Levent Yeniay

Outcome Analysis in Patients With Fournier’s Gangrene

AbstractINTRODUCTION: Despite antibiotics and aggressive debridement, the mortality rate of Fournier’s gangrene remains high. Attempts have been made to study factors that may affect prognosis; however, reliable criteria are still lacking. METHODS: The medical records of 45 patients with Fournier’s gangrene who presented at the Ege University Medical Faculty Hospital from January 1990 to May 2001 were reviewed retrospectively to analyze the outcome and identify the risk factors and prognostic indicators of mortality. Univariate analysis was performed using the chi-squared test and Fisher’s exact probability test, then multivariate analysis of statistically significant variables was performed using logistic regression. RESULTS: The most prominent associated disease was diabetes, affecting 55.6 percent of the patients. The overall mortality rate was 20 percent. However, the mortality rate among diabetics was 36 percent (P = 0.002). The other statistically significant predictors of outcome were the interval from the onset of symptoms to the initial surgical intervention (P = 0.001) and the need of fecal diversion (P = 0.009). Multivariate regression analysis disclosed that the interval from the onset of symptoms to the initial surgical intervention and diabetes were independent predictors of mortality (P = 0.001 and P = 0.003, respectively). CONCLUSION: The interval from the onset of clinical symptoms to the initial surgical intervention seems to be the most important prognostic factor with a significant impact on outcome. Given the significantly high mortality rate among diabetics, diabetes is also an independent prognostic factor. Despite the decreased number of idiopathic cases and extensive therapeutic efforts, Fournier’s gangrene remains a surgical emergency, and early recognition with prompt radical debridement is the mainstays of management.

Problematic aspects of sentinel lymph node biopsy and its relation to previous excisional biopsy in breast cancer.

Purpose: The aim of the study is to review problematic aspects of sentinel lymph node biopsy (SLNB) and to evaluate the influence of a previous excisional biopsy on these problems. Materials and Methods: A total of 345 patients were evaluated retrospectively, 156 of them had a previous biopsy. Tc-99m tin colloid was injected the day before surgery at 4 quadrants around the areola intradermally. Problems complicating SLNB are reviewed in 3 topics: visualization or gamma probe detection problems, dilated lymphatic channels, and misleading activity accumulation. Results: SLN detection rate and mean sentinel lymph node numbers were as follows in patients with and without biopsy, respectively: 95.5% versus 99.4% and 1.71 ± 0.97 versus 1.70 ± 0.92. Problems complicating the procedure occurred in 20 patients (5.8%). Among these 20 patients, 15 had a prior excisional biopsy, and incisions were located in the upper, outer and periareolar zones. Visualization or gamma probe detection problems occurred in 8 patients. Except for one with faint uptake in a sentinel node, all had a prior biopsy. Lymphatic channel dilatation complicated the procedure in 7 patients. Of these 7 patients, 4 had a previous biopsy. Misleading activity accumulations compromised SLNB in 5 patients, 4 of whom had a prior biopsy. Conclusion: Although SLNB is still applicable with a high success rate in cases with excisional biopsy, a review of problematic aspects of SLNB demonstrated a relation with the presence of a previous biopsy and its localization. The demonstration of nonvisualization preoperatively and the precise localization of atypically located activity accumulation may be helpful in the prevention of potential complications.

Effects of ropivacaine on pain after laparoscopic cholecystectomy: A prospective, randomized study

Postoperative pain after laparoscopic cholecystectomy is an ongoing problem. To relieve this pain, practitioners have used many anesthetic and analgesic drugs. This study was undertaken to assess the effects of incisional and intraperitoneal administration of ropivacaine on postoperative pain and stress response in patients undergoing laparoscopic cholecystectomy. In this prospective, singleblinded, randomized study, 45 patients with ASA (American Society of Anesthesiologists) scores I and II who were about to undergo laparoscopic cholecystectomy were divided into 3 groups. After cholecystectomy, a total of 40 mL of 3.75% ropivacaine was administered preincisionally and intraperitoneally to patients in group 1 (n=14); preincisionally and intraperitoneally to patients in group 2 (n=17); and intraperitoneally and locally at incision sites to patients in group 3 (n=14). Blood levels of epinephrine and norepinephrine were examined preoperatively, 15 min after insufflation, and at the end of the operation. Visual analog pain scale scores and analgesic requirements were used for 24-h postoperative follow-up of pain levels reported by patients. No statistically significant difference was found among the 3 groups with respect to visual analog pain scale scores, total analgesic requirements, and accompanying pain, nausea, and vomiting. The earliest analgesic requirements were seen in group 2 (P < .005), and less shoulder pain was noted in group 3 (P < .005). Norepinephrine and epinephrine levels showed no statistically significant differences between the 3 groups. Administration of ropivacaine preoperatively and postoperatively for laparoscopic cholecystectomy has similar effects on postoperative pain and the stress response of patients.

