Adil Baskiran

A swallowed dental prosthesis causing duodenal obstruction in a patient with schizophrenia: Description of a new technique

INTRODUCTION Foreign body ingestion has been a fundamental subject in the area of emergency surgery. The problem is encountered across all age groups; however, it is more common in the pediatric age group. Foreign body ingestion is rare in adults and usually occurs accidentally or in those with psychiatric problems, behavioral disorders, emotional disturbance, mental retardation, or impaired judgment caused by alcohol use. PRESENTATION OF CASE A 33-year-old Caucasian man with chronic schizophrenia was admitted to the emergency department with signs of upper gastrointestinal discomfort as a result of ingestion of a lower dental prosthesis. An abdominal X-ray showed the swallowed dental prosthesis in front of the vertebral column. A technique comprising gastrotomy and duodenal kocherization was used to remove the dental prosthesis; the prosthesis could not be removed endoscopically due to its fixed position on the duodenal wall. DISCUSSION Surgery of the duodenum is difficult and carries high mortality and morbidity. Therefore, endoscopy should be the first choice for patients in whom a foreign object is demonstrated to be fixed in the duodenum. In cases where endoscopic extraction fails, surgery should be considered. During surgery, foreign bodies should be removed, paying meticulous attention not to harm the integrity of the duodenum. CONCLUSION The technique presented in this study was performed successfully without any injury to the duodenum.

Barolith, a rare cause of acute appendicitis: a case report

A barolith consists of inspissated barium associated with feces and is seen, rarely, after barium studies for imaging the gastrointestinal system. The barium used in such studies can enter the appendiceal lumen and, rarely, cause appendicitis by obliterating or narrowing the lumen of the appendix. The appendix fills with barium and the entire appendix is visualized in 80-90% of barium swallow or enema studies, and this is accepted as a reliable sign of a non-diseased appendix Post-examination retention of barium in the appendix is very common (90~95%), and 10% of the patients retain barium in the appendix beyond 72 hours. If the barium is retained for more than two months, complicated appendicitis can result. We present a 46-year-old male who was diagnosed with acute appendicitis due to a barolith and required an appendectomy three months after a double-contrast barium enema study. After barium studies, patients should be informed regarding retention of barium in the appendix and the possibility that it can cause acute appendicitis. Thus, if abdominal pain develops, the patient can be referred quickly to a medical center for the appropriate treatment and the complications of acute appendicitis can be prevented with early intervention.

Reconstruction of Anomalous Portal Venous Branching in Right Lobe Living Donor Liver Transplantation: Malatya Approach

Reconstruction of anomalous portal vein branching (APVB) during right lobe living donor liver transplantation (LDLT) can be challenging. The goal of this article is to describe our surgical technique, named the Malatya Approach, in case of APVB during right lobe LDLT. The technique unifies the APVB and obtains a funnel‐shaped common extension with a circumferential fence by a saphenous vein conduit. In total, 126 (10.6%) of 1192 right lobe grafts had APVB that were divided into 2 groups according to the adopted surgical techniques: the Malatya Approach group (n = 91) and the previously defined other techniques group (n = 35). Both groups were compared regarding portal vein thrombosis (PVT), postoperative 90‐day mortality and survival. PVT developed in 3 patients (3.3%) in the Malatya Approach group and developed in 10 (28.6%) patients for the other group (P < 0.001). There were 8 (8.8%) 90‐day mortalities in the Malatya Approach group (1 PVT related) and 15 patients (9 PVT related) died in the other techniques group (P < 0.001). Mean follow‐up time for both groups was similar (999.1 days for the Malatya Approach group versus 1024.7 days for the other group; P = 0.47), but longterm survival in the Malatya Approach group was better than in the other group (84.6% versus 40%; P < 0.001). Multivariate analysis revealed that the Malatya Approach group showed less PVT development and longer survival (P < 0.001). This technique is promising to avoid PVT and mortalities in cases of APVB during right lobe LDLT. Liver Transplantation 23 751–761 2017 AASLD.

