Omer Yalkin

Mean platelet volume as a potential prognostic marker in patients with acute mesenteric ischemia–retrospective study

IntroductionWe investigated prognostic parameters of patients who underwent surgical intervention for acute mesenteric ischemia by evaluating demographic characteristics and laboratory data on admission.MethodsThe hospital records of 30 patients who underwent surgical interventions due to acute mesenteric ischemia between January 2008 and December 2012, were reviewed retrospectively. The records were investigated with regard to demographic data, the presence of co-morbid diseases, presenting complaints, time elapsed between symptom onset and hospital admission, laboratory findings at admission, findings at surgical exploration, surgical methods used, and treatment outcomes. The patients were divided into two groups, according to death (Group 1) or survival (Group 2), and the two groups were compared in terms of the specified parameters.ResultsOf the patients, 15 were male (50%) and 15 female (50%); their mean age was 71.4 (29–94) years. Abdominal pain was the chief complaint in all patients (100%) and mean time from pain onset to hospital admission was 21 (1–72) h. In abdominal exploration, total small bowel (SB) ischemia and necrosis was found in 6 (20%) patients and other patients had subtotal SB, segmental SB, segmental SB with colon, or isolated colon ischemia. Treatment in 15 patients (50%) ended in mortality. Mean age (p = 0.038), urea (p = 0.002), AST (p < 0.001), ALT (p < 0.001), mean platelet volume (MPV; p = 0.002), and amylase (p = 0.022) levels in Group 1 were significantly higher versus Group 2, whereas Ca (p = 0.024) and albumin (p = 0.002) levels were significantly lower.ConclusionsIn this study, unlike other parameters that have been shown to be of prognostic significance in mesenteric ischemia, MPV values at presentation were higher among non-survivors than survivors.

Rare entity: Ectopic liver tissue in the wall of the gallbladder - A case report

Ectopic liver tissue (ELT) is a rare condition, which is usually not diagnosed preoperatively, but coincidentally during abdominal surgery. While the location of ELT can vary, it is usually localized on the gallbladder wall or in close proximity. ELT is associated with various complications, a major complication being extrahepatic hepatocellular carcinoma. A 59-year-old female underwent elective surgery for chronic cholecystitis with stones. During laparoscopic exploration, a 2-cm-diameter ELT was detected in the anterior gallbladder wall and a laparoscopic cholecystectomy was performed. The case is presented due to the rare nature of ELT and as a reminder of ELT-related complications.

A rare etiology of acute abdominal syndrome in adults: Gastric volvulus - Cases series.

INTRODUCTION Gastric volvulus is a rare surgical emergency with a high mortality rate that requires urgent surgical management. PRESENTATION OF CASE A 19-year-old male and 51-year-old female patient underwent emergency surgery with a prediagnosis of acute abdomen syndrome, and a 60-year-old female patient underwent elective surgery due to diaphragmatic hernia. Abdominal exploration revealed gastric volvulus together with perforation in received emergency surgery patients, and a mesenteroaxial gastric volvulus due to diaphragmatic defect in third patient. DISCUSSION Gastric volvulus is classified into four subgroups depending on the mechanism of development, and organoaxial form is the most common type of gastric volvulus. The most challenging step in diagnosing gastric volvulus is the consideration of this diagnosis. CONCLUSION Preoperative diagnosis is often difficult, and its management involves surgical correction of the pathology followed by institution of resuscitative treatment.

A case of achalasia presented with cardiopulmonary arrest.

Achalasia is a rare disorder characterised by obstruction of the distal oesophagus and subsequent dilation of the proximal oesophagus. Patients generally complain of gastrointestinal symptoms; however, pulmonary symptoms and complications may also occur. A 35-year-old woman was brought to our emergency service complaining of sudden-onset dyspnea that started 15 minutes earlier during dinner. She suffered a cardiopulmonary arrest due to aspiration 5 minutes after being admitted to the emergency room and was intubated. Thoracic computed tomography examination showed that her oesophagus was filled with undigested food. Heller cardiomyotomy and Dor fundoplication was performed via laparotomy with the diagnosis of primary achalasia, and she was discharged as uneventful on the 5th postoperative day.

Acute appendicitis presenting with small intestinal obstruction findings - 2 cases report

