Faik Tatli

Isolated cecal necrosis mimicking acute appendicitis: a case series.

IntroductionSpontaneous non-occlusive ischemic colitis involving the cecum alone (isolated cecal necrosis) is a rare condition that is generally due to a low-flow state: shock. It presents with right lower quadrant abdominal pain and may resemble acute appendicitis. Little is known about postoperative ischemic necrosis of the remaining colon after surgical treatment of isolated cecal necrosis. We report four cases of isolated cecal necrosis mimicking acute appendicitis seen at our institution within a 4-year period.Case presentationThe patients were two men and two women with a mean age at diagnosis of 59 years (range 46-68). The patients were of Turkish ethnic origin. All patients presented to the emergency room with acute abdominal pain and had symptoms of nausea and vomiting. The medical histories for three of the patients revealed end-stage renal failure requiring hemodialysis. The other patient had chronic obstructive pulmonary disease. Right hemicolectomy with anastomosis was performed in three patients and cecal resection with ileocolostomy was performed in the remaining one patient. All of the patients healed without complications. Median follow-up of patients was 24.5 (range: 17-37) months. There was no recurrence of ischemia in the remaining colon during the follow-up period of the patients.ConclusionIsolated cecal infarction should be included in the differential diagnosis of acute pain in the right lower quadrant of the abdomen, especially in those patients on chronic hemodialysis. While diffuse ischemic disease of the intestine has high morbidity, mortality and recurrence rates, patients with isolated cecal necrosis have a good prognosis with early diagnosis and surgical treatment compared to those with diffuse ischemic disease.

Ruptured Hydatid Cysts into the Peritoneum: A Case Series.

Introduction:The rupture of a hydatid cyst into the abdominal cavity is a rare and serious complication.Methods:In this retrospective study, we evaluated ten patients who were surgically treated for ruptured hydatid cysts into the peritoneum at a university hospital in an endemic area between 2003 and 2008.Results:There were three female and seven male patients, with a mean age of 34.2 years (range 20–79). Ruptured cysts were located in the liver (7), pelvis (2), and spleen (1). Eight patients had other nonperforated hydatid cysts. Perforations were spontaneous in seven patients and traumatic in three. Patients’ diagnoses were done with abdominal ultrasound (3), computed tomography (6), and laparotomy (1). The surgical treatment of perforated cysts were radical (pericystectomy) in one patient and conservative (partial pericystectomy) in the other nine patients. There was postoperative morbidity (surgical site infection) in one patient and one postoperative recurrence of disease in another patient. Mortality was seen in one patient 2 months after operation due to pulmonary hydatid cyst and infection.Conclusion:The rupture of hydatid cysts into the peritoneal cavity should be included in the differential diagnosis of acute abdominal pain in endemic areas. Perforation in a young patient may be the first presentation of hydatid cyst. Multiple hydatid cysts may be a predisposing factor for perforation. Location of the cyst on segment VI of the liver may be a predisposing factor as well. Emergency surgery is the main treatment for intraperitoneal rupture of hydatid cysts and medical treatment should be given postoperatively.

Laparoscopic splenectomy with a vessel sealing device

When compared with open splenectomy, laparoscopic splenectomy was associated with fewer complications, however, with more hemorrhagic complications. Furthermore, the mean operative time for laparoscopy was significantly longer than for the open procedure. Vessel sealing systems are represented as decreasing operative time and blood loss in several surgical procedures. The aim of this study is to evaluate the blood loss and operating time of laparoscopic splenectomy with a vessel sealing system. We evaluated 19 laparoscopic splenectomies with a vessel sealing device, particularly focusing on operative blood loss and operating time. Patients were operated in the right lateral decubitus position usually with three ports. In all cases, dissection of the spleen and sealing of hilar vessels and short gastric vessels were performed with a vessel sealing system. No clips, sutures, or monopolar–bipolar diathermy were used. Mean operative blood loss was 88ml (range 20–400 ml) and mean operative time was 107 minutes (range 45–230 minutes). Both results were better than those of most series of laparoscopic splenectomy performed with endostaplers or endoclips. Laparoscopic splenectomy with a vessel sealing system is safe for all vascular controls in laparoscopic splenectomy and can lead to less blood loss. This technique removes the disadvantage of longer operating times for laparoscopic as compared to open splenectomy.

