M. İlhan Yildirgan

Typhoid Intestinal Perforations: Twenty-six Year Experience

BackgroundTyphoid fever (TF) is a severe febrile illness caused by Salmonella typhi. One of the most lethal complications of TF is ileal perforation (TIP). Although the mortality of associated with TIP has decreased slightly over the past decade, it is still high.Methods and ResultsThe records of the 82 surgically treated patients with TIP were evaluated retrospectively. There were 64 men with the mean age of 36.3 years (range: 7–68 years). In surgical treatment, debridement with primary closure was performed in 32 patients (39.0%), and wedge resection with primary closure was performed in 9 (11. 0%), resection with primary anastomosis in 9 (11.0%), and resection with ileostomy in 32 (39.0%). The most common postoperative complication was wound infection, which occurred in 24 patients (29.3%). The overall morbidity was highest in the ileostomy group. The overall mortality was 11.0% (9 patients). Age, gender, number, and localization of the perforations (p > 0.05) were not found to affect mortality, but prolonged preoperative period (p < 0.001), extended peritoneal contamination (p < 0.01), and ileostomy procedure (p < 0.001) were found to influence the increase in mortality.ConclusionsEarly and appropriate surgical intervention with effective preoperative and postoperative care may improve survival in TIP.

Comparison of peritoneal tumor imaging using conventional MR imaging and diffusion-weighted MR imaging with different b values

PURPOSE The aim of this study was to evaluate the utility of DW MRI with two different b values in identifying peritoneal tumors in oncology patients. MATERIALS AND METHODS Nineteen patients with known malignancy underwent abdominal and pelvic MRI before surgery. MRI included free-breathing DWI with b values of 400 and 800 s/mm2, T1-weighted fat-suppressed spoiled gradient-echo, T2-weighted fat-saturated turbo spin-echo, and 5-min delayed gadolinium-enhanced imaging. Two observers reviewed images for peritoneal tumors at ten anatomic sites within consensus. The results of laparatomy and histopathological evaluation were compared with MRI results. Sensitivity, specificity, and accuracy of identifying peritoneal metastases were calculated for conventional MRI, combined DWI with a b value of 400 s/mm2 and conventional MRI, and combined DWI with a b value of 800 s/mm2 and conventional MRI by consensus of two observers. RESULTS One-hundred and twenty-five peritoneal metastasis sites were confirmed by surgical and histopathological findings. Conventional MRI alone identified 72 peritoneal metastases (sensitivity, 0.58; specificity, 0.87; accuracy, 0.67). Combined DWI with a b value of 400 s/mm2 and conventional MRI revealed 106 peritoneal metastases (sensitivity, 0.85; specificity, 0.88; accuracy, 0.85). Finally, combined DWI with a b value of 800 s/mm2 and conventional MRI revealed 103 peritoneal metastases (sensitivity, 0.83; specificity, 0.94; accuracy, 0.86). CONCLUSION DWI with a high b value provides complementary information that can improve the detection of peritoneal tumors when combined with conventional MRI. We recommend combined MRI and DWI with a high b value for increasing the sensitivity and accuracy of the preoperative detection of peritoneal tumors.

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.

Ileosigmoidal Knotting in Children: A Review of 9 Cases

BackgroundThe purpose of this study was to review nine pediatric cases of ileosigmoidal knotting (ISK), which is an unusual form of intestinal obstruction common in adults, characterized by double-loop obstruction.MethodsA retrospective analysis was designed to examine preoperative, operative, and postoperative findings of the nine children with ISK who were surgically treated in a university hospital throughout a 38.5-year period..ResultsThe mean age was 10.6 years (range: 7–16 years). Seven patients (77.8 %) were male. The most common symptoms were abdominal pain, distention, obstipation, and vomiting, and the most common signs were abdominal tenderness and distention. The most common form was type 1A in 4 patients (44.4%) in whom the active ileum encircled the passive sigmoid colon in clockwise direction. There was a gangrene in both ileum and sigmoid colon in 7 patients (77.8%), one patient (11.1%) had gangrene in only the sigmoid colon, and the bowels were viable in 1 patient (11.1%). In the gangrenous cases, nonviable small bowel segments were resected, and anastomosis was performed, while gangrenous sigmoid colon was resected and Hartmann procedure or primary anastomosis was used. In the nongangrenous case, detorsion was performed and sigmoidopexy was added. One patient in this series (11.1%) died.ConclusionsIleosigmoidal knotting is a rare disease in children. Its preoperative diagnosis is not easy. It is generally misdiagnosed as an obstructive emergency. Aggressive preoperative resuscitation, effective and prompt surgery, and postoperative support are the basic principles of treatment. Although resection with primary anastomosis is advised in gangrenous cases, stomas may be lifesaving in unstable patients. In nongangrenous cases, definitive surgical procedures are generally used.

