Pınar Sarkut

Gallbladder polyps: Factors affecting surgical decision

AIM To determine the factors affecting the decision to perform surgery, and the efficiency of ultrasonography (USG) in detecting gallbladder polyps (GP). METHODS Data for 138 patients who underwent cholecystectomy between 1996 and 2012 in our clinic with a diagnosis of GP were retrospectively analyzed. Demographic data, clinical presentation, principal symptoms, ultrasonographic and histopathological findings were evaluated. Patients were evaluated in individual groups according to the age of the patients (older or younger than 50 years old) and polyp size (bigger or smaller than 10 mm) and characteristics of the polyps (pseudopolyp or real polyps). χ(2) tests were used for the statistical evaluation of the data. RESULTS The median age was 50 (26-85) years and 91 of patients were female. Of 138 patients who underwent cholecystectomy with GP diagnosis, only 99 had a histopathologically defined polyp; 77 of them had pseudopolyps and 22 had true polyps. Twenty-one patients had adenocarcinoma. Of these 21 patients, 11 were male, their median age was 61 (40-85) years and all malignant polyps had diameters > 10 mm (P < 0.0001). Of 138 patients in whom surgery were performed, 112 had ultrasonographic polyps with diameters < 10 mm. Of the other 26 patients who also had polyps with diameters > 10 mm, 22 had true polyps. The sensitivity of USG was 84.6% for polyps with diameters > 10 mm (P < 0.0001); however it was only 66% in polyps with diameters < 10 mm. CONCLUSION The risk of malignancy was high in the patients over 50 years old who had single polyps with diameters > 10 mm.

Functional health literacy in a group of Turkish patients: A pilot study

Abstract Background: There is currently no objective original measure developed in the Turkish language for evaluating health literacy. However, some instruments originally developed in Western countries and translated into Turkish do exist. Aims: The aim of this study was to translate and adapt the Test of Functional Health Literacy (TOFHLA) into the Turkish language and validate it among a group of Turkish patients. Methods: Interviews were held in an outpatient clinic. Illiterate patients, those with previously diagnosed mental illness and inadequate visual acuity were excluded. Results: Internal consistencies of the reading comprehension and numeracy items were 0.89 and 0.77, respectively. Inadequate health literacy was determined in 28.0% of participants, marginal in 30.0%, and adequate in 42.0%. Among the possible socio-demographic predictors of health literacy, the most significant predictor was the educational level. Participants with lower levels of education had significantly lower levels of health literacy. In general, reading comprehension scores were lower than the numeracy scores. The most disadvantaged groups were women and older people (≥40 years of age) because of their lower levels of education. Discussion: The TOFHLA in the Turkish language seems to be a valid measure. Functional health literacy was found to be inadequate or marginal. Without enhancing the overall educational level, especially of women, efforts to improve health literacy seem to be ineffective. Conclusions: Functional health literacy is related to education. Non-written visual materials should be considered as a temporary solution to improve health literacy in populations with low literacy.

Gender does not affect the prognosis of Fournier’s gangrene: a case-matched study

BACKGROUND Female gender is accepted as a poor prognostic factor for Fourniers gangrene (FG). However, there is a paucity of data in the literature regarding this matter. This case-matched study was designed to investigate the impact of gender on outcomes of FG. METHODS Study patient data were retrieved from 120-patient, prospectively maintained database. Thirty-two female patients with FG were case-matched to 32 male patients based on symptom duration (days), FG severity index score, patient age, etiology, and presence of diabetes mellitus (DM) terms. Outcomes of FG were compared between the 2 groups. RESULTS Median age was 57 years (range: 22-80 years), and 35 (54.7%) patients had DM. Patients underwent average of 3 debridement procedures (range: 1-9 debridements), and 15 (23.4%) received diverting stoma. Overall mortality rate was 28.1% (18 of 64 patients). Female gender was associated with widespread disease (p=0.009), increased need for consecutive debridements (p=0.005), prolonged length of intensive care unit stay (p=0.035), and increased requirement for split-thickness skin graft reconstruction (p=0.040). However, mortality rates were comparable between genders (p=0.264). CONCLUSION FG is often more extensive in females and seems to be associated with anatomical features of female pelvis. However, female gender is not a factor affecting prognosis of patients with FG.

Primary thyroid lymphoma.

