Ahmet Ozenc

Giant Liver Hemangioma: Therapy by Enucleation or Liver Resection

Hemangioma is the most common primary tumor of the liver. The widespread use of ultrasonography (USG) and computed tomography (CT) has made the diagnosis more common. Although the vast majority of hemangiomas are diagnosed incidentally and are asymptomatic, treatment is still controversial. Surgery is the treatment of choice, especially in giant, symptomatic hemangiomas and uncertainty of diagnosis. Twenty-two patients (median age: 46 years) underwent resection (n = 12) or enucleation (n = 10) for liver hemangioma from 1989 to 2002. The primary indication for surgery was abdominal pain. Ten patients who were treated by enucleation were compared with twelve patients who were treated by liver resection. Mean tumor size was 90 mm with a range of 40–270 mm. There were no statistically significant differences in tumor size, preoperative liver function tests, hemoglobin levels, and platelet counts between the two groups. Operative time was longer in the resection group, and statistically significant the difference was (p = 0.048). Blood transfusion requirement and blood loss during intraoperative period were higher in the resection group (p = 0.025, p = 0.01, respectively). There were three postoperative complications, 1 in the enucleation group (plevral effusion), 2 in the resection group (liver abscess and wound infection). There was no surgery-related mortality in either group. Although most hemangiomas can be removed by enucleation or liver resection with low morbidity and mortality, if the location and number of hemangiomas are appropriate, enucleation is the choice of the therapy. Hospital stay, blood transfusion requirement, and blood loss can be kept minimal by the selection of enucleation.

The abdominal cocoon: a case report.

The abdominal cocoon is a rare disease that is characterized by a total or partial encasement of the small bowel by a thick and fibrotic membrane. Thirty-five cases were reported since it was first described. It occurs primarily in females. Preoperative diagnosis is a matter of challenge and usually made at laparotomy. We report a patient with partial intestinal obstruction and abdominal cocoon which was diagnosed peri-operatively. We review the literature and discuss the etiology of this disease.

Antegrade Jejunojejunal Intussusception After Roux-en-Y Esophagojejunostomy as an Unusual Cause of Postoperative Intestinal Obstruction: Report of a Case

Abstract Postoperative intestinal obstruction in adults is rarely caused by intussusception. A case of antegrade jejunojejunal intussusception that occurred after Roux-en-Y esophagojejunostomy is described, followed by a discussion of the literature on this unusual entity.

Effect of hydrogen peroxide on permeability of the main pancreatic duct and morphology of the pancreas

BACKGROUND The direct effect of free oxygen radicals, if any, on the morphology of the pancreas has never been studied in vivo. This study was designed to evaluate the effects of hydrogen peroxide (H2O2) on permeability of the main pancreatic duct (MPD) and morphology of pancreas in cats when administered intraductally or intraarterially. METHODS Thirty-six mongrel cats were randomly allocated into three groups, and all groups were divided into two subgroups. In group I and III, MPD was perfused with either standard perfusate (group IA and IIIA) or H2O2 at a concentration of 150 microM (group IB and IIIB) for 3 hours. In group II, the splenic artery was infused either with 0.9% sodium chloride (group IIA) or H2O2 (group IIB) for 3 hours. After 3 hours, in group I and II, MPD was perfused with 99mTc labelled dextran, and the percentage of the dextran permeated from the MPD into the portal vein was calculated for the evaluation of the pancreatic duct permeability. Then, tissue samples were obtained for the examination of early histopathological changes in pancreas. In group III, following ductal perfusion studies, the cats were allowed to recover. After 24 hours animals were killed, and samples were taken for the examination of late histological changes in pancreas. In all groups, an inflammatory score was created for each animal based on the pathological changes in pancreas: edema, leukocyte infiltration, parenchymal necrosis, and hemorrhage. RESULTS Group I: All cats developed acute edematous pancreatitis with significantly higher inflammatory scores than controls (P < 0.01). Desquamation of the single layer of columnar epithelium that normally lined the duct and leukocyte infiltration around the MPD duct were found. Pancreatic duct permeability was found to be increased significantly (P < 0.01). Group II: There were no statistical differences in inflammatory scores and pancreatic duct permeability between experimental and control groups (P > 0.05). Group III: All animals developed gross acute edematous pancreatitis after 3 hours of intraductal H2O2 perfusion. Histopathological changes at 24 hours were much more pronounced in group IIIB than in group IIIA including focal necrosis and hydropic degeneration of acinar cells. CONCLUSION This study has shown that intraductal H2O2 perfusion induced acute edematous pancreatitis with marked histopathological changes and increased pancreatic duct permeability in cats. Intraarterial H2O2 infusion, however, has no effect on the permeability of the MPD and morphology of pancreas in our model.