Giant Mesenteric Cyst

Mesenteric cysts (MCs) are defined as cystic masses located in the mesentery. These are commonly located at the ileal mesentery, but they also can be found anywhere at the mesentery from the duodenum to the rectum [1]. The incidence of mesenteric cysts has been estimated to be 1:100,000 in the adult population, with a male:female ratio of 1:1 [2]. The etiopathogenesis of the disease remains unknown, and many pathologic processes have been reported, including benign proliferation of ectopic lymphatics, obstructions of the lymphatics, abdominal traumas and local degeneration of some lymph nodes [2, 3]. Most MCs remain asymptomatic [4]. A total of 40% are diagnosed incidentally during surgery. Abdominal pain, nausea and vomiting are the most frequent symptoms [1]. We present a case with an unknown abdominal mass, diagnosed as giant ileal MC and treated surgically.

Periampullary Diverticula Causing Pancreaticobiliary Disease

Our purpose was to determine if the presence of duodenal diverticula predisposes to the development of pancreaticobiliary disease. Between May 1999 and February 2001, 381 patients were examined by endoscopic retrograde cholangiopancreaticography. Of these patients, 51 had periampullary diverticula. In 27 patients the papilla was located inside the diverticulum (Group I), in 19 patients it was located at the edge of the diverticulum (Group II), and 5 patients it was located at a distance closer than 3 cm to the diverticulum (Group III). Seventeen patients in group I and 11 patients in group II had had a previous cholecystectomy. The overall incidence of biliary system stone disease was 22.2% in group I, 36.8% in group II, and 100% in group III. All patients were treated with endoscopic sphincterotomy and three (two in group I and one in group II) developed biliary system disease (cholangitis or pancreatitis). We think that sphincterotomy should be applied regardless of the presence of stone if the papilla is located inside or at the edge of the diverticulum. If the papilla is located 3 cm or more far for diverticulum, it should be considered within the frame of general sphincterotomy indications in the absence of stone disease.

Duodenal Stromal Tumor: Report of a Case

Gastrointestinal stromal tumors are rare tumors of the gastrointestinal (GI) tract that arise from primitive mesenchymal cells. Gastrointestinal stromal tumors account for approximately 80% all of gastrointestinal mesenchymal tumors. Duodenal stromal tumors (DSTs) manifest with unexplained melena, pain, bleeding, anemia, sometimes a partial duodenal obstruction and, rarely, with obstructive jaundice. If the tumor is successfully treated, its prognosis is usually good because of its non-aggressive nature. If resected, the prognosis is favorable in a majority of cases, and it is much better than in carcinomas of the duodenum. In this article, we report a case of DST originating from the first and second portion of the duodenum. Our patient did not have any problems postoperatively and remained symptom-free at 18 months after surgery.

Recombinant human growth hormone modulates the hepatic acute-phase response and P-selectin in burned rats.

The purpose of this study was to determine the effect of recombinant human growth hormone (rhGH) on serum constitutive proteins, cytokines, P-selectin, and insulin-like growth factor (IGF-1) in the thermally injured rats.Sprague-Dawley rats (64 males) were given 30% total body surface area full thickness scald burn. They were randomly divided to receive either 2.5mg/kg per day im rhGH or saline (control). Rats were sacrified on postburn days 1, 2, 5, and 7, and serum constitutive proteins, cytokines, P-selectin, and IGF-1 levels were measured.Serum IGF-1 levels were increased on days 2, 5, or 7 after burn in rhGH-treated rats compared with controls (P<0.001, <0.01 and <0.001, respectively). Serum transferrin and albumin levels were increased on days 7 after burn in rhGH-treated rats compared with controls (P<0.05). The cytokines increased after thermal injury. The rhGH decreased serum levels of tumor necrosis factor-alpha on postburn days 1 compared with controls (P<0.001). Serum levels of interleukin-1 were decreased on days 1 and 2 after burn in rhGH treated rats compared with controls (P<0.001, <0.01, respectively). Rats receiving rhGH showed significantly increased P-selectin levels at 5 and 7 postburn days compared with controls (P<0.001). Our data indicate that rhGH, given after thermal injury, increased albumin, transferrin, IGF-1, and P-selectin levels and decreased serum tumor necrosis factor-alpha and interleukin-1 levels.

Posttraumatic gallbladder torsion in a child

Torsion of the gallbladder in an 8-year-old boy, which was precipitated by blunt abdominal trauma from a ball-strike during a soccer game, is reported. Of the 13 reported childhood cases of gallbladder torsion, this is the first to be precipitated by blunt abdominal trauma in the presence of congenital anatomic predilection.

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