Olgu Sunumu / Case Report Altıntoprak ve Ark. Acute Appendicitis and Small Intestinal Obstruction Sakaryamj 2014;4(2):89-92 90 Giriş Acute appendicitis is the most common emergency surgical condition in worldwide. Clinical findings of acute appendicitis that are accepted as ‘typical’ are only seen in 60% of all patients. In other patients, various non-typical clinical findings are encountered. Small intestinal obstructions are another surgical situation frequently encountered by emergency departments. Intestinal obstructions are generally seen in their mechanical form, and their etiology is most commonly postoperative adhesions. Acute appendicitis rarely presents in small intestinal obstruction findings. The reason for intestinal obstruction in acute appendicitis is generally adhesions due to periappendicular inflammation or localized/generalized peritonitis due to a perforated appendix. However, since the appendix is a mobile organ, its location may change inside the abdomen, and in cases of inflammation it may adhere to surrounding tissues causing a subsequent mechanical obstruction, as seen in one of the cases in this report. In this article 2 appendicitis cases with intestinal obstruction are reported. Case 1: A sixty-eight-year-old woman with abdominal pain and vomiting complaints consulted the emergency unit on the fourth day of her complaints. No abdominal operation were present in her medical history. Abdominal distension and diffuse tenderness were present in her physical examination, and intestinal sounds were increasing. Leukocytosis was present according to whole blood count, which was 12 x 10/mm. Intestinal-type air-fluid levels were detected by abdominal graphy, and subsequently a computed tomography (CT) scan was performed. According to CT, dilatation was present in all segments of the small intestine, and inflammation was present in the pericecal area (Figure 1a). In operation, perforated appendicitis and a paralytic obstruction secondary to the inflammation in the terminal ileum were determined (Figure 1b). Appendectomy was performed following abscess drainage, and the patient was discharged on the third day postoperation without complications. Case 2. A forty-two-year-old man with abdominal pain and vomiting complaints consulted the emergency unit on the second day of his complaints. Abdominal distension, diffuse tenderness and defance were present in his physical examination, and intestinal sounds were increasing. Small intestinal-type air-fluid levels were detected by direct abdominal graphy. Leukocytosis was present according to the whole blood count, which was 18 x 10/mm. The patient had no medical history of abdominal initiations, and a CT scan with oral contrast material was performed. According to the CT a sudden narrowing was present in the small intestinal lumen of the terminal ileum, and the intestinal segments proximal to this point were dilated (Figure 2a). With a primary diagnosis of acute mechanical obstruction, the patient underwent emergency surgery. During surgical exploration, a long appendix and acute appendicitis were discovered; after leaving the cecum, the appendix wrapped around the ileum loop and mesenterium like a napkin ring, and adhered to the cecum once more. It was determined that the reason for intestinal obstruction was the mechanical pressure exerted by the appendix on the ileal loop (Figure 2b and c). The operation was terminated following appendectomy. The patient was discharged on the third day post-operation without complications. Figure 1: Abdominal CT; a) dilatation was present in all segments of the small intestine, and inflammation was present in the pericecal area (arrows). This appearance suggest that a perforated appendicitis. Intraoperative appearance; b) perforated appendicitis and intense inflammation seen. Figure 2: (a) Abdomen CT; a) It’s the dilatation in proximal intestine segments and partial stricture on ileum level seen (arrow). No inflamation symptom or free fluid in the abdomen. Intraoperative appearance; b-c) It’s the adhesion of long appendix to intestine mesentery depending on inflamation and its ileum segment compAltıntoprak ve Ark. Acute Appendicitis and Small Intestinal Obstruction Sakaryamj 2014;4(2):89-92 91 Discussion: Acute appendicitis is the most frequent acute abdominal syndrome etiology of abdominal surgeries. The probability of a person developing acute appendicitis during their lifetime has been calculated as 7%. A careful medical history and a detailed physical examination are the basic tools in the diagnosis of acute appendicitis. The presence of leukocytosis in laboratory test results is a supportive finding in the diagnosis. Despite these diagnostic tools, radiological monitoring is needed for diagnosis in approximately one third of all patients. On the other hand, intestinal obstructions form 20% of all emergency surgical operations and 60% of these involve the small intestine.4 Post-operative adhesions are the most frequent cause of small intestine obstructions in adults, and are the first etiologic diagnosis considered in patients with intestinal obstructions and abdominal surgery history. Clinical findings of intestinal obstruction and leukocytosis were present in both the cases presented in our report upon initial consultation, but neither had a history of abdominal surgery. The presentation of acute appendicitis via intestinal obstruction findings is a rare situation and what is extremely rare is its appearance via a mechanical obstruction. The mechanism involved in these cases was first defined in 1901 and in 1908 it was classified into 3 sub groups: mechanical, septic, and combined types.5 Early and correct diagnosis of patients with mechanical small intestine obstruction is important for reducing morbidity and mortality. If the etiologic factor is acute appendicitis with suppressed clinical manifestations in a patient with delayed diagnosis of mechanical small intestine obstruction, the morbidity and mortality risk will no doubt increase by the hour. It is predicted that results will develop progressively, particularly in patients of advanced age; clinical manifestations occur more often in this age group. The importance of early diagnosis and definitive therapy may be better understood in light of one of our patients, who was in the >65 age group and had no clinical or radiological findings suggesting acute appendicitis. Acute appendicitis-dependent small intestine obstructions may be placed in 2 main categories, paralytic and mechanic, if the combined type comprising both situations together is put aside. Paralytic is the most common etiology, and the physiopathology may be defined as the reduction of peristalsis in the adjacent small intestinal segment caused by peri-appendicular inflammation. The physiopathology of mechanical causes is the mechanical pressure on the adjacent small intestinal segment. The etiology of the obstruction in our first patient was paralytic, whereas in our second patient it was mechanical, which is a very rare, as we mentioned above. Although detailed anamnesis, physical examination, laboratory tests, and conventional graphies aid in the diagnosis of obstruction in patients with obstructional findings, CT is a more sensitive method of diagnosis. The degree (completepartial), the level (small intestine-colon), and the etiology (intra-luminal/extra-luminal) of the obstruction and the presence of other accompanying intra-abdominal pathologies may be determined by CT. Balthazar et al. reported that the sensitivity, specificity, and accuracy of abdominal CT in the diagnosis of mechanical small intestine obstructions are 83%, 93%, and 91% respectively, and they remarked on the superiority of CT, especially in patients with small intestine obstructional findings with no clarified etiology despite clinical-biochemical or radiological examinations. Intestinal obstructional findings, leukocytosis, and intestinal-type air-fluid levels were present in both of our patients upon consultation, but abdominal CT scanning was needed since these findings did not suggest a specific diagnosis. The etiological cause in the first patient was perforated appendicitis, and it was discovered in the preoperative period via CT. In the second patient only obstruction of the terminal ileum level was determined via CT; the real diagnosis was determined during the operation. In conclusion, as the most frequent surgical acute abdominal syndrome etiology, appendicitis may appear with unexpected clinical manifestations depending upon appendix length, location inside the abdomen, and degree of inflammation, in addition to its known classical findings. Conflict of Interest : The authors declare that have no conflict interest Altıntoprak ve Ark. Acute Appendicitis and Small Intestinal Obstruction Sakaryamj 2014;4(2):89-92 92

