Oktay Tekesin

Garlic oil and Helicobacter pylori infection

PBC. In 1989, a 45-yr-old woman was admitted to the hospital because of right upper quadrant abdominal pain, asthenia, anorexia, and weight loss in the previous 3 months. On physical examination, irregular hepatomegaly was noticed. There were no palpable adenopathy or splenomegaly. Laboratory data showed elevation of alkaline phosphatase and were otherwise within normal limits. Abdominal ultrasonography and CT scan disclosed several space-occupying lesions in right and left hepatic lobes. Fine-needle aspiration of one of these lesions was informed as metastases of poorly differentiated carcinoma. An extensive search of a primary tumor was unsuccessful. An exploratory laparotomy was performed; liver nodules and hilar adenopathy were noticed. Pathological examination of adenopathy showed a large B-cell lymphoma (centroblastic lymphoma). Extent of disease was evaluated with a chest CT scan and a bone marrow biopsy that were normal. The patient was treated with eight cycles of chemotherapy (cyclophosphamide, doxorubicin, vincristine, and prednisone); a complete remission of liver lesions was observed. Six years later, she complained of arthralgia, pruritus, and Raynaud’s phenomenon. Antimitochondrial antibodies were positive (1/1280), and a percutaneous liver biopsy showed an inflammatory process of the portal triads with focal ductal injury, compatible with stage I PBC. Signs of malignant infiltration were not appreciated. In our patient, the diagnosis of PHL in assumable in the absence of liver histology, in view of the clinical and radiological presentation, the response to therapy with long lasting remission, and the evidence of lymphomatous involvement of the hilar lymph nodes. Unfortunately, we cannot elucidate whether PBC was present when the patient was first seen, for liver biopsy and antimitochondrial antibodies were not performed. We believe that, although our case does not fulfill the strict criteria proposed by Caccamo et al. (2), it should be considered as a PHL, because extension to affected lymph nodes probably reflects local dissemination.

hydatid acute pancreatitis: a rare complication of hydatid liver disease. Report of two cases

Acute pancreatitis (AP) is known to be a rare complication of hydatid disease. We present two cases of AP due to intrabiliary ruptured hydatid cysts of the liver. High serum and urine amylase levels and ultrasonographic findings, compatible with AP, were detected. On ultrasonography and computed tomography dilated bile ducts and cystic masses in the liver were seen. A communication between the bile ducts and a cyst in one case, and a total common bile duct obstruction with hydatid material in the other case, were seen on endoscopic retrograde cholangiopancreatograms. The patients were treated surgically with mainly omentoplasty. Recovery was uneventful. A diagnosis of AP should be kept in mind in patients with hydatid liver disease presenting with upper abdominal pain.

Gossypiboma Mimicking a Distal Pancreatic Mass: Report of a Case

Gossypiboma (retained surgical sponge) is a pseudotumor within the body that is composed of non-absorbable surgical material with a cotton matrix. Because the symptoms of gossypiboma usually are nonspecific and may appear years after surgery, the diagnosis of gossypiboma may be difficult because the condition may mimic a benign or malignant soft-tissue tumour in the abdomen and pelvis. A 61-year-old woman with a one-year history of left upper-quadrant pain and weight loss was referred to our center. She had undergone peptic ulcer perforation 23 year ago. Physical examination revealed dullness and palpable mass in the left upper abdomen. On examination by computed tomography (CT), a hypodense mass of 12 cm in diameter between the greater curvature of the stomach, pancreas, and splenic hilus was detected. Upon exploration, a mass lesion of 10 cm in diameter was detected between the greater curvature of the stomach and splenic hilus, which caused dense adhesions not in communication with the pancreas. It was excised and a splenectomy was performed. After a macroscopic examination, the mass lesion was diagnosed as gossypiboma. Although ultrasonography (US), CT, angiography, and magnetic resonance imaging (MRI) may be used to diagnose gossypiboma, definitive diagnosis is possibile only upon surgery or histopathological examination. As a result, when an abdominal mass is observed, surgeons should carefully investigate the patient’s past surgical history while taking the possibility of gossypiboma into consideration.

Magnetic compression anastomosis for patients with a disconnected bile duct after living-donor related liver transplantation: a pilot study.

