K. Yalçın Polat

Ileosigmoidal Knotting: Outcome in 63 Patients

PURPOSE:This study was designed to review the outcomes of 63 patients with ileosigmoidal knotting.METHODS:Sixty-three, surgically treated patients (47 males; 74.6 percent) were reviewed retrospectively. The mean age was 45.6 (range, 7–75) years. The most common symptoms were abdominal pain and obstipation, and the most common signs were abdominal tenderness and distention. The preoperative diagnosis was obstructive emergencies in 49 patients (77.8 percent) and nonobstructive emergencies in 14 (22.2 percent).RESULTS:All patients underwent emergency laparotomy. The most common type of ileosigmoidal knotting was Type 1A in 30 patients (47.6 percent), in which the active ileum encircled the passive sigmoid colon in a clockwise direction. Fifty patients (79.4 percent) developed gangrenous bowel. Resection of gangrenous segments and enteroenteric or enterocolic anastomosis combined with the Hartmann procedure was the most preferred operation, used in 34 patients (54 percent). The mortality rate was 15.9 percent (10 patients), and toxic shock was the most frequent cause of death.CONCLUSIONS:Ileosigmoidal knotting is a rare but serious form of intestinal obstruction. Its preoperative diagnosis is difficult and may present as an obstructive or nonobstructive emergency. Early and effective resuscitation, prompt surgical intervention selected on the basis of clinical and operative findings, and effective postoperative intensive care are the basis of treatment.

Extraskeletal Ewing's sarcoma in the abdominal wall : A case report

Extraskeletal Ewing sarcoma (EES) is a rare soft tissue tumour that is morphologically indistinguishable from the more common Ewing sarcoma of bone. It must be differentiated from other small, blue round cell tumours, including primitive neuroectodermal tumour and neuroblastoma. The most frequent sites of occurrence are the chest wall, lower extremities, and paravertebral region. Less frequently, the tumour occurs in the pelvis and hip region, the retroperitoneum and the upper extremities [1,2]. The age at the time of diagnosis, unlike its osseous counterpart, has a wide range, from infancy to the elderly, and has a slight predominance in male patient [2,3]. A 65-year old man presented with a painless mass in the abdominal wall. There was no history of weight loss, trauma or infection for the last year. Physical examination revealed an irregular mass approximately 5 cm in diameter in the left upper quadrant of the abdominal wall. Other laboratory results were normal. Contrast enhanced axial CT scan showed a 5 cm in diameter hypodense mass with peripheral contrast enhancement in the left rectus muscle (Figure 1). An ultrasound-guided fine needle aspiration for cytological examination was performed and it revealed diffuse lymphoma. To confirm the diagnosis, open biopsy of the mass was done. Histopathological examination showed a neoplasm with focal areas of fibrosis with a vague trabecular pattern, existing necrosis and fairly uniform, round, blue, mediumsized cells in a diffuse pattern (Figure 2). The vacuolated cytoplasm of the tumour cells showed a high content of glycogen demonstrable by Periodic acid-Schiff (PAS). The tumour was negative for epithelial membrane antigen, high and low molecular weight cytokeratin, CD20, CD68, leukocyte common antigen, desmin, muscle specific actin. Immunohistochemical evidence of CD99 in Ewing sarcoma, were strongly positive, confirming extraosseous Ewing sarcoma. A technetium methylene diphosphonate whole body bones scan showed normal skeletal uptake of tracer and no evidence of bone involvement. The mass and entire left rectus muscle bellies were resected via a left paramedian incision. Becoming defect was covered by composix mesh (Figure 3). The postoperative course was uneventful, and the patient was discharged from the hospital at the tenth postoperative day. One month after the discharge chemotherapy was carried out including vincristine, doxorubicine, cyclophosphamide, and etoposide for six cycles, and the patient has had no recurrence of the disease during at the one year follow-up. Ewing sarcoma commonly arises from bone, but rarely may have an extraskeletal origin. EES is a rare soft tissue tumour that is morphologically indistinguishable from the more common Ewing sarcoma of

Giant hepatic artery aneurysm causing portal hypertension

Hepatic artery aneurysms are rare and account for nearly 20% f all visceral artery aneurysms. Thirty-four percent of aneurysms re intrahepatic. The risk of rupture is between 20% and 80% 1,2]. Ruptured aneurysm is associated with a rate of mortality f 21% [3,4]. In addition, hepatic artery aneurysms may present s Quinke’s triad of abdominal pain, haemobilia and obstrucive jaundice [2]. Jaundice may occur by external compression or y rupture into the biliary tree with thrombotic debris occludng the lumen. A 77-year-old male patient with abdominal pain nd obstructive jaundice had been referred to our department for omputed tomography (CT) scan. Multislice tomographic examinaion revealed hepatomegaly and splenomegaly. A right accessory