Nazan Okur

A rare cause of obstructive jaundice: fascioliasis.

A 56 year old woman was admitted to the clinic with severe colicky right upper abdominal pain. There was a three-week history of jaundice. Pathological biochemical laboratory results of her serum were as follows: direct bilirubin 4.53 mg/dl, total bilirubin 3.08 mg/dl, AST 45 U/L, ALT 72 U/L. Surgical treatment, cholecystectomy + choledochtomy + T-tube drainage, was performed. Exploration of the choledochus revealed two Fasciola hepatica. The patient was also given antihelmintic treatment. We present a case of fascioliasis-induced acute cholangitis that was diagnosed and treated via surgery. A review of the literature on extraction of living parasites is also included.

Alterations in pituitary gland volume in Polycystic Ovary Syndrome: A structural magnetic resonance imaging study.

The purpose of this prospectively designed cross-sectional observational study was to evaluate the effect of polycystic ovary syndrome (PCOS) on pituitary gland volume (PGV) under the hypothesis that endocrinologic changes may lead to morphologic changes of the pituitary gland. Twenty-six PCOS patients and 31 control subjects underwent magnetic resonance imaging (MRI) of the pituitary. Informed consent was obtained from all subjects. PGV was significantly larger in PCOS patients than in control subjects. Luteinizing hormone/follicle-stimulating hormone ratio was the only predictor of PGV. The association between pituitary gland enlargement and PCOS should be kept in mind when pituitary hypertrophy is detected on MRI.

Cystic lymphangiomatosis with severe intra‐abdominal bleeding in a newborn: Case report

We report the case of a newborn girl with intestinal cystic lymphangiomatosis who presented with abdominal distension and intra‐abdominal bleeding following a prenatal ultrasound diagnosis of intestinal anomaly. Postnatal abdominal ultrasound revealed disseminated submucosal and intramural cystic dilatations of various sizes in the bowel and intestinal lymphangiomatosis was diagnosed. The presence of severe bleeding diathesis and widespread disease led to conservative treatment. The patient died on postnatal day 7 and postmortem examination confirmed cystic lymphangiomatosis. Detection of intestinal hyperechogenicity and/or dilatation in prenatal ultrasonography and the persistence of these findings during pregnancy are suggestive for pathologies such as meconium ileus, meconium peritonitis, and intestinal atresia. Although rare, intestinal lymphangiomatosis should be kept in mind in patients whose prenatal sonographic findings persist until birth.

Spontaneous postoperative choledochoduodenal fistula due to bile duct injury following laparoscopic cholecystectomy.

Highlights • Class E injuries are the most common major bile duct injuries and can cause serious clinical condition including bile leak.• Iatrogenic operative injuries may be a cause of spontaneous postoperative choledochoduodenal fistula even in transaction type complete injuries.• Spontaneous closure of a postoperative bile fistula doesn’t guarantee that it is not a transaction type injury.

Effects of Parenchymal Thickness and Stone Density Values on Percutaneous Nephrolithotomy Outcomes

Background It is unclear whether parenchymal thickness (PT), in combination with stone density measured by Hounsfield Units (HU), affects stone-free rates after PCNL. The aim of the present study was to investigate the relationship between PT in combination with stone density values and the outcomes of PCNL. Material/Methods From 2009 to 2014, data from 216 PCNL patients were prospectively analyzed. In total, 120 patients were included in the study. Using NCCT images, stone burden, stone localization, stone density as HU values, PT, and operative-postoperative parameters were recorded. Results Stone localization, stone type, stone burden, and presence of hydronephrosis were statistically significant factors affecting stone-free status (p<0.001, p<0.001, p<0.01, and p<0.01, respectively). The stone-free rate in patients with thicker renal parenchyma was higher than in patients with lower parenchymal thickness (p<0.01). No correlation was detected between stone density and success rate (p>0.05). Drop in Hb (%) was only correlated with parenchymal thickness (p<0.01). In univariate analyses, factors that affected blood transfusion requirement were PT, BMI, and operative times (p<0.01, p<0.05, and p<0.05, respectively). Conclusions Stone location, stone burden, and presence of hydronephrosis detected with NCCT were factors affecting PCNL outcome. Stone density values did not correlate with the rate of bleeding or success of PCNL. PT measured by NCCT may predict bleeding and may guide surgeons in determining preoperative blood requirements. The outcome of PCNL appeared to be better in patients with thicker renal parenchyma and should be taken into consideration in the clinical evaluation of patients undergoing PCNL.

