Arif Özdemir

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.

Laparoscopic Cholecystectomy in a Single, Non-teaching Hospital: An Analysis of 1557 Patients

BACKGROUND Laparoscopic cholecystectomy may lead to serious complications, although it is the gold standard treatment for gallstones. In this article, the aim was to review our experience with laparoscopic cholecystectomies. SUBJECTS AND METHODS All laparoscopic cholecystectomies were performed in a single, non-teaching hospital between January 2000 and October 2010 and were reviewed retrospectively to analyze the effect of preoperative risk factors on outcome and the associated major complications. RESULTS This study included 1557 laparoscopic cholecystectomies, and the mean age of the patients was 54.1±12.3 years. The mean duration of the operation and the mean length of stay were 43.4 minutes and 1.2 days, respectively. Conversion to an open cholecystectomy was necessary in 39 patients, and thus the conversion rate was 2.5%. In total, 57 (3.7%) complications occurred in 51 patients. Serious common bile duct injury was seen in 4 (0.27%) cases. The other common complications included bile leakage in 10 (0.64%) and postoperative bleeding in 7 (0.45%) patients. The mortality rate was 0.13%. Risk factors for conversion to open surgery were male gender, age >55 years, emergency admission due to acute cholecystitis, and a history of previous acute cholecystitis attacks. Factors that increased the morbidity rate were male gender, an American Society of Anesthesiologists score of III, emergency admission due to acute cholecystitis, and a history of previous acute cholecystitis attacks. CONCLUSIONS Our results may serve as a baseline for comparison with future studies done at single, non-teaching hospitals where surgical teams perform laparoscopic cholecystectomies over a long period of time.

Nonfunctional Pancreatic Neuroendocrine Tumors: Advances in Diagnosis, Management, and Controversies

In this article, we aimed to review the literature on the clinics and management of nonfunctional pancreatic neuroendocrine tumors (NPNET). Pancreatic neuroendocrine tumors (PNET) are rare tumors with a <1/100,000 incidence and constitute approximately 2 to 10% of all pancreatic tumors. Nonfunctional PNETs are difficult to detect at early stages since they have no symptoms. Except those detected accidentally during different diagnoses, the majority of PNETs are detected in the advanced stages, with symptoms related to tumor size or liver metastasis. We reviewed the studies published in the English medical literature through PubMed and summarized the clinical features and current approaches to the treatment and follow-up of the NPNET. The common imaging techniques used for the detection of tumor localization, size, locoregional, and metastatic involvement are contrasted computed tomography, magnetic resonance imaging, endoscopic ultrasonography, and somatostatin receptor scintigraphy. Surgical resection is the only curative treatment. However, in advanced locoregional disease and liver metastasis, interventive ablative therapies such as palliative reductive surgery, selective hepatic arterial embolization, radiofrequency ablation; and systemic therapies, such as peptide receptor radionuclide therapy, chemotherapy, somatostatin analogous therapy, interferon, VEGF inhibitor, and mTOR inhibitor may be used as symptom relieving or may improve progression-free survival and total survival. Current knowledge on NPNET shows that the treatment should be personalized considering the prognostic features and life expectancy of the patient.

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.

Hyperfunctioning parathyroid cysts: a case report

Abstract Parathyroid cysts are infrequent lesions of which most are non-functional. They are often misdiagnosed as thyroid cysts. Pre-operative diagnosis and differentiation from thyroid cysts is generally difficult. We hereby report a case that was admitted to the emergency room and was diagnosed as hypercalcemic crisis. The mass found during the neck examination was thought to be a thyroid nodule. A right total and left subtotal thyroidectomy was performed. Palpable thyroid nodule was diagnosed as cystic parathyroid adenoma postoperatively. When a cystic lesion is found in the neck of a patient, a pararthyroid cyst should be considered.

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.