Inanc Samil Sarici

Local thrombolytic therapy in acute mesenteric ischemia.

BackgroundThe aim of the study was to evaluate the local thrombolytic therapy (LTT) in combination with laparoscopy, in management of acute mesenteric ischemia (AMI).MethodsFrom January 2000 to January 2010, patients who were admitted to the hospital with AMI due to acute arterial occlusion were analysed retrospectively. Patients presenting with acute abdomen with a suspicion of AMI were evaluated with computerized tomography angiography (CTA). Patients who had findigs of AMI on CTA, were underwent selective mesenteric angiography and LTT eventhough without peritoneal signs. LTT was carried out before or after laparoscopy or laparotomy, and initiated with recombinant plasminogen activator.ResultsLTT was performed in 13 (17.1%), out of 76 patients. From the remaining patients, 56 underwent necrotic bowel resection and 7 underwent tromboembolectomy. The median age was 62 years (45–87). The median duration of symptoms was 24 h. Four (30.7%) patients presented within 24 h onset of symptoms, whilst 9 (69.3%) patients presented after 24 h onset of symptoms. There were 5 (39.5%) patients, who presented with abdominal pain without peritoneal signs on physical examination and 8 (61.5%) patients, who had peritoneal signs. The mortality rate was 20% (1/5) in the first group who presented without peritoneal signs, whilst it was 62.5% (5/8) in the remaining.ConclusionEarly intervention in AMI is the key to better results. CTA combined with early laparoscopy and LTT may have beneficial effects at this setting.

Factors That Affect the False-Negative Outcomes of Fine-Needle Aspiration Biopsy in Thyroid Nodules

Background. The purpose of this study was to assess the factors that affect the false-negative outcomes of fine-needle aspiration biopsies (FNABs) in thyroid nodules. Methods. Thyroid nodules that underwent FNAB and surgery between August 2005 and January 2012 were analyzed. FNABs were taken from the suspicious nodules regardless of nodule size. Results. Nodules were analyzed in 2 different groups: Group 1 was the false-negatives (n = 81) and Group 2 was the remaining true-positives, true-negatives, and false-positives (n = 649). A cytopathologist attended in 559 (77%) of FNAB procedures. There was a positive correlation between the nodule size and false-negative rates, and the absence of an interpreting cytopathologist for the examination of the FNAB procedure was the most significant parameter with a 76-fold increased risk of false-negative results. Conclusion. The contribution of cytopathologists extends the time of the procedure, and this could be a difficult practice in centres with high patient turnovers. We currently request the contribution of a cytopathologist for selected patients whom should be followed up without surgery.

Mezenter Ven Trombozuna Yaklaşım: Tek Merkez Deneyimi

BACKGROUND Mesenteric vein thrombosis occurs rarely and is responsible for approximately 5-15% of all cases of acute mesenteric ischemia. The aim of this report was to discuss the management of mesenteric vein thrombosis based on our experience with 34 patients. METHODS In the present study, 34 patients who were admitted to our emergency surgery department between January 2007 and January 2010 with a diagnosis of acute mesenteric vein thrombosis were assessed retrospectively. Patients with peritoneal signs first underwent diagnostic laparoscopy to rule out perforation or bowel gangrene. We performed a second-look laparoscopy within 72 hours of the first operation. All patients were administered 100 mg/kg of the anticoagulant enoxaparin twice daily. In the 6th and 12th months of follow up, CT angiography was performed to evaluate recanalization of the veins. RESULTS CT angiography revealed superior mesenteric vein thrombosis in 25 (73%) patients, portal vein thrombosis in 24 (70%) patients, and splenic vein thrombosis in 12 (35%) patients. Eleven patients with peritoneal signs underwent diagnostic laparoscopy; eight of the patients underwent small bowel resection, anastomosis, and trocar insertion. During second-look laparoscopy, small bowel ischemia was found in two patients and re-resection was performed. CONCLUSION Early diagnosis with CT angiography, surgical and non-surgical blood flow restoration, proper anticoagulation, and supportive intensive care are the cornerstones of successful treatment of mesenteric vein thrombosis.