Abdominal cocoon syndrome as a rare cause of mechanical bowel obstruction: report of two cases.

An abdominal cocoon is an extremely rare condition, and has been reported mainly in young adolescent women as a cause of small bowel obstruction. In these patients, the small bowel is encased in a fibrous sac called an abdominal cocoon. We hereby present two cases who were diagnosed only by laparotomy and their correlation with the literature. They both received early intervention, thus preventing the need for bowel resection. The pathology of both membranes showed inflammation.

Dermatofibrosarcoma Protuberans of the Breast: Dermatofibrosarcoma Protuberans of the Breast

A48 years old female patient was performed excisional biopsy 5 years ago due to breast mass. Approximately 18 months after first excision, second excision was performed due to mass development in the same area. The patient presented to our clinic, there was an inflammatory mass in the breast which was underwent excisional biopsy previously. The tumor was growing gradually for 1 year and had intermittent bleeding. On physical examination the left breast had lost its normal form and there was an approximately 10 cm lobulated and protruding lesion, which held nearly whole of the breast (Fig. 1). There was no axillary lymphadenopathy and the other breast was normal. Breast ultrasonography revealed thick walled cystic lesion with dense content located in the middle outer quadrant of the left breast. Histogical essay of the excisional biopsy specimen revealed Dermatofibrosarcoma protuberans (DFSP). No sign of distant metastasis was found in thorax CT and abdominal ultrasonography. Patient underwent left total mastectomy and axillary dissection. On pathologic examination the mass was nodular, protuberant, and white in color. The mass size was 10 · 7 · 6 cm, infiltrating cutis and had 0.2 cm distance to pectoral fascia. On microscopic examination tumor infiltrated dermis diffusely beginning from just underneath the epidermis. In deep regions, the tumor spreaded along the breast connective tissue and interdigitated with lobules of the breast fat. Tumor was composed of uniform slender fibroblasts arranged in a distinct monotonous storiform pattern. There was low mitotic activity and no obvious pleomorphism. MIB-1 proliferating index was about 5%. Immunohistochemistry demonstrated diffuse CD34 positivity. With these findings, tumor was diagnosed as DFSP (Fig. 2). Metastasis was not detected in the 12 lymph nodes that were dissected from the left axilla. Patient was evaluated in the breast tumor council and was decided to be applied adjuvant radiotherapy. Dermatofibrosarcoma protuberans is a relatively uncommon neoplasm of the deep dermis and subcutaneous tissue with low-grade malignant potential. Growth rate is variable and increases after recurrence. As tumor can remain stable for years, it may show slow growth pattern accompanied by periods of rapid growth. The differential diagnosis should include dermatofibroma, epidermal inclusion cyst, neurogenic tumor, malign melanoma, fibrosarcoma, and malign fibrous histiocytoma. Characteristic protrusion of the skin is a very important sign and without the presence of protrusion the differential diagnosis may be challenging. Skin biopsy is golden standard for certain diagnosis. Local recurrence occurs in 20–55% of patients with DFSP. This ratio reaches as high as 73% in cases with fibrosarcomatous changes which worsens prognosis. Local recurrence after conservative surgery is reported to be 43%, however, this ratio drops to 1, 6% when Mohs micrographic surgery (MMS) and to 0% when extensive surgical excision (surgical borders >5 cm) is applied. Most of the recurrences occur within first 3 years of primary excision and, however, this period can be longer. Despite its local aggressiveness, DFSP rarely causes distant metastases. The rare distant metastases of DFSP which usually occur after multiple local recurrences are reported to be related to insufficient excision of vascular structures involved by the tumor and usually occur after multiple efforts to resect local recurrences. As an uncommon soft tissue tumor with a low rate of metastasis, we found our case of DFSP patient worth reporting as, in discordance with the literature, she had lung metastasis without the presence of local recurrence after a long period of 7 years Address correspondence and reprints request to: Levent Yeniay, MD, Ege Universitesi Tip Fakultesi Hastanesi Genel Cerrahi AD 35100 Bornova/ Izmir/Turkiye or e-mail: levent. yeniay@ege.edu.tr.

A new and simple predictive formula for non-sentinel lymph node metastasis in breast cancer patients with positive sentinel lymph nodes, and validation of 3 different nomograms in Turkish breast cancer patients.