Primary thyroid lymphoma is an uncommon thyroid malignancy. The treatment modalities significantly differ from other thyroid malignancies. Frequently it is accompanied by Hashimotos thyroiditis, and it may be difficult to differentiate the two entities histologically. Patients typically present with suddenly growing mass in the thyroid gland. Discrimination between primary and secondary lymphoma is important due to variations in diagnostic tools, treatment modalities and prognosis. Surgery, chemotherapy, radiotherapy or combinations of these modalities may be applied in treatment. In this report, three cases with primary thyroid lymphoma in which three different treatment modalities have been applied are presented.

An extremely rare cause of gastric outlet: breast lobular carcinoma metastases to stomach.

A 47-year-old female was admitted with complaints of epigastric abdominal pain, nausea, vomiting, and weight loss that started 3 months ago. Gastroscopy evaluation revealed gastric outlet obstruction due to chronic ulceration in the pyloric region. Endoscopic biopsy samples reported chronic active inflammation. Her physical examination revealed a mobile and solid mass about 2 9 2 cm in size on the upper-outer quadrant of the left breast, and a palpable lymph node of 1.5 cm in diameter on the left axilla. Computerized contrast tomographic imaging revealed a focal density area over the upper-middle of the left breast, about 2.5 cm in diameter, and lymph nodes in the left axilla. Circumferential wall thickening at the pyloric level with distention was observed in abdominopelvic computerized tomography. Patient was operated with antrectomy-truncal vagotomy-gastroenterostomy procedure. A pathologic evaluation reported massive tumoral mass at the distal gastric localization with infiltration to periserosal adipose tissue (T3) and the local invasion pattern was similar to gastric carcinoma with primary neuroendocrine differentiation. Immunohistochemistry showed that carcinoma cells were positive for CK7, ER, PR, GCDFP-15 and Ecadherin was negative (Fig. 1). The patient underwent mastectomy operation in the same hospitalization period after she had clinically stabilized from the first operation. Modified radical mastectomy operation was performed. Pathologic evaluation demonstrated a 3 9 2 9 1.2 cm mass, which histopathologic findings correlated as lobular carcinoma. Immunohistochemical staining was positive for ER, PR, GCDFP-15, and negative for E-cadherin and cerbB2 (Fig. 2). Thirty-one metastatic lymph nodes and one benign lymph node were obtained on axillary dissection. Postoperative follow-ups were all normal and the patient was discharged at the end of the first month. Surgical oncology council opted for the patient to take chemotherapy and hormonotherapy in the postoperative period. Gastrointestinal metastases generally emerge after several years in patients with breast cancers. This period ranged from 5 to 20 years and even 30 years, after the diagnosis of primary breast cancer (26). Symptoms are generally nonspecific in patients with gastric metastasis. Metastases of lobular breast carcinoma are generally characterized by diffuse infiltration of stomach, and radiologic imaging studies may reveal linitis plastica pattern (12,13,14). Metastatic infiltration of the stomach is generally limited to the submucosa or seromuscular layer. Because of this, histopathologic diagnosis must include deep biopsies. Immunohistochemical staining of metastatic breast carcinomas is generally CK7-, GCDFP-15-, CEA-, estrogen receptor (ER)and progesterone receptor (PR)-positive, and CK-20-negative. Among gastrointestinal malignancies, only those of the gastric, colorectal, pancreatic, and transitional cell carcinomas are CK-20 positive, unlike breast carcinomas, which are all are CK-20-positive (17). Survival rates for gastrointestinal metastases of the breast are generally lower than 2 years in most patients (26). The survival rate was better in patients after Address correspondence and reprint requests to: Pinar Sarkut, MD, Department of General Surgery, Uludag University School of Medicine, 16059 Gorukle, Bursa, Turkey, or e-mail: pinartasar@gmail.com

Coexistence of gastric multiple neuroendocrine tumors with unusual morphological features and gastric signet-ring cell carcinoma

The coexistence of signet-ring cell carcinoma and neuroendocrine tumors is very rare. We report a 57-year-old man who presented with a history of weight loss and nausea. Gastric mucosal biopsies obtained during gastrointestinal endoscopy revealed a gastric signet-ring cell carcinoma. The patient underwent a total gastrectomy with a standard D2 lymph node dissection. Ten individual tumors were detected in the resected specimen. Based on the histopathological and immunohistochemical findings, the final diagnosis was co-existing signet-ring cell carcinoma and neuroendocrine tumor. Spindle-shaped cells and extracytoplasmic mucin were noted in some tumor cells forming the neuroendocrine component. This case is a rare synchronous tumor because of its unusual neuroendocrine component.