The rate of operative success achieved with radioguided occult lesion localization and intraoperative ultrasonography in patients with recurrent papillary thyroid cancer

BACKGROUND To investigate the rate of operative success in excision of nonpalpable lymph nodes with metastatic disease achieved with radioguided occult lesion localization (ROLL) and intraoperative ultrasonography (IOUS) in patients with papillary thyroid cancer (PTC). METHODS Twenty consecutive PTC patients with nonpalpable lymph nodes with metastatic disease localized in previously operated fields were randomized to receive ROLL (n = 11) or IOUS (n = 9). Nodes were excised along with adjacent soft tissue to accomplish a compartment-oriented dissection. The duration of operation, rate of postoperative complications, pre- and postoperative serum thyroglobulin (Tg) levels, and the findings of postoperative neck ultrasonography and postablation scan were recorded in all patients. Measures of operative success included a postoperative Tg level <50% of preoperative Tg level and no abnormal lesions on postoperative imaging. RESULTS Histopathologic examination confirmed the excision of all preoperatively identified metastatic nodes. Additional nodes also were excised (2.3 ± 3.3 per specimen in the ROLL group and 1.6 ± 1.8 per specimen in the IOUS group), 23% of which were metastatic. No postoperative complications occurred in either group. The duration of operation was similar in the 2 groups (P = .4). Postoperative imaging confirmed the clearance of suspicious nodes in all patients. The rate of operative success in ROLL and IOUS group were 100% and 89%, respectively. CONCLUSION In patients with recurrent PTC, a high rate of operative success in excision of nonpalpable metastatic lymph nodes was achieved by both ROLL and IOUS. We recommend compartment-oriented dissection; this approach may maximize the removal of metastatic nodes not identified by preoperative imaging.

Curative surgery for locally advanced retroperitoneal mature teratoma in an adult. Case report

INTRODUCTION Primary teratomas of retroperitoneum are not usual in the adult population. These tumors most commonly seen at the gonadal and sacrococcygeal regions. Herein we describe a case of an 18-year-old female who had a benign cystic teratoma at the retroperitoneum. PRESENTATION OF CASE The patient underwent an operation at another hospital following a misdiagnosis of hydatid cyst. The patient was referred to our hospital because of the detection of an unresectable tumor during her operation. A computerized tomography (CT)-angiography revealed a cystic mass, with a diameter of 14cm which was invaded into the retrohepatic suprarenal inferior vena cava and also extended to the posterior aspect of the liver. Additionally the mass invaded the posterior wall of the inferior vena cava and the right renal vein. The tumor was completely resected with a vascular resection. The inferior vena cava was reconstructed with a 12cm Dacron(®) graft and the renal vein was implanted. The patients postoperative period was uneventful. DISCUSSION Germ cell tumors of retroperitoneum are usually seen in children, but there are also some reports of adult cases in the literature. Adult cases are especially seen in females. Imaging studies are paramount for diagnosis, preoperative strategy and safe surgical excision. CT scans and MRIs can identify various components of these tumors. CONCLUSION Even though primary retroperitoneal teratomas are quite rare in adults. Preoperative radiology imaging and strategy is critical for performing a safe surgery. The gold standard treatment strategy for this neoplasm is the surgical resection.

Comparison of Platelet Distribution Width and CA19-9 in Resectable Pancreas Cancer

Background: Platelets are considered an important source of prothrombotic agents associated with inflammation in cancer related diseases. We aimed to compare the diagnostic accuracy of the platelet distribution width (PDW) and CA19-9 in resectable pancreas cancer. Method: A total of 83 stage-1 and 2 pancreatic adenocarcinoma (PAC) patients, and 85 age and sex-matched healthy participants were included in the study. All preoperative patient data, including PDW and CA19-9 were analyzed in terms of sensitivity, specificity, positive and negative predictive values, likelihood ratios, and diagnostic accuracy. Results: Demographic features were not significantly different among the groups. Platelet distribution width and CA19-9 were significantly higher in PAC compared to control group (p= 0.0001). Diagnostically, the sensitivity and specificity were 79% and 85% for PDW, while 78% and 91% for CA19-9. Diagnostic accuracy was measured by the area under the ROC curve, and PDW differs significantly (p<0.001), with a value of 0.874 (95% CI: 0.804-0.929). Conclusion: Platelet distribution width indicated similar sensitivity and specificity with CA19-9 in patients with resectable PAC. This result strongly advice that PDW, which has more routine option and cost-effectivity than CA19-9, can be used for diagnosis of resectable PAC as a strong alternative.