Background: Nomogram accuracies for predicting non-sentinel lymph node (SLN) involvement vary between different patient populations. Our aim is to put these nomograms to test on our patient population and determine our individual predictive parameters affecting SLN and non-SLN involvement. Patients and Methods: Data from 932 patients was analyzed. Nomogram values were calculated for each patient utilizing MSKCC, Tenon, and MHDF models. Moreover, using our own patient- and tumor-depended parameters, we established a unique predictivity formula for SLN and non-SLN involvement. Results: The calculated area under the curve (AUC) values for MSKCC, Tenon, and MHDF models were 0.727 (95% confidence interval (CI) 0.64–0.8), 0.665 (95% CI 0.59–0.73), and 0.696 (95% CI 0.59–0.79), respectively. Cerb-2 positivity (p = 0.004) and size of the metastasis in the lymph node (p = 0.006) were found to correlate with non-SLN involvement in our study group. The AUC value of the predictivity formula established using these parameters was 0.722 (95% CI 0.63–0.81). Conclusion: The most accurate nomogram for our patient group was the MSKCC nomogram. Our unique predictivity formula proved to be as equally effective and competent as the MSKCC nomogram. However, similar to other nomograms, our predictivity formula requires future validation studies.

The effect of radiocolloid preference on major parameters in sentinel lymph node biopsy practice in breast cancer

INTRODUCTION The possible effects of radiocolloid preference on sentinel lymph node biopsy (SLNB) were investigated. METHODS A total of 200 patients with T1-2N0M0 breast cancer were evaluated. The first 100 patients underwent SLNB using (99m)Tc tin colloid (TC) and the next 100 using (99m)Tc nanocolloid (NC). Radiocolloid was injected intradermally at four quadrants of the periareolar region the day before surgery. All patients underwent lymphoscintigraphy 1 h after injection. All nodes having fourfold activity of the background were harvested using gamma probe. RESULTS Sentinel lymph node (SLN) identification rate by gamma probe was 98% in each group. The number of SLNs identified by lymphoscintigraphy, gamma probe and pathological evaluation was 1.39 ± 0.7, 1.70 ± 1.0 and 2.23 ± 1.70 in the TC and 2.03 ± 0.94, 2.60 ± 1.36 and 3.05 ± 1.90 in the NC group, respectively (P<.05). Metastatic SLN was found in 24 (24.4%) of 98 patients in the TC group and 41 (41.8%) of 98 patients in the NC group (P=.04). None of the patients showed dispersion to internal mammarian lymph nodes. Lymphatic vessel visualization was observed in eight (8.1%) of 98 TC patients and in 47 (47.9%) of 98 NC patients (P=.000). SLNs were the only metastatic node(s) in 54.1% of TC and 73.1% of NC patients. CONCLUSION The periareolar intradermal injection technique gives a high detection rate in the localization of SLNs independently from the choice of the tracer. Mean SLN numbers and lymphatic vessel visualization frequency were significantly higher using a smaller albumin Tc-99m nanocolloid as compared to a stannous fluoride Tc-99m tin colloid. The results of our study support the idea that the influence of increased number of SLNs on positive SLN frequency is critical.

Precipitating Factors for Lymphedema Following Surgical Treatment of Breast Cancer: Implications for Patients Undergoing Axillary Lymph Node Dissection