The effect of hepatectomy on coagulation: an evaluation by thromboelastography

Objectives Liver has a major role in coagulation. The hemostatic derangements measured by the mostly used coagulation parameters as prothrombin time, activated partial thromboplastin time, and thrombocyte count do not always correlate with the bleeding associated with liver diseases and these factors do not measure the thrombotic risks. So, thromboelastography is used in new clinical and laboratory research. The aim of this study is to study the effect of different levels of hepatectomy on coagulation. Methods Laparatomy, 40% hepatectomy, and 70% hepatectomy was performed in three different groups of rats. Prothrombin time, international normalized ratio, activated partial thromboplastin time, thrombocyte count, fibrinogen levels, and thromboelastography parameters were obtained at the 0, 6, and 24th hour of the study. Results Fibrinogen level at the 24th hour was greater than the early hours in both of the hepatectomy groups. Prothrombin time and international normalized ratio values were significantly higher in hepatectomy groups than in the sham group. There were no statistically significant difference in the clotting time, clot formation time, &agr;-angle, and maximum clot firmness values in any of the thromboelastography channels, in any of the study times, in between the sham, 40% hepatectomy, and 70% hepatectomy groups. Conclusion There is no difference between 40 and 70% hepatectomy when the coagulopathy is evaluated. The coagulation derangements as reflected by the increase in fibrinogen and prolongation of prothrombin time and activated partial thromboplastin time after hepatectomy were not supported by thromboelastography parameters in this study.

Renal Cell Carcinoma and Ipsilateral Pheochromocytoma With Neoplasm-to-Neoplasm Metastasis

A total of 13 cases of pheochromocytoma associated with renal cell carcinoma has been reported previously,l including 1 in which renal cell carcinoma was metastatic to ipsilateral pheochromocytoma.2 We report the fourteenth case of pheochromocytoma associated with renal cell carcinoma and the second in which renal cell carcinoma was metastatic to pheochromocytoma. CASE REPORT A 43-year-old man with a 2-year history of headache and high blood pressure was hospitalized with symptoms of pheochromocytoma. He also reported sweating and palpitation episodes. Physical examination showed an enlarged thyroid gland. Urinary vanillylmandelic acid and metanephrine were increased. Radiological evaluation revealed bilateral suprarenal masses (2 x 3 x 4 and 4 x 4 X 3 cm. on the right and left sides, respectively) as well as a 7 cm. lesion on the anterolateral right kidney. Thyroid scan showed a multinodular goitre with hypoactive areas but thyroid function tests were normal. Fine needle aspiration biopsy revealed atypical cells. Using a bilateral subcostal incision exploration was performed, which was compatible with the radiological evaluation. Right nephrectomy with para-aortic lymph node dissection and bilateral adrenalectomy were done. Pathological examination revealed renal cell carcinoma in the right kidney, pheochromocytoma in the right suprarenal gland, and renal cell carcinoma metastasis to the pheochromocytoma in the right and to the left suprarenal glands (see figure). Convalescence was uneventful and blood pressure returned to normal. A total of 11 courses of adjuvant chemotherapy with prednisolone, vinblastine and medmxyprogesterone acetate was given weekly until it was withheld due to neutropenia. Two

A case of acute pancreatitis in a patient with systemic lupus erythematosus.

