, effective and economic method for the embolization of pseudoaneurysms caused by penetrating gluteal injuries. Experimenting with other embolization materials does not seem to be justified.

Endovascular treatment of a superior mesenteric artery aneurysm secondary to Behcet's disease with Onyx (ethylene vinyl alcohol copolymer).

Behcet's disease is a complex multisystemic chronic inflammatory disease that is characterized by oral and genital aphtous ulcers and vasculitis. Aneurysms of major arteries are the most important cause of mortality in Behcet's disease. Four patients with superior mesenteric artery (SMA) aneurysms related to Behcet's disease have been reported in the literature. We report here the first successful endovascular treatment of a giant, wide-necked SMA aneurysm secondary to Behcet's disease. We performed a balloon-assisted embolization technique using ethylene vinyl alcohol copolymer (Onyx, ev3, Irvine, CA, USA). There were no signs of recurrence during 2-year follow-up.

Cystic echinococcal liver disease: new insights into an old disease and an algorithm for therapy planning.

Human cystic echinococcosis (CE) continues to be a major health problem in developing countries. A review of current literature discloses four alternatives for the management of active CE, consisting of surgery, percutaneous treatment (PT), chemotherapy, and follow-up without intervention, but no clear guidelines for directing patients to the different management options. Palliation of symptoms or prevention of complications is the main rationale for the treatment of CE. Surgery has long been considered as the gold standard treatment. However, a meta-analysis comparing the clinical outcomes of patients treated with PT with those of a control group treated with surgery found PT to be more effective, safer, and cheaper. Medical therapy is considered to be ineffective when the criterion of success is defined as the disappearance of the lesion. However, medical therapy seems to be effective when the goal of therapy is defined as the prevention of complications in asymptomatic patients. We propose an algorithm for therapy planning in CE where the first line of therapy for patients with active lesions is PT. Patients with lesions unsuitable for PT are directed to surgery if they are symptomatic, have complicated lesions or have lesions that are prone to rupture. Asymptomatic patients with uncomplicated lesions are directed to medical therapy. Medical therapy failures are redirected to surgery.

Endoluminal stenting of mycotic saccular aneurysm at the aortic arch.

Endovascular grafts have been widely used for the treatment of aneurysms since the early 1990s. They are preferred especially for use in patients in whom conventional surgical methods carry high risks of death and morbidity. Increasing operator experience and technical refinements in endovascular grafting have enabled these procedures to be performed even in critical segments of the aorta, such as the thoracic and arch levels. In this report, we present the case of a patient who was treated successfully with an endovascular graft for a mycotic saccular aneurysm located just below the left subclavian artery.

Endoscopic and radiologic interventions as the leading causes of severe cholangitis in a tertiary referral center.

BACKGROUND: Iatrogenic factors became the leading mechanisms of severe cholangitis in a referral center. PATIENTS AND METHODS: The records of the 58 patients treated for severe cholangitis between 1996 and May 2004 (inclusive) were evaluated. RESULTS: The most frequent underlying diseases were periampullary tumors and mid-bile duct carcinomas (22), followed by proximal cholangiocarcinomas (14). The triggering mechanism was an incomplete endoscopic retrograde cholangiopancreatography (ERCP) in 32 patients, incomplete or inappropriate percutaneous transhepatic biliary drainage (PTBD) in 6, apparently successful ERCP and stenting in 1, and percutaneous transhepatic cholangiography in 1. PTBD was the treatment of choice (38). Mortality was 29% (17/58); the major causes were refractory sepsis (8) and incomplete biliary drainage (advanced tumor, technical failure, or hemobilia) (8). CONCLUSIONS: In this series composed predominantly of patients referred after development of sepsis, ERCP and PTBD complications were the leading mechanisms of severe cholangitis. Nonoperative biliary manipulations are invasive procedures with potentially fatal complications. The decisions to perform such procedures and periprocedural management are responsibilities of an experienced multidisciplinary team.

Alveolar echinococcosis in Turkey. Experience from an endemic region.

BACKGROUND: Radical resection is the only potentially curative treatment for hepatic alveolar echinococcosis (AE). Although Turkey is an endemic region, population screening is not performed and early diagnosis is rare. Consequently, surgeons are compelled to explore possibilities such as near-total resection and biliodigestive anastomosis for palliation of jaundice. METHODS: Surgery was performed in 32 patients with hepatic AE with the following indications: (1) resection; (2) palliation of jaundice; (3) definite assessment of operability; (4) failure in the management of cavity infection by percutaneous methods. Curative resection (R0 = complete resection of all parasitic mass [n = 9], and R1 = a resection in which a small remnant was left on a vital structure [n = 8]) were performed in 17 patients, intrahepatic cholangiojejunostomy in 7, laparotomy-external drainage in 7, and debulking in 1. RESULTS: Perioperative mortality rates were 2/17, 0/7, 2/7 and 1/1, respectively. Twelve patients in the curative resection group are alive without recurrence/progression of the small remnant during a median follow-up of 59 (range 27-116) months. One patient developed an inoperable recurrence that was treated with albendazole. One patient was lost to follow-up. Long-term albendazole treatment was effective in all R1 patients except a patient who had slow asymptomatic progression. Successful palliation of jaundice was achieved in 5 of the 7 intrahepatic cholangiojejunostomy patients. CONCLUSIONS: The results of R1 resection in alveolar hydatid disease are similar to those of R0 resection; a small remnant is successfully controlled by albendazole. In patients with jaundice due to hilar invasion, biliary diversion from segment 3 or 5 is effective for palliation of the jaundice and facilitates albendazole treatment.