BACKGROUND AND STUDY AIM We present the use of the magnetic compression anastomosis (MCA) technique for treatment of disconnected bile duct after living-donor related liver transplantation (LDLT) using the recently introduced through-the-scope magnet. PATIENTS AND METHODS The MCA technique was used in patients with disconnected bile duct who could not be treated with either percutaneous or endoscopic procedures. All patients already had a percutaneous external biliary drainage catheter before the procedure. The magnet was placed percutaneously into the proximal side of the obstruction by pushing a 5-Fr catheter over a guidewire. Concurrently, endoscopic retrograde cholangiopancreatography (ERCP) including endoscopic papillary sphincterotomy was performed. The sister magnet was then carefully advanced to the opposite side of the obstruction with a 5-Fr catheter over a guidewire. After the confirmation of biliary recanalization, a guidewire was passed through the stricture and a percutaneous dilation of the stricture was performed with a balloon-tipped catheter. Endoscopic balloon dilation of the stricture, insertion of two plastic stents and the removal of the internal drainage catheter were performed during the first ERCP session. Stent exchange and multiple side-by-side stent placements were planned at regular intervals (3 monthly) for all patients. RESULTS A total of six LDLT patients with disconnected bile duct (aged 37 - 68, four men) underwent the MCA technique between September 2014 and July 2015. Biliary recanalization was achieved 13 - 42 days after the magnet placement procedure. The success rate of the procedure was 100 %. CONCLUSIONS The MCA technique using a small magnet (diameter 2.4 mm) is effective and useful in LDLT patients with disconnected bile duct.

The effect of trimetazidine on intrahepatic cholestasis caused by carmustine in rats

This study investigated the effect of trimetazidine (TMZ), known as an anti-oxidant agent, on intrahepatic cholestasis caused by Carmustine (BCNU) in rats. Rats were assigned into four groups. The first group (Saline) consisted of 12 rats, which were injected with 2 ml/kg of saline intraperitoneally (IP) 48 h before the study. The second group (corn oil group, n=15), which were injected with 2 ml/kg of corn oil IP 48 h before the study. The third group (BCNU group, n=16), which were injected with 2 ml/kg of corn oil+25 mg/kg BCNU IP 48 h before the study. The fourth group (TMZ group, n=12), which were injected with 2.5 mg/kg per day of TMZ IP, administered at the same hour of the day as a single-dose. Twelve hour after the first dose of TMZ, corn oil 2 ml/kg+BCNU 25 mg/kg IP were injected, and the rats were included in the study 48 h after the administration of corn oil+BCNU. Following a pentobarbital anaesthesia, abdomen was opened with incision, a cannula was placed into the channel of choledocus, and the amount of bile was measured per hour. Then intracardiac blood sample was taken, and consequently centrifuged to obtain the plasma. Finally, the rats were killed with cervical dislocation, and their livers were removed and weighted. In addition to histopathological examination of liver, the levels of malon dialdehyde (MDA), oxidised glutation (GSSG), and reduced glutation (GSH) were detected. Also the osmolality of bile and plasma was estimated in mOsm/kg. As a result, the biliary flow was seen to decrease in BCNU group (P<0.005), but to be normal in TMZ group. The serum level of conjugated biluribin was higher in BCNU group compared to other groups (P<0.05 for each). Although the level of total glutation was lower (P<0.005) in TMZ group, GSH/GSSG ratio was normal. These findings suggest that TMZ has a protective effect on intrahepatic cholestasis caused by BCNU.

Gastric Metastasis of Renal Cell Carcinoma 5 Years after Left Radical Nephrectomy: A Case Report

Gastric metastasis of renal cell carcinoma (RCC) is unusual and few cases have been reported in the literature. We here report a 63 years-old male with multiple gastric and concomitant other organ metastasis of RCC 5 years after left radical nephrectomy. He presented with iron deficiency anemia without any gastrointestinal symptom. Radyological imagings showed multipl polypoid masses in the stomach and metastatic tumors in pancreas, lung and bilateral adrenal glands. Esophagogastroduodenoscopy showed multiple gastric “volcano-like” polypoid masses in the stomach. Histopathological examination and immunohistochemical staining showed the features of metastasis of clear cell carcinoma.

Efficacy of Endoscopic Nasobiliary Drainage in Consecutive 100 Patients: A Single Center Experience

Objective: The aim of this retrospective study was to assess the efficacy of endoscopic nasobiliary drainage (ENBD) at a tertiary referral center. Methods: Patients who had been performed ENBD were included in the study. Results: ENBD was performed in 100 patients (53 female, median age: 46 (17-84)) with biliary leak (n=30), cholangitis (n=67), and iatrogenic duodenal perforation (n=3). The most common etiologies for biliary leak were laparoscopic cholecystectomy (LC) (n=19) and orthotopic liver transplantation (OLT) (n=8). The most common site of biliary leak was found to be cystic duct stump (15/19, 79%) in LC patients, and biliary anastomosis in OLT patients (6/8, 75%). All of the patients with biliary leak (n=30) underwent to endoscopic papillary sphincterotomy (EST). Healing of biliary leak was observed in all patients. Viscous pus in the bile was observed during ERCP procedure in all patients with cholangitis. The most common etiologies for cholangitis were malignant biliary obstruction (n=21), benign biliary stricture (n=18), and bile duct stone (n=14). Of the 67 patients with cholangitis, EST was performed in 64 (95.5%) patients. Recovery was achieved, and second ERCP session or surgical treatment was applicable in all 67 patients with cholangitis. Conclusions: ENBD with EST is efficient and safe to treat both the postoperative biliary leaks and the lifethreating cholangitis, and gives chance to perform subsequent definite treatments in patients with cholangitis.