Comparison of platelet rich plasma versus fibrin glue on colonic anastomoses in rats

PURPOSE To compare platelet rich plasma (PRP) and fibrin glue about the effect of anastomotic healing. METHODS Thirty six Wistar-Albino male rats diveded into 3 groups according to control(Group1), PRP (Group 2) and fibrin glue(Tisseel VH) (Group 3). The colon was transected with scissor and subsequently an end to end anastomosis was performed using continuous one layer 6/0 vicryl sutures. Postoperative 7th day effect of anastomotic healing measuring with tissue hydroxyproline(TH) level and anastomotic bursting pressure(ABP); moreover comparison of cytokine (IL-6 and IL-10) and procalcitonin levels on 1st,3rd and 7th days. RESULTS There was no statistically significant difference of the ABP and hydroxyproline levels between PRP and fibrin glue on the 7th day. There was no statistically significant difference between levels of proinflammatory cytokine (IL-6) (P=0.41), anti-inflammatory cytokine (IL-10) (P=0.35), and procalcitonin levels (P=0.63) on 1, 3 and 7 days. CONCLUSION Fibrin glue and platelet rich plasma are shown to be effective in healing intestinal anastomoses without superior to each other.

Endoscopic Management of Colonic Perforation due to Ingestion of a Wooden Toothpick.

Patient: Male, 18 Final Diagnosis: Perforation Symptoms: Abdominal pain Medication: — Clinical Procedure: Endoscopy Specialty: Surgery Objective: Rare disease Background: Toothpick ingestion is implicated in bowel injuries that may cause violent complications, mimicking diseases causing acute abdomen. Case Report: A 18-year-old man was admitted with a 3-day history of a swallowed wooden toothpick. The patient had tenderness in the left flank area. Computed tomography indicated toothpick impaction at the splenic flexura of the colon. It was successfully removed with colonoscopy. After the procedure, abdominal radiography showed free air as a sign of perforation. Along with conservative management, the patient was discharged without surgery. Conclusions: There is need for greater awareness of the hazardous of an ingested toothpick. Endoscopic approach should be considered in the first-line management of toothpick perforations.

SHOULD ANGIOGRAPHY BE ROUTINELY EMPLOYED IN HIGH GRADE LIVER INJURIES UNDERGOING DAMAGE CONTROL SURGERY

Objective : The management of traumatic liver injuries involves various strategies ranging from observation to operative intervention and includes various options such as angiography and/or damage-control surgery. In this study, we aimed to clarify whether routine angiography is necessary or can be reserved for selected patients with persistent bleeding after depacking. Methods: During the 11-year period from January 2000 to December 2010 all patients with blunt or penetrating trauma who sustained a liver injury and underwent a damage control laparotomy in our institution were retrospectively reviewed. Following variables were extracted from patient charts: demographics, the mechanism of injury, shock status, Injury Severity Score, liver injury grades, associated injuries, angioembolization, duration of hospitalisation, time to depacking, mortality. Angioembolization.was performed when persistent bleeding was encountered after depacking. Results: A total of 513 patients with hepatic injury were admitted during the study period. Damage control surgery was undertaken in 60 patients, of whom 21 patients underwent angioembolization. The factors associated with a high Injury Severity Score were admission in shock status (p=0.009) and associated organ injuries (p<0.001). Extremity injury was the most commonly encountered associated injury (n=15, 25.0%). In the damage control surgery group, mortality was not significantly different between angioembolization (n=4, 19%) and non-angioembolization (n=14, 33%) groups (p=0.369). Conclusion: The most patients with abdominal packing after liver trauma may not require routine angiography. Angioembolization may be used selectively in patients with persistent bleeding after depacking. Key words: Angiography; embolisation; trauma; packing

Bilateral elastofibroma dorsi: A case report

INTRODUCTION Elastofibroma dorsi(EFD) is slow-growing, benign, soft tissue tumor of unclear pathogenesis, typically located at the subscapular region of elderly people. It may be unilateral or bilateral. As it exhibits benign behavior, it should be surgically removed only in symptomatic patients. Magnetic resonance imaging (MRI) is a useful tool for assessment of EFD and can potentially help avoid the need for unnecessary biopsy and surgery. PRESENTATION OF CASE A 62-year-old woman presented with 2 years complaint of back pain, particularly aggravated with shoulder movements and swelling with bilateral elastofibroma dorsi. Both masses were totally excised with bilateral posterolateral subscapular incision. Symptoms were completely controlled and significant discomfort from the surgical procedure was completely resolved with in a few weeks interval from the operation. DISCUSSION The pathogenesis of the EFD still remains unclear. Elastofibroma dorsi has an unspecific clinical presentation and can be confused with other tumors of the periscapular region Imaging studies are useful for diagnosis. CONCLUSION Elastofibroma dorsi is benign soft tissue tumor mostly observed in the subscapular regions of elderly female patients. The surgery is indicated in symptomatic cases and must be confined to simple excision of the lesion.