Fatih Altintoprak

Aetiology of idiopathic granulomatous mastitis

Idiopathic granulomatous mastitis is a rare chronic inflammatory lesion of the breast that can clinically and radiographically mimic breast carcinoma. The most common clinical presentation is an unilateral, discrete breast mass, nipple retraction and even a sinus formation often associated with an inflammation of the overlying skin. The etiology of idiopathic granulomatous mastitis is still obscure. Its treatment remains controversial. The cause may be the autoimmune process, infection, a chemical reaction associated with oral contraceptive pills, or even lactation. Various factors, including hormonal imbalance, autoimmunity, unknown microbiological agents, smoking and α 1-antitrypsin deficiency have been suggested to play a role in disease aetiology. In this review, causing factors in the aetiology of idiopathic granulomatous mastitis are reviewed in detail.

Is the Use of a Drain for Thyroid Surgery Realistic? A Prospective Randomized Interventional Study

Background. The use of a suction drain in thyroid surgery is common practice in order to avoid hematomas or seromas. The aim of this study was to determine the efficacy of routine drainage after thyroid surgery. Methods. In this prospective randomized trial, 400 patients who underwent either a total thyroidectomy or lobectomy for thyroid disorders were randomly allocated to either the nondrainage (group 1) or the drainage (group 2) group. The volume of fluid collection in the operative bed, postoperative pain, complications, and length of hospital stay were then recorded. Results. Both groups were homogeneous according to age, gender, thyroid volume, type of procedure performed, and histopathological diagnosis. After assessment by USG, no significant difference was found between the groups in the fluid collection of the thyroid bed (P = 0.117), but the length of hospital stay was significantly reduced in group 1 (P = 0.004). Conclusions. In our experience, the use of drain for thyroid surgery is not a routine procedure. However, it should be used in the presence of extensive dead space, particularly when there is retrosternal or intrathoracic extension, or when the patient is on anticoagulant treatment. This trial was registered with clinical Trials.gov NCT01771523.

Intestinal obstruction due to phytobezoars: An update

The term bezoar refers to an intraluminal mass in the gastrointestinal system caused by the accumulation of indigestible ingested materials, such as vegetables, fruits, and hair. Bezoars are responsible for 0.4%-4% of cases of mechanical intestinal obstruction. The clinical findings of bezoar-induced ileus do not differ from those of mechanical intestinal obstruction due to other causes. The appearance and localization of bezoars can be established with various imaging methods. Treatment of choice depends on the localization of the bezoar which makes the clinical findings.

Idiopathic Granulomatous Mastitis: An Autoimmune Disease?

Purpose. This study aimed to investigate the autoimmune basis of idiopathic granulomatous mastitis (IGM) by determining the anti-nuclear antibody (ANA) and extractable nuclear antigen (ENA) levels of patients diagnosed with IGM. Material and Methods. Twenty-six IGM patients were evaluated. Serum samples were analyzed for autoantibodies by indirect immunofluorescence (IIF) using a substrate kit that induced fluorescein-conjugated goat antibodies to human immunoglobulin G (IgG). IIF patterns were read at serum dilutions of 1 : 40 and 1 : 100 for ANA positivity. Using the immunoblot technique, the sera of patients were assayed at dilutions of 1 : 40 and 1 : 100 for human autoantibodies of the IgG class to 15 lines of highly purified ENAs. Results. In the IIF studies for ANA, positivity was identified for four different patterns in the 1 : 40 diluted preparations, for three different patients in the 1 : 100 diluted preparations and only one pattern was identified at the 1 : 320 dilution. In the ENA studies, positivity was identified for four different pattern in the 1 : 40 dilution, and only one pattern was identified at the 1 : 100 dilution. Conclusion. This study was not able to support the eventual existence of an autoimmune basis for IGM.