The Views of Nurses On Nutritional Assessment And Nutritional Support of Hospitalized Patients

** D Kara Yılmaz, Öğr. Gör. Uludağ Üniversitesi Sağlık Yüksekokulu, Hemşirelik Bölümü, Bursa *** P Sarkut, Yrd. Doç.; S Kılıçturgay, Prof. Dr. Uludağ Üniversitesi Tıp Fakültesi, Genel Cerrahi Bölümü, Bursa Yazışma Adresi / Address for Correspondence: Pınar Sarkut, Yrd. Doç. Dr. Uludağ Üniversitesi Tıp Fakültesi, Genel Cerrahi Bölümü, 16059 Görükle / Bursa Tel.: 0 224 295 20 41 Faks: 0 224 295 00 99 e-posta: pinartasar@gmail.com **** F Düzgün, Uzm. Hem.; C Kuzu, Hemşire Uludağ Üniversitesi, Sağlık Uygulama ve Araştırma Merkezi, Bursa ÖZ Amaç: Bu araştırmanın amacı, hemşirelerin hastalarda nutrisyon değerlendirmesine yönelik görüşlerinin incelenmesidir. Yöntem: Araştırmanın evrenini bir üniversite hastanesinde yetişkin hastalara hizmet veren dâhili, cerrahi klinikler ve yoğun bakım ünitelerinde (genel cerrahi, reanimasyon, beyin cerrahi ve kalp-damar cerrahi) çalışan hemşireler oluşturmuştur (N:400). Araştırmanın örneklemini ise araştırmaya katılmayı gönüllü olarak kabul eden 334 hemşire oluşturmuştur. Araştırma verilerinin toplanmasında hemşirelerin tanıtıcı bilgilerini içeren ve çalıştıkları kliniklerde yapılan nütrisyon değerlendirmesine yönelik olarak görüşlerini belirlemek amacıyla araştırmacılar tarafından geliştirilmiş anket formu kullanılmıştır. Verilerin değerlendirilmesinde, ortalama ve yüzdelik değerler hesaplanmıştır. Bulgular: Araştırmaya katılan hemşirelerin yaş ortalamalarının 33.41±6.85 olduğu, %35’inin mesleki tecrübe yılının 5-10 yıl arasında olduğu ve %60.8’inin dâhili kliniklerde çalıştığı saptanmıştır. Hemşirelerin %46.4’ü çalıştıkları kliniklerde malnütrisyon görülme durumuna ilişkin fi krinin olmadığını, %49.7’si çalıştıkları kliniklerde nütrisyon sorunları üzerinde öncelikli olarak hekimlerin, %39.2’si hemşirelerin durduğunu belirtmişlerdir. Katılımcı hemşirelerin %37.4’ü nutrisyonel değerlendirmenin doktorlar tarafından, %23’ü diyetisyenler tarafından ve %15’i hemşireler tarafından yapıldığını belirtmiştir. Araştırmaya katılan hemşireler hastalarda etkin ve devamlı olarak nütrisyon değerlendirmesi yapmalarındaki en önemli engellerin iş yükü fazlalığı (%87.7) ve bilgi eksikliği (%41) olduğunu belirtmişlerdir. Sonuç: Araştırma sonucundan, hemşirelerin nütrisyon değerlendirmesinde etkin rol alamadıkları ve bunun en büyük nedeninin iş yükü fazlalığı olduğu bulunmuştur.

Retrospective analysis of clinicopathological features of solid pseudopapillary neoplasm of the pancreas

Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare neoplasm that accounts for 2–3% of all primary pancreatic neoplasms. This study aimed to characterize clinicopathological features associated with SPNs and to retrospectively evaluate the relationship of these features with predictive parameters associated with aggressive behavior. We reviewed 16 cases of SPN of the pancreas that had been diagnosed between 2005 and 2014 at our pathology department. A total of 16 cases, 15 female and one male, were evaluated in this study. The patient age ranged from 13 years to 63 years with a median of 35.70 years. The mean tumor diameter ranged from 2 cm to 18 cm with a mean diameter of 5.90 cm. We identified a significant association between the presence of clear cells and perineural invasion (p = 0.019), which was considered to be a predictive factor for aggressive behavior. Other features (i.e., localization, nuclear grooves, central hyalinization, myxoid stroma, eosinophilic bodies, foamy histiocyte aggregates, multinucleated cells, and calcification) were not significantly associated with predictive factors for aggressive behavior. One patient died as a result of a pancreatic fistula that developed as a postoperative complication. The remaining 15 patients are alive and have not demonstrated any signs of recurrence or metastasis. The current study suggested that the presence of clear cells might serve as a possible prognostic indicator of perineural invasion, which is a predictive parameter associated with aggressive behavior in SPN.

Can heat shock protein 32 be used for the early diagnosis of acute mesenteric ischemia

OBJECTIVE Acute mesenteric ischemia is a challenging and fatal disease. The aim of this study was to detect the heat shock protein 32 (HSP32) response in intestinal tissue and systemic blood to intestinal ischemia and ischemia/reperfusion to define a tool for the early diagnosis of acute mesenteric ischemia. MATERIAL AND METHODS Thirty female Wistar albino rats were equally divided into 3 groups. Group 1 rats underwent simple laparotomy and closure (control). In Group 2 rats, 1-hour intestinal ischemia followed by 5-hour reperfusion was performed, and Group 3 rats were subjected to 6-hour intestinal ischemia. The experiment was repeated with a 24-hour waiting period. At the end of the waiting period, blood was withdrawn from the tail veins of the rats and the rats were sacrificed via cardiac puncture. Re-laparotomy was subsequently performed and intestinal tissue and luminal samples were obtained for biochemical and pathological investigations. The HSP32 levels of intestinal tissues, luminal contents and blood levels were compared among the groups. RESULTS At the end of the 24-hour waiting period, the median tissue HSP32 levels were 0.43 (0-6.6) ng/mL for Group 1, 9.51 (2.5-49.9) ng/mL for Group 2 and 43.13 (6.3-121.3) ng/mL for Group 3 (p=0.001). The median blood HSP32 levels were 0.11 (0.1-1.4) ng/mL for Group 1, 0.42 (0.1-0.7) ng/mL for Group 2, and 0.25 (0.1-1.2) ng/mL for Group 3 (p=0.047). The HSP levels in the luminal contents were undetectable. CONCLUSION Both ischemia and ischemia/reperfusion significantly raised intestinal tissue HSP32 levels in comparison with the control group. However, this change was not reflected in the circulating blood or luminal contents.

Is stoma care effective in terms of morbidity in complicated ileostomies

Background Performing transient or permanent ileostomy is one of the common procedures involved in colorectal surgery. Complication rates up to 40% have been reported in ileostomies. In this report, the effect of specific stoma care unit on ileostomy and its complications were investigated. Methods A total of 141 patients, who were operated and underwent ileostomy, due to different causes, at Department of General Surgery, Uludağ University, Bursa, Turkey, between 2003 and 2006, were examined, retrospectively. Patient records were examined in terms of age, sex, surgery indications, urgent/elective state, benign/malign origin, ileostomy type, complications and stoma care, and education. χ2 test was used to compare the categorical data. Results Among the patients, 95 (67%) were male and 46 (33%) were female. The mean age was 47 years (17–67). Some of the subjects (49%) were operated urgently and some (51%) were under elective conditions. The ileostomy types used included the following: end ileostomy (43%), loop ileostomy (46%), and double-barrel ileostomy (11%). Permanent ileostomy was performed in 23 patients and transient ileostomy was performed in 118 patients. The patients were operated because of either benign (48%) or malign (52%) causes. Complications developed in 37 (26%) patients. The rate of development of complication was markedly higher in ileostomies performed under urgent conditions (61% vs 39%) (P<0.001). The complications included mucocutaneous separation (12 patients), maceration in the peristomal skin (ten patients), retraction (five patients), necrosis (three patients), prolapsus (three patients), and other metabolic complications (four patients). The complications were treated with care (68%) and surgical revision (32%). Conclusion The rate of ileostomy was found to be higher in the male patients compared to female patients. The risk of development of complications was found to be higher in ileostomies performed under urgent conditions. The most common complication observed was mucocutaneous separation. Ileostomy complications can be treated conservatively with professional care and education.