Hayrullah Derici

Acute Intraperitoneal Rupture of Hydatid Cysts

BackgroundRupture into the abdominal cavity is a rare but serious complication of hydatid disease. The cysts may be ruptured after a trauma, or spontaneously as a result of increased intracystic pressure. Rupture of the hydatid cyst requires emergency surgical intervention.MethodsSeventeen patients received surgical treatment for intraperitoneal rupture of the cysts over a period of 18 years. Age, gender, time to surgery from the onset of the symptoms, laboratory findings, diagnostic procedures, surgical treatment modalities, in-hospital stay, morbidity, mortality and recurrence were evaluated retrospectively.ResultsFive cases (29.4%) had a history of blunt abdominal trauma. Ultrasonography scans revealed intra-abdominal fluid in all cases. Intraperitoneal multiple cysts with heterogeneous cavity or cystic structures in the liver were shown in 14 cases. Computed tomography and magnetic resonance imaging showed multiple cystic lesions in the liver and peritoneum with intra-abdominal free fluid. Procedures to fill the cystic cavities were applied after removal of the intraperitoneal fluid. Four patients (23.5%) died in the early postoperative period. A total of nine morbidities developed in six patients (35.3%). Median hospital stay was 18 days and median follow-up was 78 months. Intra-abdominal recurrence occurred in one case (7.7%).ConclusionsRupture of hydatid cysts into the peritoneal cavity, although rare, presents a challenge for surgeons. This pathology should be included in the differential diagnosis of acute abdomen in endemic areas. Computed tomography scan, in addition to clinical presentation, is essential for diagnosis. Emergency surgery is the main treatment for acute ruptured hydatid cysts. The morbidity and mortality rates of surgical interventions for ruptured hydatid cysts are higher than the rates for elective uncomplicated cases.

Prosthetic repair of incarcerated inguinal hernias: is it a reliable method?

Background and aimIt is generally accepted that most inguinal hernias should be operated on electively using synthetic grafts. However, limited information is available on the usage of these materials in patient with incarcerated and strangulated hernias. The objective of this study is to compare the outcomes of incarcerated inguinal hernia repair with or without graft.Materials and methodsOne hundred-thirteen patients with incarcerated inguinal hernia that underwent surgery were included in this study. Patients who underwent Lichtenstein repair were assigned to group I; those who underwent primary repair were assigned to group II. Demographics and characteristics of patients in each group were compared. Chi-square and Students t-tests were used.ResultsNo statistical difference was found between patients who did and did not receive anastomosis in both groups in terms of surgery duration, length of hospital stay, postoperative morbidity, and mortality. Recurrence was found in 4.0% and 20.8% patients in group I and group II, respectively (P = 0.036).ConclusionsMesh repair can be preferred in incarcerated inguinal hernia patients because recurrence rate was significantly lower in patients who underwent Lichtenstein repair in this study.

Does near total thyroidectomy offer advantage over total thyroidectomy in terms of postoperative hypocalcemia

Total thyroidectomy (TT) has emerged as a surgical option in the surgical treatment of patients with multinodular goiter. TT carries potential risk to all parathyroid glands and both recurrent laryngeal nerve. The aims of this study are to evaluate the difference between serum calcium levels before and after total and near total thyroidectomy and to compare the rate of postoperative hypocalcemia according to surgical procedures. This prospective study included 143 consecutive patients undergoing surgical therapy for non-toxic multinodular goiter. Patients were randomly assigned to surgical procedures. Patients in group 1 (n=75) performed TT, and patients in group 2 (n=68) performed near total thyroidectomy (NTT). The difference between serum calcium levels and percentage decrease in serum calcium levels before and after thyroidectomy were calculated. TT had a 33-fold (OR: 33.1; 95% CI: 7.5-145.02) increased risk for hypocalcemia. Moreover, TT had a 8-fold (OR: 8.09; 95% CI: 3-21.4) and a 27-fold (OR: 27.9; 95% CI: 3.5-219.6) higher risk than NTT for moderate and severe percentage decreases in serum calcium level, respectively. NTT can offer an advantage over TT in terms of postoperative hypocalcemia in the patients with benign multinodular goiter.