Unexpectedly ease surgery for a worrisome abdominal mass: Pedunculated GISTs

INTRODUCTION Discovery of abdominal masses often poses significant diagnostic difficulties. GISTs are mesenchymal masses, with specific histological features. Dimensions may vary from millimeters to giant tumours. We would like to present our case, which had an unexpectedly easy operative course which was easily handled with a simple surgical excision with a short operative duration. PRESENTATION OF CASE A 38 years old female patient was diagnosed to have an abdominal heterogen mass of 15cm×12cm×10cm in dimension. Abdominal computed tomography revealed the solid mass between the stomach and pancreas corpus and tail, possibly orginating from the pancreas. With the preoperative diagnosis of locally invasive distal pancreas cancer the patient underwent laparotomy, following the dissection, the mass was observed to be originating from the posterior gastric Wall, extending exophytically with a peduncle of 5cm in width, without any visual evidence for peritoneal invasion and metastasis. The tumour and the peduncle was resected with stapler device. Total operation time was 30min. Postoperative course was uneventful. Pathologic diagnosis was gastrointestinal stromal tumour (GIST). DISCUSSION Pedunculated large GISTs are not frequent and they can enlarge as 15cm in diameter and compress the neighbouring organs. When they were huge, it is difficult to differentiate the origin of the masses. GISTs should be considered in differential diagnosis of giant abdominal masses. CONCLUSION When GISTs are huge and pedunculated, it can be difficult to differentiate the origin of the masses. This case report presents unexpectedly ease surgery for a worrysome abdominal mass.

Living donor liver transplantation for Budd-Chiari syndrome: Overcoming a troublesome situation.

Background: The aim of the study was to report the detailed surgical techniques of living donor liver transplantation (LDLT) in patients with Budd–Chiari syndrome (BCS). Methods: Demographic and surgical techniques characteristics of 39 patients with BCS who underwent LDLT were retrospectively reviewed. Thirty-two of them had native vena cava inferior (VCI) preservation and 6 had retrohepatic VCI resection with venous continuity established by cryopreserved VCI (n = 4) or aortic graft (n = 2). In 1 patient, the anastomosis was established between the graft hepatic vein (HV) and the suprahepatic VCI. For preservation of the native VCI, immediately before the graft implantation, the thickened anterior, and right/left lateral walls of the recipient VCI were resected caudally and cranially until the intact vein wall was reached, and then an anastomosis was created between the (HV) of the graft reconstructed as a circumferential fence and the reconstructed recipient VCI. For resection of the retrohepatic VCI, the anastomosis was created with the same technique in all 6 patients in whom VCI was reformed by using a vascular graft. Results: Post-LT complications developed in 19 of the patients. Complications related to the biliary anastomosis accounted for 12 of these cases, with 11 treated by PTC and/or ERCP, and 1 by hepaticojejunostomy. Two of the 39 patients developed recurrent BCS and were treated by interventional radiological methods. Thirteen patients died and none were related to the BCS recurrence. Conclusion: Favorable outcomes are achievable with LDLT treatment of patients with BCS, which carries important implications for countries with inadequate cadaveric donor pools.

The Efficacy of Negative Pressure Wound Therapy in the Management of Acute Burns

BACKGROUND The aim of the present study was to evaluate the outcomes and efficacy of negative pressure wound therapy in the management of acute burns. METHODS Patients with acute burns who have received negative pressure wound therapy at the Dr. Lutfi Kırdar Kartal Research and Training Hospital Tertiary Burn Care Center between January 2014 and December 2015 were included in the study. Patient data were retrospectively reviewed by analyzing data from our prospective patient database. RESULTS A total of 38 patients were evaluated for the study. Three patients were excluded due to mortality prior to the completion of the treatment course. There were 32 (91.6%) male and 3 (8.4%) female patients. The mean age of the patients was 49.5±16 years. The etiological factors included electrical burn injury in 19 (54.3%), chemical burn injury in 7 (20%), flame burn injury in 6 (17.2%), and hot water burns in 3 (8.4%) patients. The severity of the burns was grade 3 or 4 in all of the patients included in the study. The mean duration of negative pressure wound therapy was 10.1±3.9 days. There were no procedure-related complications throughout the duration of the study. During the standard application of the device, one patient experienced local pain; therefore, low pressure (75 mmHg) was applied during therapy, and pressure was steadily increased. As a result of the application of this therapy, a decrease in the surface area, edema, and secretion of the wound and an increase in the granulation tissue and perfusion of the wound were observed in all treated patients. Wound cultures revealed no bacterial growth in any of the patients. The mean duration of surgical wound closure was 11.2±3.7 days. No complication was observed related to wound closure. The mean duration of hospital discharge in the postoperative period was 6.7±2.1 days. CONCLUSION Well-designed, randomized control studies showing the efficacy of negative pressure wound therapy in patients with burns are lacking. The results of the present study showed that negative pressure wound therapy may reduce the number of wound debridement sessions, time of wound closure, and hospitalization in major burn injuries exposing the underlying tendons and bones.