Alternative hepatic arterial reconstruction technique in case of total pancreaticoduodenectomy after celiac artery resection in pancreas cancer: Iliac–hepatic bypass

Surgery is the only treatment method in pancreatic cancer. Unfortunately, metastatic diseases or invasion of the main vascular structures are observed in a majority of cases at the time of diagnosis; these structures originate from the body, neck, and tail of the pancreas and are considered inoperable. The first celiac artery resection for the treatment of cancer was described by Appleby in 1953. Here, we describe our hepatic artery reconstruction technique in a case with pancreatic body cancer. A 37-year-old male patient was admitted to our emergency department owing to syncope. The patient was diagnosed with acute renal failure secondary to fluid loss. Thereafter, his general condition was stable and laboratory results improved. Abdominal computed tomography was performed. Pancreatic cancer originating from the pancreatic body was detected. A pancreatic biopsy was performed and neoadjuvant gemcitabine and paclitaxel chemoradiotherapy were initiated. Surgical treatment was recommended for the identification of regression after neoadjuvant chemoradiotherapy. Following intraoperative Doppler ultrasonography, en bloc distal pancreatectomy and splenectomy involving the celiac artery trunk and total gastrectomy were performed. However, the surgical margin reliability in a frozen section revealed that the tumor was still present. Therefore, the surgical procedure was replaced with total pancreaticoduodenectomy. The hepatic artery reconstruction was performed from the left main iliac artery using a 4-mm ringed GORE-TEX® graft. The iliac-hepatic bypass for hepatic artery reconstruction in pancreatic cancer could be an alternative surgical technique.

The Prevalence of Incidentally Detected Idiopathic Misty Mesentery on Multidetector Computed Tomography: Can Obesity Be the Triggering Cause?

Purpose Misty mesentery appearance is commonly reported in daily practice, usually as a secondary finding of various pathological entities, but sometimes it is encountered as an isolated finding that cannot be attributed to any other disease entity. We aimed to assess the prevalence of cases with incidentally detected idiopathic misty mesentery on computed tomography (CT) and to summarize the pathologies leading to this appearance. Methods Medical records and initial and follow-up CT features of patients with misty mesentery appearance between January 2011 and January 2013 were analysed. The study included cases with no known cause of misty mesentery according to associated CT findings, clinical history, or biochemical manifestations, and excluded patients with diseases known to cause misty mesentery, lymph nodes greater than a short-axis diameter of 5 mm, discrete mesenteric masses, or bowel wall thickening. Results There were a total of 561 patients in whom misty mesentery appearance was depicted on abdominopelvic CT scans. A total of 80 cases were found to have isolated incidental idiopathic misty mesentery, giving a prevalence of 7%. The common indication for CT examination was abdominal pain. There was a slight female predominance (51.3%). 67.5% of all patients were classified as obese and 17.5% as overweight. Conclusions The results of the present study show that idiopathic incidental misty mesentery appearance has a significant prevalence. Also, the high body mass index of these patients and the growing evidence of obesity-induced inflammatory changes in adipose tissue are suggestive of an association between obesity and misty mesentery appearance on CT.

Laparoskopik low anterior rezeksiyon sonrası oluşan anastomoz darlığında balon dilatasyon uygulaması: İki olgu sunumu

Benign anastomoz darliklari kolorektal cerrahi sonrasi ortaya cikabilen gec komplikasyonlardandir. Tedavide her ne kadar endoskopik girisimler onerilmekteyse de balon dilatasyonu dusunulmesi gereken ilk secenektir. Laparoskopi yardimli low anterior rezeksiyon ve stapler anastomoz yapilan iki hastamizdan birinde postoperatif 6. ayinda digerinde ise 9. ayinda ileri derecede anastomoz strikturu tespit edildi. Hastalardan biri ishal-kabizlik ataklari, rektal kanama gibi yakinmalarla basvururken diger hasta tamamen asemptomatikti ve anastomoz darligi kontrol kolonoskopisinde saptandi. Her iki hastaya da akalazya tedavisinde kullanilan “ower-the-wire” balonu ile iki seans endoskopik dilatasyon uygulandi.