Abstract Systemic lupus erythematosus (SLE) is an auto-immune disease which can affect multiple organs. It may also involve the pancreas and in rare cases may cause acute pancreatitis. The etiology of acute pancreatitis in SLE is a matter of controversy. We present a case diagnosed with SLE that developed acute pancreatitis while being treated with cor-ticosteroids. During the course of the disease, pancreatic pseudocysts developed and were treated by percutaneous drainage. There are few reports in the literature about the therapy of acute pancreatitis and percutaneous drainage of pseudocysts in SLE. We discuss the pathogenesis and therapy for acute pancreatitis in SLE patients.

Portomesenteric Gas due to Intestinal Obstruction: a Case Report

Abstract A case of mesenteric vein gas as a nonfatal complication of intestinal obstruction is reported. A 48-year old woman presented postoperatively signs and symptoms of acute abdomen on the eighth day following a gastric pull-up surgery due to an oesophageal carcinoma. The abdominal tomography findings revealed dilated jejunal segments and free gas in the superior mesenteric vein and end branches of the portal vein in the left hepatic lobe. The patient underwent a second laparotomy with a provisional diagnosis of intestinal ischaemia. Intraoperative gross appearance of the intestines revealed no ischaemic finding, the pathology was the dense adhesions between the jejunal segments and previous incision site. On the basis of these findings, the operation was ended with adhesiolysis. One month after the operation, the patient was well, there were no complications. As the authors, we think that the main reason for por-tomesenteric gas is mucosal destruction and that these cases may be followed conservatively as long as intestinal ischaemia is excluded.

Renal Cell Carcinoma Metastasis to Focal Nodular Hyperplasia Focus on Liver in a Patient With Von Hippel-Lindau Disease

Von Hippel-Lindau disease is an autosomal dominant disorder occurring in 1 of 36,000 births and associated with various tumors and cysts in the central nervous system and other visceral organs. At present, metastasis from renal cell carcinoma (RCC) and neurologic complications are the most common causes of death from Von Hippel-Lindau disease. We report a case of Von Hippel-Lindau disease diagnosed during a screening and was found to have metastasis of RCC to a focal nodular hyperplasia lesion on the liver. In the literature, misdiagnosis of benign liver lesions as metastases of RCC has been reported, but there has not been a case reported to have a metastasis of RCC within a benign liver lesion. To our knowledge, this is the first case of RCC metastasis to a benign lesion of the liver.

Nine years' experience of needle localized breast biopsy in a university hospital: results and evaluation of the role of the surgeon in decision making.

Abstract Background: Needle localized breast biopsy is an effective means of detecting breast cancer in its early stages. We analysed the indications for needle localized biopsies, evaluated the results, and determined the surgeon’s role in the decision-making process. Methods: The needle localized open biopsy results of 350 patients were assessed. Results: Malignancy was encountered in 7 of 56 patients in whom the radiologist suggested follow-up due to mammo-graphical images, although a surgeon performed a biopsy with the assessment of the patient’s historical and clinical findings (12.5%). Biopsy failure rates were higher for office-based ambulatory patients (9.1%) than for those patients who underwent biopsies in an operating theatre (1.9%; P < .05). Patients undergoing operating theatre biopsies under local anaesthesia showed statistically significant failure rates compared with those under general anaesthesia (p = .04). The rate of malignancy of micro-calcification was highest in patients younger than 40 years of age (64.3%), while spicular lesions were commonly malignant in patients over 50 years of age. Conclusions: From our experience, we suggest that needle localized biopsies should be performed in the operating theatre with the patient under general anaesthesia. Although both micro-calcifications and spicular lesions have a high rate of malignancy in all decades, micro-calcifications are more prevalent in younger patients while spicular lesions prevail in older patients. The final decision, to follow-up or biopsy, should be based on a patient’s clinical and historical perspective and not only on the guidance of the mammography report.