ASYMPTOMATIC GOSSYPIBOMA MIMICKING A LIVER MASS

Gossipiboma ozellikle karin ici cerrahi girisimler sonrasinda gorulen hem cerrah hem de hasta icin cok ciddi sonuclara yol acabilecek nadir bir durumdur. Vucut icinde yer alan, pamuk yapidan olusan bir kitleyi tanimlamakta kullanilan bir terimdir. Gossypium (Latince, pamuk) ve boma (Svahilice, unutulan cismin yeri) kelimelerinden koken almaktadir (1). Karin ici cerrahi girisim sonrasi 1/3000-1/5000 arasi degisen oranlarda gorulebilecegi bildirilmekle birlikte yasal, tibbi sorunlar ve bazi hastalarin asemptomatik olabilmeleri nedeniyle bu oranin daha yuksek oldugu dusunulmektedir (2,3). En sik genel cerrahi girisimler sonrasinda gorulmekle birlikte kardiyovaskuler, ortopedik, urolojik islemler sonrasinda da gorulmektedir (4). En sik unutulan yabanci cisim cerrahi tamponlardir (3-5). Erken donemde karin ici abse gibi ciddi komplikasyonlara neden olabilmekle birlikte, yillarca asemptomatik kalip yalanci tumor goruntusu vererek insidental olarakta saptanabilirler (3,6,7).

Flapless conventional thyroidectomy: A prospective, randomized study

PurposeConventional thyroid surgery is one of the most common operations performed worldwide. The conventional technique involves placement of small or large cutaneous flaps. However, the published data regarding flap use for thyroidectomy are contradictory. This study presents the results using a flapless conventional thyroidectomy and the efficacy of this approach in a thyroidectomy. In addition, the study determined whether there are any advantages associated with the use of this approach in comparison to conventional thyroid surgery.MethodsOne hundred and forty-two patients underwent a thyroidectomy. The patients were randomly assigned to surgical procedures. Patients in Group 1 (n = 70) underwent a conventional thyroidectomy, and patients in Group 2 (n = 70) underwent a conventional thyroidectomy without a cutaneous flap.ResultsThere was no significant difference between the two groups in terms of age, sex, body mass index, length of incision, gland volume, and length of hospital stay. Postoperative pain was significantly less in Group 2 than in Group 1 (P = 0.006). Patients in Group 2 showed significantly lower requirement for postoperative intravenous analgesic (P = 0.001), and postoperative peroral analgesic (P = 0.023) in comparison to those in Group 1. Incidences of transient vocal cord paralysis and hypocalcemia were 1.4% and 1.4%, respectively. Of 140 patients, 5 (3.6%) developed postoperative wound complications.ConclusionsThese results indicate that a flapless thyroidectomy is safe and technically feasible, and therefore could be an alternative to a conventional thyroidectomy.

Multiple malign gastrointestinal polyps and rectal carcinoma in a young patient with Peutz-Jeghers syndrome

Peutz-Jeghers syndrome (PJS) is a rare familial disorder with autosomal transmission characterized by multiple intestinal polyposis and mucocutaneous pigmentation. Most of the polyps which occur in the large intestine, small intestine, and stomach are hamartomatous in nature. The potential of neoplastic transformation in PeutzJeghers polyposis, as well as the increased risk of cancer at gastrointestinal and nongastrointestinal sites, are widely recognized. The risk of development of colorectal cancer has been reported as 2–13% in patients with PJS. Malignant degeneration of polyps of the rectum, small intestine, duodenum, and stomach at a young age and eventuating as an advanced rectal carcinoma is a very rare occasion. We dealt with a young patient with PJS who had rectum carcinoma and multiple malignant foci of cancer of polyps in the small bowel, duodenum, and stomach. A 23-year-old male patient was admitted to the emergency room with abdominal pain, obstipation, and distention. He was operated for mechanical intestinal obstruction 7 years before, and hamartomatous polyps were excised and diagnosed as PJS. The father died from PJS and a sister was operated for sigmoid colon carcinoma 3 years before. Physical examination revealed melanin pigmentations on the face, buccal mucosa, and palms, and macules at the perianal and genital regions. The abdomen was found to be distended, and the bowel sounds were increased. Rectal examination exposed a tumoral mass at 2 cm from the anal verge. Rectoscopic biopsy revealed adenocarcinoma. The patient was operated emergently due to mechanical bowel obstruction. During laparotomy, a circular rectal tumoral mass infiltrating the whole rectum and hardly permitting passage, multiple polyposis measuring 2–6 cm in diameter at the small intestine, and cholelithiasis were disclosed. Abdominoperineal resection, excision of 18 polyps by “sliding polypectomy” at five enterotomies, and cholecystectomy was performed. Histopathological examination revealed signet cell carcinoma of the rectum with perinodal invasion; 27 out of 28 lymph nodes were infiltrated by carcinoma, and two of the small intestinal polyps had foci of adenocarcinoma. Postoperative upper gastrointestinal endoscopy exhibited multiple millimetric polyps in the duodenum and stomach which were not noticed during the operation. Histopathological examination revealed malignant transformation of the duodenal and gastric polyps. The patient had an uneventful postoperative course, and a relaparotomy for the malignant polyps of the duodenum and stomach was planned. The patient insisted to leave the hospital for a few weeks before the second operation. Unfortunately, he died at the emerH. Derici . Y. Peker . F. Tatar . N. Cin . V. Deniz 3rd Surgery Clinic, Ataturk Training and Research Hospital, Izmir, Turkey

Giant colon lipoma.