An extremely rare mass of bladder: lipoma in the bladder

There have been described many benign tumours of bladder, but non-epithelial ones are rare [1]. Specifically, bladder lipoma was reported only in a handful of cases in medical literature. This is one of the benign formation of soft tissue. It may also cause voiding disorders such as dysuria, frequency, and haematuria [2]. Herein, we presented an extremely rare case who was admitted to urology outpatient clinic with voiding disorders and was diagnosed as bladder lipoma. A 67-year-old female patient was admitted to our outpatient clinic with chief symptom of dysuria. Urinary frequency and nocturia were other complaints. She had no comorbidity and was a non-smoker in her medical history. Her physical examination, laboratory tests, and urine analysis were normal. Her body mass index (BMI) was 24.9 kg/m (normal). Transabdominal ultrasonography (US) revealed that the patient had an echogenic, round, and solid mass measuring approximately 8 mm at the dome of the bladder while there was no significant US finding related with kidneys. The lesion was seen as in the bladder, not out of bladder’s surface. Therefore, we performed cystoscopy in our outpatient clinic under local anaesthesia by flexible cystoscopy. There was a smooth, yellow and benign-looking tumour, at the dome of bladder, in endoscopic view. As the tumour did not seem like epithelial tumour, magnetic resonance imaging (MRI) was performed. The tumour was hyperintense in both T1and T2weighted images, while there was loss of signal in SPIR T1and T2-weighted images. These findings were specific for lipoma in MRI (Fig. 1). There was no enhancement of the lesion itself in post-contrast series which showed only enhancement of the bladder mucosa overlying the mass. Furthermore, there was no finding suggestive of pelvic lipomatosis in MRI. The informed consent was obtained from patient. In the operation room, first spinal anaesthesia was performed and the genital area was sterilized in lithotomy position. The cystoscopy was indwelled. In endoscopic view, there was a tumour at the dome of bladder, and there was no additional tumour (Fig. 2). The tumour was suitable for resection in endoscopic route. Therefore, it was treated by transurethral resection. There was no residual tumour after endoscopic resection (Fig. 3). The mucosal bleeding was cauterized after resection. A urethral catheter was indwelled. On the first day of surgery the urethral catheter was removed, and the patient was discharged. The pathology specimens were assessed by a single experienced pathologist and ‘‘lipoma’’ was diagnosed as an encapsulated tissue formed by mature lipocytes adjacent to the smooth muscle fibres (Fig. 4a). Liposarcoma was ruled out due to absence of immature, atypical lipoblasts (Fig. 4b). After treatment by transurethral resection, symptoms of patient disappeared. She has been without voiding symptoms during last 6 months and she was in follow-up period, in our outpatient clinic. & Y. Akin yigitakin@yahoo.com

Travmatik Torasik Aort Disseksiyonu Endovasküler Tamiri: Olgu sunumu

Travmatik torasik aort disseksiyonlari genellikle hayati tehdit eden ve maruz kalanlarin % 75 inin kaybedildigi ciddi yaralanmalardir. Acik cerrahi ile greft interpozisyonu geleneksel kabul gormus tedavidir. Ancak acil multitravmali hastalarda ek yaralanmalar nedeni ile uygulama alani azdir ve mortalite oranlarida yuksektir. Travmatik torasik aort yaralanmalarinda endovaskuler greftleme ile tamir, konvansiyonel acik cerrahiye gore dusuk mortaliteye sahip guvenli bir alternatiftir. Bu yazida endovaskuler stent greft ile tamir edilen travmatik torasik aort disseksiyonlu bir olguyu sunduk