Mean platelet volume as a potential prognostic marker in patients with acute mesenteric ischemia–retrospective study

IntroductionWe investigated prognostic parameters of patients who underwent surgical intervention for acute mesenteric ischemia by evaluating demographic characteristics and laboratory data on admission.MethodsThe hospital records of 30 patients who underwent surgical interventions due to acute mesenteric ischemia between January 2008 and December 2012, were reviewed retrospectively. The records were investigated with regard to demographic data, the presence of co-morbid diseases, presenting complaints, time elapsed between symptom onset and hospital admission, laboratory findings at admission, findings at surgical exploration, surgical methods used, and treatment outcomes. The patients were divided into two groups, according to death (Group 1) or survival (Group 2), and the two groups were compared in terms of the specified parameters.ResultsOf the patients, 15 were male (50%) and 15 female (50%); their mean age was 71.4 (29–94) years. Abdominal pain was the chief complaint in all patients (100%) and mean time from pain onset to hospital admission was 21 (1–72) h. In abdominal exploration, total small bowel (SB) ischemia and necrosis was found in 6 (20%) patients and other patients had subtotal SB, segmental SB, segmental SB with colon, or isolated colon ischemia. Treatment in 15 patients (50%) ended in mortality. Mean age (p = 0.038), urea (p = 0.002), AST (p < 0.001), ALT (p < 0.001), mean platelet volume (MPV; p = 0.002), and amylase (p = 0.022) levels in Group 1 were significantly higher versus Group 2, whereas Ca (p = 0.024) and albumin (p = 0.002) levels were significantly lower.ConclusionsIn this study, unlike other parameters that have been shown to be of prognostic significance in mesenteric ischemia, MPV values at presentation were higher among non-survivors than survivors.

CT Findings of Patients with Small Bowel Obstruction due to Bezoar: A Descriptive Study

Purpose. The aim of this study was to present the computed tomography (CT) findings of bezoars that cause obstruction in the small bowel and to emphasize that some CT findings can be considered specific to some bezoar types. Materials and Methods. The records of 39 patients who underwent preoperative abdominal CT and subsequent operation with a diagnosis of intestinal obstruction due to bezoars were retrospectively analyzed. Results. In total, 56 bezoars were surgically removed from 39 patients. Bezoars were most commonly located in the jejunum (n = 26/56, 46.4%). Sixteen (41.0%) patients had multiple bezoar locations in the gastrointestinal tract. Common CT findings in all patients were a mottled gas pattern and a focal ovoid or round intraluminal mass with regular margins and a heterogeneous internal structure. Furthermore, some CT findings were determined to be specific to bezoars caused by persimmons. Conclusions. Preoperative CT is valuable in patients admitted with signs of intestinal obstruction in geographic regions with a high bezoar prevalence. We believe that the correct diagnosis of bezoars and the identification of their number and location provide a great advantage for all physicians and surgeons. In addition, some types of bezoars have unique CT findings, and we believe that these findings may help to establish a diagnosis.

Postmastectomy Pain: A Cross-sectional Study of Prevalence, Pain Characteristics, and Effects on Quality of Life

Background:Postmastectomy pain syndrome (PMPS) is defined as a chronic (continuing for 3 or more months) neuropathic pain affecting the axilla, medial arm, breast, and chest wall after breast cancer surgery. The prevalence of PMPS has been reported to range from 20% to 68%. In this study, we aimed to determine the prevalence of PMPS among mastectomy patients, the severity of neuropathic pain in these patients, risk factors that contribute to pain becoming chronic, and the effect of PMPS on life quality. Methods:This cross-sectional study was approved by the Sakarya University, Medical Faculty Ethical Council and included 146 patients ranging in age from 18 to 85 years who visited the pain clinic, general surgery clinic, and oncology clinic and had breast surgery between 2012 and 2014. Patients were divided into two groups according to whether they met PMPS criteria: pain at axilla, arm, shoulder, chest wall, scar tissue, or breast at least 3 months after breast surgery. All patients gave informed consent prior to entry into the study. Patient medical records were collected, and pain and quality of life were evaluated by the visual analog scale (VAS) for pain, a short form of the McGill Pain Questionnaire (SF-MPQ), douleur neuropathique-4 (DN-4), and SF-36. Results:Patient mean age was 55.2 ± 11.8 years (33.0–83.0 years). PMPS prevalence was 36%. Mean scores on the VAS, SF-MPQ, and DN-4 in PMPS patients were 1.76 ± 2.38 (0–10), 1.73 ± 1.54 (0–5), and 1.64 ± 2.31 (0–8), respectively. Of these patients, 31 (23.7%) had neuropathic pain characteristics, and 12 (9.2%) had phantom pain according to the DN-4 survey. Patients who had modified radical mastectomy were significantly more likely to develop PMPS than patients who had breast-protective surgery (P = 0.028). Only 2 (2.4%) of PMPS patients had received proper treatment (anticonvulsants or opioids). Conclusions:PMPS seriously impacts patients’ emotional situation, daily activities, and social relationships and is a major economic burden for health systems. We conclude that the rate of PMPS among patients receiving breast cancer surgery in Turkey is 64.1% and that challenges to the proper treatment of these patients deserve further investigation.

