O.V. Unalp

Recurrent Pilonidal Sinus: Lay Open or Flap Closure, Does It Differ?

Treatment options of pilonidal sinus, which has high recurrence rates, is still controversial. In this study, we aimed to analyze for possible factors affecting recurrence. Forty-one patients with recurrent pilonidal sinus were included in this study. Of them, 33 were male and 9 were female (mean age, 24.9 years; age range, 16-42). Factors (i.e., risk factors) were detected in 32 patients. Excision-secondary healing and lay open was performed on 30 of the patients admitted with recurrence. Excision and flap closure was applied on 11 patients. Our recurrence rate was 9.7%. The recurrence rate of our study is compatible with the literature. Comparative studies are needed to determine the appropriate method to decrease recurrence rate.

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.

Results of Surgery-Related Complications in Donors of Right Lobe Liver Graft: Analysis of 272 Cases

BACKGROUND Living donor liver transplantation has been a new light of hope for patients with end-stage liver failure on the cadaveric waiting list. However, living donor liver transplantation still has ethical problems which cannot be overcome. Exposure of healthy donor candidates to major surgery which can be fatal is the largest of these ethical problems. In this study, we aimed to determine our rate of complications associated with surgery in donors who underwent right lobe donor hepatectomy. MATERIALS AND METHODS Between September 2004 and December 2009, 548 liver donor candidates were examined. The right liver lobe donor hepatectomy was performed on 272 donor candidates who passed the elimination system. Demographic data as well as intraoperative findings, complication rates, and numbers were collected retrospectively. Donor complications were categorized according to the Clavien classification. RESULTS Two hundred seventy-two donors who underwent right lobe donor hepatectomy were included in this study. One hundred sixteen (42.6%) of 272 donors were female, whereas 156 (57.4%) were male. There was no donor mortality. Grade 1 and grade 2 complications were observed in 105 (38%) of 272 donors. The most common complications were fever of unknown origin (20.9%) and prolonged hyperbilirubinemia (3.6%). Grade 3 complications and grade 4 complications were observed in 6 donors (2%) and 3 donors (1%), respectively. Three donors were underwent re-operation due to bleeding. The re-laparatomy rate in our series was detected as 1.10%. One donor, categorized as grade 4B according to the Clavien classification, had small bowel perforation and intra-abdominal sepsis secondary to mechanical bowel obstruction. CONCLUSIONS Donor mortality is a fact of living donor liver transplantation that cannot be ignored like donor morbidity. However, right liver lobe donor hepatectomy can be performed successfully with minimal complication rates with multidisciplinary and rigorous donor care in the preoperative and postoperative period.

Unusual treatment of Kasabach-Merritt syndrome secondary to hepatic hemangioma: embolization with bleomycin.

SummaryKasabach–Merritt syndrome (KMS) is a rare complication of cavernous hemangiomas characterized with anemia, thrombocytopenia, and consumption coagulopathy. This syndrome usually develops due to superficial soft tissue hemangiomas in infancy and childhood. KMS developing secondarily to hepatic hemangioma is very rare. In this report, we aimed to present the treatment of KMS developing secondarily to giant cavernous hemangioma of the liver with transarterial chemoembolization using bleomycinZusammenfassungDas Kasabach-Meritt Syndrom (KMS) ist eine seltene Komplikation von kavernösen Hamangiomen, charakterisiert durch Anämie, Thrombozytopenie und Verbrauchskoagulopathie. Ein KMS als Folge eines Hämangioms der Leber ist extrem selten.Im vorliegenden Bericht wollten wir die Behandlung eines KMS, welches als Folge eines riesigen kavernösen Hämangioms der Leber entstanden war, mittels transarterieller Embolisation mit Bleomycin vorstellen.

Prognostic Factors in Peptic Ulcer Perforations: A Retrospective 14-Year Study

Regarding the complications of peptic ulcer, a perforation remains the most important fatal complication. The aim of our retrospective study was to determine relations between postoperative morbidity and comorbid disease or perioperative risk factors in perforated peptic ulcer. In total, 239 patients who underwent emergency surgery for perforated peptic ulcer in Ege University General Surgery Department, between June 1999 and May 2013 were included in this study. The clinical data concerning the patient characteristics, operative methods, and complications were collected retrospectively. One hundred seventy-five of the 239 patients were male (73.2%) and 64 were female (26.8%). Mean American Society of Anesthesiologists (ASA) score was 1 in the patients without morbidity, but mean ASA score was 3 in the morbidity and mortality groups. Primary suture and omentoplasty was the selected procedure in 228 of the patients. Eleven patients underwent resection. In total, 105 patients (43.9%) had comorbidities. Thirty-seven patients (67.3%) in the morbidity group had comorbid diseases. Thirteen (92.9%) patients in the mortality group had comorbid diseases. Perforation as a complication of peptic ulcer disease still remains among the frequent indications of urgent abdominal surgery. Among the analyzed parameters, age, ASA score, and having comorbid disease were found to have an effect on both mortality and morbidity. The controversial subject in the present study is regarding the duration of symptoms. The duration of symptoms had no effect on mortality nor morbidity in our study.