Fractured esophageal self-expandable metallic stent in a patient with advanced lung cancer: a case report and review of the literature

Self-expandable metallic stents (SEMS) are the currently recommended treatment modality for palliation of dysphagia resulting from unresectable malignant esophageal obstruction. The most common post-SEMS-placement complications are migration, perforation, bleeding, and tumor ingrowth or overgrowth. We report herein a patient with advanced lung cancer invading the esophagus with the very rare late complication of spontaneous stent fracture 8 months after esophageal SEMS placement, together with a comprehensive review of the related literature. To the best of our knowledge, this is the first report describing the spontaneous fracture of an esophageal SEMS inserted for the palliative treatment of malignant esophageal obstruction due to extrinsic invasion by lung cancer.

A severe case of esophageal ulcer causing a tight stricture despite long-term D-penicillamine treatment

SummaryD-penicillamine has long been used in the management of rheumatic diseases due to the effects on inhibition of collagen synthesis. Herein, we report a severe case of esophageal ulcer causing a tight stricture extending through the distal esophagus despite the long-term D-penicillamine treatment in a patient with Wilson’s disease. D-penicillamine would theoretically be expected to contribute to the healing of an esophageal ulcer. However, the drug failed to have a favorable outcome, which is notable and worth reporting.ZusammenfassungD-Penicillamin wird seit Langem bei der Behandlung rheumatischer Erkrankungen wegen seiner Kollagensynthese-hemmenden Wirkung verwendet. Wir berichten über einen Patienten mit Wilson’scher Erkrankung, bei dem trotz Langzeitbehandlung mit D-Penicillamin ein schweres Ulkus des Ösophagus mit einer Striktur auftrat, die sich über den distalen Ösophagus ausbreitete.Theoretisch würde man erwarten, dass D-Penicillamin zur Heilung eines Ösophagusulkus beiträgt. Es erscheint uns bemerkenswert und einer Publikation würdig, dass bei unserem Fall dieses Medikament keine günstige Entwicklung des Ösophagusulkus bewirkte.

Patients with Ectopic Papilla of Vater, Bulbar Stenosis and Choledocholithiasis: A New Syndrome?

Patients with Ectopic Papilla of Vater, Bulbar Stenosis and Choledocholithiasis: A New Syndrome? Galip Ersoz, Omer Ozutemiz, Sinan Akay, Oktay Tekesin Introduction: Ectopic localization of papilla of Vater and/or stenosis at duodenal bulb may cause challenges in the cannulation of papilla and the endoscopic treatment of the biliary diseases. Twelve patients with biliary stones, stenosis and deformity at the duodenal bulb, and papilla ectopically located at duodenal bulb or junction of the first and second parts of the duodenum; and their endoscopic management are presented here. Patients All of the patients were male, median age was 46 (35-52). In eight (%67) of the patients, there were accompanying stones in the gall bladder. One of the patients was diagnosed as secondary biliary cirrhosis. In none of the patients, there were symptoms related to duodenal stenosis. In 9 (%75) of the 12 patients the duodenoscope could not be advanced beyond the bulbus into descending duodenum because of the mechanical obstruction and deformity. The stenotic parts in the bulbus were dilated with TTS balloons with diameters ranging from12 to18 mm. Thus, ectopic papillae could be reached in all of the cases. Papilla could not be cannulated in one patient (%8) and in the remaining 11 cases, biliary stones ranging from 6 to 14 mm were detected with cholangiography. Since the site of the sphincterotomy and distal common bile duct (CBD) indentation could not be evaluated, papillary orifice and distal CBD were dilated with balloons starting from a 4 mm diameter and increasing the diameter of the balloons stepwise to 4 to 15 mm. In 6 (%50) of the patients, the stones could be extracted in the same endoscopy session with the cholangiography. In 3 (%25) of the patients, stones could be extracted in a second session and in the remaining 3 (%25), the endoscopic treatment for the biliary stones had failed. In one of the patients, after dilatation of CBD with a 12 mm balloon, retroperitoneal perforation in the intrapancreatic segment of the CBD occured and he was operated. No other major complication occured. Conclusion The shared features which may constitute a new syndrome of the presented cases are 1) male gender 2) ectopic location of the papilla 3) deformity and stenosis in the bulbus 4) presence of stones in the CBD. Bile duct stones can be treated with endoscopic balloon dilatation of distal CBD and papilla, bearing in mind that a serious complication such as perforation might be encountered.