Effect of topical steroid treatment on idiopathic granulomatous mastitis: clinical and radiologic evaluation.

Idiopathic granulomatous mastitis (IGM) is a rare inflammatory, noncaseating, chronic granulomatous benign disease. The etiology of IGM is still unknown. It is postulated to be an autoimmune localized response. The use of a course of oral steroids provides an important regression of breast mass and skin lesions. Topical corticosteroids are used to treat many skin diseases, but no study is available on the sole use of topical steroids for treating IGM. Eleven women with IGM were treated with topical steroid and evaluated using mammography, ultrasonography, and dynamic MRI. At the end of the 12th week, patients were clinically and radiologically evaluated for the regression of breast and skin lesions. Pre‐ and post‐treatment time‐intensity curve patterns (TICs) were also compared. During the topical steroid treatment, the inflammation signs in the affected breast had markedly disappeared, the fistulas had become inactive, and the fistula orifices and/or skin erosions had closed in nine patients. The median follow‐up period was 17 months (range: 12–48 months). Recurrence was observed in two patients (2/11) at 5 and 8 months, which were treated again topically. The inflammatory findings of the breast skin completely resolved after 8 weeks of treatment, and no side effects or steroid‐related complications occurred. In the pretreatment period, TICs from enhancing areas showed a Type 1 pattern in three cases, a Type 2 pattern in five cases, and a Type 3 pattern in three cases. After topical steroid treatment, TIC was not changed only in one patient (Type 2). Type 1 patterns were determined in seven cases and Type 2 patterns in two cases. In addition, in two patients, TICs were not determined due to complete healing. Our MRI findings showed that topical steroid therapy may be useful because it affects mammary parenchyma as well as mammary skin. Further studies with a greater number of patients are needed to determine the topical steroid therapy dosing and duration, and to better understand the efficacy for treating IGM.

Retrospective Review of Pilonidal Sinus Patients With Early Discharge After Limberg Flap Procedure

The aim of this study was to evaluate the results of cases with pilonidal sinus (PS) disease that underwent Limberg flap (LF) transposition and to compare the short and long-term results of early discharge cases with those in the literature. A total of 345 patients who underwent rhomboid excision and LF transposition for PS were evaluated retrospectively. No major anesthetic or surgical complications occurred. Partial wound dehiscence, localized flap necrosis, hematoma, wound infection, and seroma rates were determined as 4.0, 2.1, 1.5, 3.3, and 3.7% respectively. All patients other than those with a hematoma or localized necrosis were discharged with a drain in place 24 hours after the operation. The recurrence rate was 3.9% after a mean 33.1-month follow-up (range, 6-72 months). As a result, we found that short and long-term results of patients who underwent LF and were discharged 24 hours after the operation were similar to those in the literature. We suggest that patients without postoperative complications, such as hematoma or flap necrosis, can be discharged early.

Topical Steroids to Treat Granulomatous Mastitis: A Case Report

Idiopathic granulomatous mastitis (IGM) is a rare and chronic benign disease of the breast. Histologically, the disease presents as an intense inflammatory reaction with non-caseated granulomas that are the characteristic symptom of the disease. No consensus exists on the best treatment modality for this disease. In this report, we present a patient with granulomatous mastitis who was treated successfully with low-dose oral and topical steroids. Our aim here is to discuss various approaches for IGM in view of the literature and present treatment with topical steroids, which has not been reported.