Androgen Insensitivity Syndrome Diagnosed in an Elderly Patient During a Strangulated Inguinal Hernia Repair

Androgen Insensitivity Syndrome Diagnosed in an Elderly Patient during a Strangulated Inguinal Hernia Repair INTRODUCTION A strangulated inguinal hernia is a common indication for emergency surgery. In comparison, complete testicular feminization is a rare genetic disease that can present with an inguinal hernia because of ectopically positioned testicles. PRESENTATION OF CASE A 70-year-old female was admitted to the emergency service complaining of a painful swelling in the right inguinal region for 1 day. The physical examination indicated a strangulated inguinal hernia and surgery was performed. On exploring the inguinal region, a strangulated indirect inguinal hernia and hard 2 × 3-cm mass were detected. The histopathological examination of the excised mass showed testicular tissue, and complete testicular feminization (CTF) was diagnosed after further examinations. DISCUSSION Androgen insensitivity syndrome (AIS), the most frequent cause of male pseudohermaphroditism. The diagnosis of patients with AIS is usually made at the beginning of the second decade when a healthy person with a female phenotype complains of no menarche. Making a first diagnosis after the 5th decade is extremely rare. CONCLUSION While AIS can be diagnosed in early adulthood, cases might not bediagnosed until the patient is of advanced age.

Recurrent intestinal ischemia related to Behçet’s Disease

Behçets disease is a systemic inflammatory disease that may affect multiple organs. However, intraabdominal complications requiring surgical intervention are rare in the natural course of the disease. A 32-year-old male patient with Behçets disease who had been followed for 5 years with a diagnosis of acute abdominal syndrome was operated on twice in 18 days. Intestinal ischemia was identified in different segments of the jejenum during each operation. Recurrent segmental intestinal ischemia within a short time interval is rare, although the gastrointestinal involvement can be seen in the normal course of Behçets disease.

An Unusual Cause of Abdominal Pain: Three Lead Pellets within the Appendix Vermiformis

Most ingested foreign bodies usually pass out in the feces uneventfully. Complications such as intestinal perforation and bleeding usually occur with sharp, thin, stiff, long, and pointed objects. This case describes the management of three lead pellets within the appendix vermiformis. A 45-year-old male visited our clinic complaining of a 4-month history of abdominal pain. The patient inquiry revealed that he had eaten hunted rabbit meat on numerous occasions and had unintentionally ingested three lead pellets. Plain abdominal films and a barium enema showed foreign bodies in the right lower abdominal quadrant. Since the lead pellets were thought to have migrated extraluminally, they were removed through laparotomy under fluoroscopic guidance. An appendectomy was performed. Pathologically, three lead pellets were embedded in the appendix, which showed signs of intramucosal inflammation. Foreign bodies causing appendicitis are rare. However, if stiff or pointed objects enter the appendicular lumen, there is a high risk of appendicitis, perforation, or abdominal pain. An appendectomy was required to remove the ingested lead pellets in the appendix.

Retroanastomotic hernia after Moynihan's gastroenterostomy.

Retroanastomotic hernias after gastroenterostomies-either antecolic or retrocolic-are extremely rare but are associated with high mortality rates due to delayed identification which precludes immediate surgical reduction. In this report, we present a 77-year-old man with retroanastomotic herniation of the efferent loop segments that occurred 14 years after a Moynihans gastroenterostomy.