To the Editor: Axillary lymph node dissection (ALND) remains the standard of care in the management of invasive breast carcinoma (1,2). However, questions have been raised about the routine performance of this procedure due to relatively high morbidity rate (3,4). Lymphedema is the most common complication of ALND resulting in chronic and debilitating arm swelling. This retrospective analysis was performed to identify the predisposing factors that significantly impact on the likelihood of lymphedema following breast cancer surgery. Between January 1990 and December 2000, 1,155 breast cancer patients were treated surgically at Ege University Medical Faculty. All patients had invasive carcinomas and underwent ALND, with either mastectomy (with or without adjuvant radiotherapy [RT]) or breast conserving surgery [BCS] with adjuvant RT. A total of 681 patients (59%) were given postoperative RT to the breast with 50 Gy over 4 weeks with a boost to the tumor side. A group of 327 patients with gross residual or N2 disease, or having ‡4 positive ALNs received axillary RT. None of the patients received neoadjuvant treatment and there were no immediate reconstructions. The patients were observed for a minimum of 36 months. The occurrence of lymphedema was determined by means of the difference in circumferential arm measurement (10 cm below and 10 cm above the lateral epicondyl) between the treated side and the contra-lateral side. Arm swelling involving a difference >2 cm was accepted as lymphedema. Statistical analysis was performed using SPSS 14.0 for Windows. Statistical methods for univariate analysis included the chi-squared test applied to categorical data and analysis of variants, and the Student t-test for continuous variables. Statistically significant variables were entered into multivariate regression analysis using logistic regression. With an average follow-up of 66.7 ± 27 months, 538 patients developed lymphedema (46.6%, LE [+] group). At time of initial diagnosis, the presence of locally advanced disease (p < 0.001, RR = 2.06, 95% CI, 1.42–3.00), and clinically positive lymph nodes (p = 0.002, RR = 1.44, 95% CI, 1.14–1.82) were significant factors contributing to the risk of lymphedema. The number of lymph nodes removed during ALND (range, 7–52 nodes) showed a statistically significant difference between LE [+] and LE [)] groups (17.9 ± 6.4 versus 16.2 ± 5.7, respectively, p < 0.001). The lymphedema rates corresponding to axillary clearance with £10, 11–15, 16–20, and >20 lymph nodes removed were 34.0%, 44.4%, 47.2%, and 54.9%, respectively (p < 0.001). ALN involvement was also found to contribute to the occurrence of lymphedema, with a significantly increased risk noted in node positive (55.7%) versus node negative (35.5%) patients (p < 0.001, RR = 2.28, 95% CI, 1.79–2.89). The corresponding rates in patients with axillary metastasis involving 1–3, 4–9, and ‡10 nodes were 47.9%, 61.0%, and 73.5%, respectively (p < 0.001). The incidence of lymphedema was found to increase in patients undergoing mastectomy (49.2%) versus BCS (32.0%) (RR = 2.05, 95% CI, 1.47–2.88). Furthermore, adjuvant RT of the breast appeared to increase the lymphedema rate significantly. The development of lymphedema was more frequent in irradiated (52.7%) versus nonirradiated (37.8%) patients (RR = 1.53, 95% CI, 1.20–1.95). The patients treated with axillary RT (n = 66) had the highest risk of lymphedema (RR = 34.5, 95% CI, 8.3–142.5). However, despite the fact that all patients undergoing BCS were irradiated, they were found to have a lower incidence of lymphedema (32%) than the patients undergoing mastectomy without irradiation (37.6%) (RR = 1.70, 95% CI, 1.47–1.97). The risk of lymphedema was found to be unrelated to chemotherapy. Multivariant Address correspondence and reprint requests to: Dr. Murat Dayangac, MD, Florence Nightingale Hastanesi, Abide-I Hurriyet Cad. No: 290, 34381 Sisli ⁄ Istanbul, Turkey, or e-mail: dayangac@mail.ege.edu.tr.

Autoimmune Pancreatitis and Treatment Approaches with Case Reports

OBJECTIVE In this study, we aimed to review retrospectively the data of 10 patient who were treated and followed-up in our clinic and to review the current approaches in the diagnosis and treatment of autoimmune pancreatitis (AIP). MATERIAL AND METHODS We reviewed 10 patients retrospectively who were operated on and had the diagnosis of AIP histopathologically in the Ege University School of Medicine Department of General Surgery. RESULTS Between June 2001-November 2010, 10 patients who were diagnosed as AIP were examined retrospectively. Radiologically, a pancreatic mass was found in the pancreatic head with ultrasound in 7 (70%) of 10 patients and suspicious lesions were identified in the head of the pancreas in 3 (30%) patients. All patients were operated on in our clinic with the preliminary diagnosis of pancreatic head tumor; 8 patients underwent Whipples procedure, 1 patient underwent pylorus preserving pancreaticoduodenectomy, and in 1 patient an exploratory pancreatic biopsy (frozen section) was carried out. CONCLUSION Autoimmune pancreatitis is a disease with increasing incidence and characterized by lymphoplasmocytic cell infiltration and fibrosis. Patients with a pancreatic mass, if there is an autoimmune disease or chronic pancreatitis suspected in the detailed history, it is necessary to evaluate patients in terms of AIP serologically to protect the patients from an incoorectng diagnosis and morbidity of surgery.

Severe decrease in SpO2 and methemoglobinemia following subareolar isosulfan blue administration and clinical relevance

The level of axillary lymph node involvement in breast cancer is a critical decision factor for adjuvant therapy and the most important indicator of prognosis and survival. Sentinel lymph node biopsy is a minimally invasive technique with low morbidity in axillary staging of breast cancer. Radiocolloid substances (Technetium-99m) and/or blue dyes such as methylene blue or isosulfan blue are used during sentinel lymph node biopsy. Isosulfan blue stain is frequently used in sentinel lymph node biopsy and rarely causes complications. The present case report presents a severe decrease in SpO2 due to methemoglobinemia following isosulfan blue administration as well as skin and urine signs and inconsistency with clinical picture in a 67-year-old, 77 kg, ASA II female case who underwent sentinel lymph node biopsy under general anesthesia.