Colon lipomas are rare, non-epithelial tumors. They are generally smaller than two centimeters and asymptomatic, they are incidentally diagnosed and do not require treatment. Large and symptomatic colon lipomas are rather rare. Its differential diagnosis is generally made by histopathological examination of the resected specimen. A fifty-year-old female patient presented with the symptoms of abdominal pain, swelling in the abdomen and loss of weight. During colonoscopy, there was a submucosal mass of 8×6 cm, which almost completely obstructed the lumen in the hepatic flexure and was covered by a mucosa that was sporadically ulcerated and necrotic in nature. In magnetic resonance imaging, an ovoid mass with a diameter of 8.5 cm at its widest dimension was detected, which had signal intensity similar to that of adipose tissue. Since the patient was symptomatic and differential diagnosis could not be made, she underwent laparoscopic right hemicolectomy. A submucosal lipoma was detected on histopathological examination of the specimen. The patient was discharged without any problems on post-operative day 7. Definite diagnosis of lipomas before surgery is challenging; they may be mistaken for malignancy, especially if the lesion is large and ulcerated. For large and symptomatic colon lipomas, surgery is required to both prevent complications and rule out malignancy.

Jejunogastric intussusception, a rare complication of gastric surgery: report of two cases.

Jejunogastric intussusception is a rare complication of gastric surgery. It usually presents with abdominal pain, nausea, vomiting, and hematemesis. A history of gastric surgery can help in making an accurate diagnosis. An early diagnosis and urgent surgical intervention is mandatory. We herein report two cases of patients with jejunogastric intussusception who presented with acute abdomen and hematemesis.

A new approach in bowel preparation before colonoscopy in patients with constipation: A prospective, randomized, investigator-blinded trial

OBJECTIVE Enema administration in the morning of routine colonoscopy is known to be useless. However, the potential bowel cleansing effects of distal colon emptying with enema prior to purgatives are not known. The aim of this study is to investigate the effects of enema use before purgatives in preparation for colonoscopy. MATERIAL AND METHODS Two hundred twenty-seven patients were randomly assigned into three groups; enema before purgative use, enema after purgative use, and no enema. Patients were compared in terms of age, sex, BMI, Rome III constipation criteria, history of abdominal surgery, tolerance to the preparation procedure, complications during preparation such as nausea, vomiting, headache and dizziness, cecal insertion time, total duration of colonoscopy, polyp determination rate and colonic cleansing based on the Boston Bowel Preparation Scale. RESULTS One hundred two (44.9%) patients were male and 125 (55.1%) female. The mean age and BMI was 55.4±11.8 years and 28.8±4.7, respectively. No difference was observed between the groups in terms of sex, age, or BMI. The number of fulfilled Rome criteria and of previous abdominal surgeries were significantly higher in females than in men. Right colon Boston Bowel Preparation Scale score was higher in the group using enemas before purgatives than the scores of other groups. This improvement was statistically significant in the female patient group with higher constipation rate. CONCLUSIONS Use of enemas before purgatives in patients with constipation significantly improves adequacy of right colon cleansing.

Laparoscopic repair in simultaneous occurrence of recurrent chronic traumatic diaphragmatic hernia and transdiaphragmatic intercostal hernia.

Endoscopic hemostasis of tumoral lesions is a challenging situation, since no endoscopic therapy has been proved to be superior3. Choice of therapy will be dictated by the tumor’s appearance and the personal experience of the endoscopist. Reports show that hemoclips have been applied in both successful2 and failed4 attempts to achieve hemostasis. In the present case, the tumor appeared to be friable and an attempt to apply hemoclips could have led to mucosal tearing and recurrent bleeding. Endoloop ligation of such lesions has been described to treat bleeding tumors and also to resect lesions in patients deemed nonsurgical candidates, through ischemic necrosis (loop-andlet-go)1. Although the surgical approach is considered the treatment of choice for such lesions, the endoloop technique is a useful, feasible, cheap and safe alternative for patients considered unsuitable for surgery or as a temporary measure to stabilize patients before the surgical treatment.