Success of microvascular surgery; repair mesenteric injury and prevent short bowel syndrome: a case report

BackgroundSuperior mesenteric injury is a rare entity but when it occurs, short bowel syndrome is one of the uninvited results of the emergency surgical procedures.Case presentationWe present a 19-year-old boy with blunt abdominal trauma which caused serious mesenteric injury. Because ultrasound revealed free intraabdominal fluid, he underwent emergency laparotomy. Adequate vascularization of approximately 20 cm of proximal jejunal segment and approximately 20 cm of terminal ileum was observed. Nevertheless, the mesentery of the rest of the small intestine segments was ruptured completely. We performed an end-to-end anastomosis between a distal branch of the superior mesenteric artery in the mesentery of the ileal segment and a branch of the superior mesenteric artery using separate sutures of 7.0 monofilament polypropylene. The patients gastrointestinal passage returned to normal on the postoperative day 2. He recovered without any complication and was discharged from hospital on the postoperative day seven.DiscussionIn this case report, we emphasize the importance of preservation of injured mesenteric artery due to abdominal trauma which could have resulted in short bowel syndrome.

Glasgow coma scale and APACHE-II scores affect the liver transplantation outcomes in patients with acute liver failure.

BACKGROUND The timing and selection of patients for liver transplantation in acute liver failure are great challenges. This study aimed to investigate the effect of Glasgow coma scale (GCS) and APACHE-II scores on liver transplantation outcomes in patients with acute liver failure. METHOD A total of 25 patients with acute liver failure were retrospectively analyzed according to age, etiology, time to transplantation, coma scores, complications and mortality. RESULTS Eighteen patients received transplants from live donors and 7 had cadaveric whole liver transplants. The mean duration of follow-up after liver transplantation was 39.86+/-40.23 months. Seven patients died within the perioperative period and the 1-, 3-, 5-year survival rates of the patients were 72%, 72% and 60%, respectively. The parameters evaluated for the perioperative deaths versus alive were as follows: the mean age of the patients was 33.71 vs 28 years, MELD score was 40 vs 32.66, GCS was 5.57 vs 10.16, APACHE-II score was 23 vs 18.11, serum sodium level was 138.57 vs 138.44 mmol/L, mean waiting time before the operation was 12 vs 5.16 days. Low GCS, high APACHE-II score and longer waiting time before the operation (P<0.01) were found as statistically significant factors for perioperative mortality. CONCLUSION Lower GCS and higher APACHE-II scores are related to poor outcomes in patients with acute liver failure after liver transplantation.

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.

Management of iatrogenic bile duct injuries: Multiple logistic regression analysis of predictive factors affecting morbidity and mortality

OBJECTIVE Iatrogenic bile duct injuries remain a challenge for the surgeons to overcome. The predictive factors affecting morbidity and mortality are important for determining the best management modality. MATERIAL AND METHODS The patients who referred to Ege University Faculty of Medicine after laparoscopy associated iatrogenic bile duct injury are grouped according to Strasberg-Bismuth classification system. The type and number of prior attempts, concomitant complications, and treatment modalities are analyzed using the SPSS version 18 (IBM, Chicago, IL, USA). The variables with p<0.10 were considered for univariate analysis and then evaluated for predictive factors by forward Logistic Regression method using multiple logistic regression analysis. RESULTS According to the analysis of 105 patients who were referred during 2004-2014, the type and number of prior attempts are considered predictive factors in sepsis. In multiple logistic regression analysis, abscess formation, concomitant vascular injury, and serum bilirubin level are significantly effective in predicting mortality. CONCLUSION The management of iatrogenic bile duct injuries should be carefully planned with a multidisciplinary approach. The predictive factors affecting morbidity and mortality are important in determining the best modality for managing iatrogenic bile duct injuries. Abscess formation, vascular injury, and serum bilirubin level are the potential risk factors. Therefore, we can strongly recommend immediate assessment of patients for prompt diagnosis and referring to an HPB center, to avoid further injuries.

Results of 1001 liver transplantations in 23 years: Ege University experience

BACKGROUND/AIMS Liver transplantation (LT) is now the standard of care for most end-stage liver diseases. Over the next 30 years, advances in medicine and technology will greatly improve the survival rates of patients after this procedure. The aim of the present study was to analyze retrospectively the results of 1001 patients withLT. MATERIALS AND METHODS Medical reports of 989 patients were analyzed retrospectively. Data were obtained from the patients data chart. Descriptive statistics were used to describe continuous variables (mean, median, and standard deviation). RESULTS A total of 1001 LTs for 989 recipients were performed at Ege University Organ Transplantation and Research Center between 1994 and 2017. Therewere 639 male and 350 female recipients. Among 1001 LTs, there were 438 deceased donors and 563 living donors. The age interval of the patients was 4 months to 71 years old. The median Model for End-Stage Liver Disease score was 20. There were 12 deceased liver donors using the split method. There were 12 cases subject to retransplantation. In living donor LT grafts, 423 right lobes, 46 left lobes, and 94 left lateral sectors were used. In the first monitoring,the total annual mortality rate was 130 cases (13%). The mortality rate in retransplantation was found to be 66%. A 1-year survival rate of 87% was generally stablished. CONCLUSION LThas been improving consistently over the last two decades. Ege University is one of the biggest liver transplant centers in Turkey for both technical and educational perspective.