NON-RECURRENT INFERIOR LARYNGEAL NERVES: REPORT OF TWO CASES AND REVIEW OF THE LITERATURE

Although the non-recurrent inferior laryngeal nerve (NRILN) is a rare occurrence, it may become damaged inadvertently during cervicotomy and causes permanent ipsilateral vocal cord paralysis. Several published reports have described an incidence of NRILN of 0.21–1.6%, with most occurring on the right side.1–3 However, it is difficult to establish the exact incidence of this anomaly. To date, three anatomical variants have been recognized: In type 1, NRILN arises from cervical vagus directly and descends into the larynx at the level of the upper thyroid pole. In type 2A, NRILN follows a transverse path parallel to and over the trunk of inferior thyroid artery, at the level of isthmus. In type 2B, NRILN follows a transverse path parallel to and under the trunk of inferior thyroid artery, making a downward curve.1,2 The most common is type 2A. Herein, we present findings of two cases in which one of them showed previously unrecognized anatomical variant of a NRILN. Two female patients of age 42 and 47 years presented with swelling of their thyroids. Physical, radiological and laboratory examinations showed multinodulary goitre. During thyroidectomies, when the right inferior laryngeal nerves (ILN) could not be identified in a normal anatomic position, we continued to dissect further laterally and found NRILN. In the first patient the NRILN arose from vagus nerve, passed over carotid artery and descended into the larynx at the level of the upper thyroid pole (type 1) (Fig. 1). In the second patient the NRILN followed a transverse path parallel to and over the trunk of inferior thyroid artery, making a slightly downward curve (type 2A). The nerves were carefully traced and preserved. The patient’s postoperative courses were uneventful. Although an NRILN was observed in a cadaver by Stedman 1823, it was not introduced in the surgical published work until 1932. Since then, numerous reports of NRILN have appeared with

Comparative Analysis of Laparoscopic Cholecystectomy Performed in the Elderly and Younger Patients: Should We Abstain from Laparoscopic Cholecystectomy in the Elderly?

Background: The elderly population is gradually increasing due to an increase in the quality of life and therefore the frequency of gallbladder stones in the population is also increasing. However, a considerable number of physicians tend to postpone or solve the problem with medical treatment instead of performing surgery in the elderly patients. In this study, we aim to compare the outcomes of laparoscopic cholecystectomy (LC) in the elderly and younger patients. Material and Methods: The medical records of 665 patients undergoing LC were evaluated retrospectively. The patients were divided into two groups: ≥60 years of age and <60 years of age. Ages, genders, comorbid diseases, indications of surgery, American Society of Anesthesiologists scores, whether it is converted to an open cholecystectomy or not, reasons for conversion if it is converted, total duration of surgery, initiation of oral nutrition, duration of discharge, and postoperative complications of the patients in both groups were recorded. Results: The American Society of Anesthesiologists scores were statistically significantly higher in ≥60 years age group (p<0.001). The rate of experiencing acute cholecystitis with a stone in the gallbladder was significantly higher in the 60 years group (p=0.025). Comorbidity was statistically significantly higher in the ≥60 years age group (p<0.001). Hospitalization period, the mean hour of initiation of oral nutrition were statistically significantly higher in the ≥60 years age group (p<0.001, p=0.001). Conversion to an open cholecystectomy and postoperative complication rates of the ≥60 years age group were statistically significantly higher (p=0.034, p<0.001). Conclusion: We think that LC can be safely performed in the elderly people as well. However, it should be kept in mind that comorbidity may make the surgery and postoperative follow-up period complicated.

Is the appendix length/diameter ratio an early-indicator for the perforation in acute appendicitis?

Objective: Acute appendicitis is the most frequent reason for the stomachaches resulting in the surgery. The acute appendicitis perforation might create complications that are of vital importance. In this study, it is aimed to examine the relationship of appendix length/diameter ratio with acute appendicitis perforation. Methods: Using the pathology results of appendectomy materials of 144 patients that applied to emergency service between March 2013 and May 2014 and were operated due to the suspicion of acute appendicitis, the length/diameter ratios were calculated. The patients were divided into 2 groups as perforated appendicitis and non-perforated appendicitis. The number of patients and the length/diameter ratios were calculated and recorded for both groups. PearsonÂ’s Chi-Square test was used for statistical analysis. Results: In pathological examination of 144 patients involved in this study, non-complicated acute appendicitis was diagnosed in 123 (85.4%) patients, while 21(14.6%) patients were found to have perforation. In present study, the results indicating that the length/diameter ratio might be used as early indicator for the perforation were achieved. When the appendix length/diameter ratio declined below 10, then the perforation frequency significantly increased (p