Significance and outcome of living-donor liver transplantation in acute mushroom intoxication

Introduction: Mushroom intoxication (MT) can lead to acute liver injury which may result in Mushroom intoxication-related liver failure (M-ALF) requiring liver transplantation (LT). In the present study, we want to share the experience of our institute regarding living-donor LT (LDLT) due to mushroom poisoning. Aim: The aim of this study is to identify the predictors of poor prognosis in patients with ALF secondary to mushroom intoxication requiring LDLT. Materials and Methods: All patients with MT between 2008 and 2016 were evaluated. Demographics, symptoms, interval between symptoms and admission to our institute, laboratory data, model for end-stage liver disease (MELD)/pediatric end-stage liver disease (PELD) scores, clinical course, and outcomes of supportive therapy and LT were evaluated. There were two groups in the study: Group A = responsive to supportive therapy (n = 9) versus Group B = unresponsive to supportive therapy (n = 9). Results: During the study, a total of 18 patients were admitted with M-ALF. Twelve (66.7%) of them were female, and the mean age was 39.9 ± 18.2 years. All of the nine patients in Group A fully recovered with supportive therapy. In Group B, one patient died during waiting period for LT and 8 patients received LDLT LDLT. Three of the eight patients who were transplanted died in the postoperative early period within postoperative 5 days. The patients in Group B had significantly higher MELD/PELD scores and encephalopathy rate than in Group A (P < 0.05). International normalized ratio (INR), bilirubin, ammonium levels, and platelet count were significantly different between groups (P < 0.05). The patients in Group B had significantly longer interval before admission to our institute (P < 0.05). Conclusion: The presence of encephalopathy, higher MELD/PELD, INR, bilirubin, ammonium levels, and lower platelet count was related to poor prognosis in MT. LDLT provides a good therapeutic option in patients with M-ALF. The time is a crucial factor in successful treatment of MT. Early admission to a tertiary referral center with expertise in LT results in a better prognosis and increased survival following M-ALF.

The efficacy of laboratory tests and ultrasonography in the diagnosis of acute appendicitis in gravid patients accoridmg to the stages of pregnancy

BACKGROUND Normal physiologic changes during pregnancy result in similar laboratory and symptomatology changes as those during acute appendicitis (AA), making the diagnosis extremely difficult. The aim of the present study was to analyze the efficacy of conventional laboratory and radiologic tests in the diagnosis of AA according to different stages of pregnancy. METHODS Twenty-five pregnant patients with pathologically confirmed AA operated at our department between 2012 and 2017 were retrospectively analyzed in terms of changes in conventional laboratory parameters as well as neutrophil-to lymphocyte (NLR) and platelet-to-lymphocyte (PLR) ratios to aid the diagnosis of AA according to different stages of pregnancy. RESULTS There were no significant changes in C-reactive protein levels, leukocyte and neutrophil counts, and accuracy of ultrasonography between patients in the first (group 1) and second + third trimesters (group 2) (p>0.05). Lymphocyte count was significantly lower (p>0.05), whereas NLR and PLR were significantly higher in group 2 (p<0.05). CONCLUSION Laboratory values change significantly during pregnancy, and NLR and PLR seems to be valuable tools for evaluating AA in a stage-specific manner in pregnant patients.

Surgical Treatment of Portal Vein Thrombosis With the Use of Cadaveric Venous Patch After Donor Hepatectomy: A Case Report

Live donors should be the priority of transplant professionals to prevent surgery-related morbidity and mortality during living-donor liver transplantation. Portal vein thrombosis after donor hepatectomy is an important complication which can be prevented by careful preoperative as well as perioperative evaluation. If portal vein thrombus occurs after donor hepatectomy, anticoagulation and surgical thrombectomy and even portal vein reconstruction should be kept in mind. Cadaveric venous patches can be used for the reconstruction of narrowed and angulated portal veins. Here we report the surgical treatment of a donor with a cadaveric venous patch who developed portal vein thrombosis after donor hepatectomy.