Taner Ozkececi

A giant mesenteric fibromatosis case presenting with mechanical intestinal obstruction and successfully resected with partial duodeno-jejunectomy and right hemicolectomy

The term “desmoid” was coined by Muller in 1838 and is derived from the Greek word “desmos”, meaning band or tendon.1 Mesenteric fibromatosis accounts for approximately 0.03% of all malignant and benign neoplasms.2 It often arises from the abdominal wall or the extremities of parous women. It can also originate, though rarely, from the mesentery.3 It may be locally aggressive but does not metastasize. Its biological behavior is similar to that of fibrous lesions and fibrosarcoma. The most common symptoms are abdominal pain, nausea, vomiting, abdominal mass on palpation, weight loss, and fever. The tumor may lead to complications such as small bowel or ureteric obstruction, intestinal perforation, enterocutaneous fistula, and intestinal hemorrhagia.4,5 A 57-year-old male presented to our hospital with complaints of abdominal pain, vomiting, distension, and swelling. The patient had been suffering abdominal discomfort for five years and had undergone two colonoscopic examinations in those five years, but no disorders had been found. Abdominal examination revealed distension, a metallic sound, muscular rigidity, and tenderness. X-ray examination revealed multiple air-fluid levels (Figure 1). An abdominal ultrasound showed a large solid mass in the right upper quadrant of the abdominal region. Since the intravesical pressure was measured as 25 cm H2O, the patient was diagnosed with mechanical intestinal obstruction, and laparotomy was performed following fluid and electrolyte replacement and antibiotic treatment. Abdominal exploration revealed an elastic hard tumor of 8×10 cm in diameter that appeared to originate from the jejunal mesentery, involving the third and fourth parts of the duodenum, the proximal jejunum and the ascending colon. The ascending colon, the proximal jejunum and the anterior face of the involved parts of the duodenum were surrounded by the mass. Thus, by right hemicolectomy, the first 60 cm massive small intestine and partial duodenum were exised to resect the mass en bloc. The proximal small bowel segment was anastomosed to the transverse colon in an end-to-side fashion, and the duodenum was sutured transversely. The postoperative course was uneventful, and the patient was allowed to go home on the eighth postoperative day. Figure 1 X-ray films showing multiple air-fluid levels Microscopic examination revealed tumor cells, showing infiltrative progress in adipose tissue (Figure 2). The tumor cells had pale eosinophilic cytoplasm and were embedded in a collagen network interrupted by fibrotic sections, but mitosis was not seen (Figure 3). Immunohistochemical analysis showed that the tumor cells expressed vimentin and actin (Figure 4) but not S100, desmin, CD34 or CD117. Macroscopic examination, microscopic examination and immunohistochemical features were suggestive of an intraabdominal desmoid tumor. Figure 2 Tumoral tissue infiltrating the adipose tissue (H&E×20) Figure 3 Microscopic image showing cell groups with fusiform nucleus that is forming bundles (H&E×100) Figure 4 Severe positivity with vimentin antibody in the cell cytoplasm immunohistochemically Desmoid tumors are the most common primary tumors of the mesentery and constitute about 3.5% of all fibrous tissue tumors3,4 The difference in sex distribution is statistically insignificant, but there is a slightly higher incidence of this tumor in women than in men.7 There are two forms: the sporadic or primary form and the secondary form. The sporadic or primary form is extremely rare and is a variant of a benign stromal neoplasm of fibroblast-myofibroblast origin. It is usually secondary to trauma or hormonal stimulation or associated with familial polyposis coli or Gardner’s syndrome. Desmoid tumors have been seen in about 10% of familial adenomatous polyposis cases.8 At present, desmoid tumors are clinicopathologically classified into three types: abdominal, extra-abdominal and intra-abdominal.9 Desmoids of the abdominal wall are proliferative fibrous tumors, and extra-abdominal desmoids (desmoids outside the abdominal wall) are histologically the same as abdominal desmoids. Extra-abdominal desmoids are different in that they are usually invasive and spread even to areas surrounding deep blood vessels and nerves; in addition, they are difficult to remove completely and are likely to recur after surgery. Trauma may be a major factor precipitating the onset of this type of tumor. A definite episode of trauma has been noted in a high percentage of cases (19–63%).10 Accidental blunt injuries, lacerations, intramuscular injections, fractures, and different endocrine or genetic factors have also often been implicated.11 In the present case, symptoms were sporadic, and the patient had no previous history of any of the above conditions. Imaging techniques such as abdominal USG and CT are the most useful means for determining the exact localization of the tumor. In CT scans, a solid lesion is observed as a mass with soft tissue density.12 Most mesenteric tumors are large and appear in women in their reproductive years, often during or after pregnancy.6 Regression of these tumors has been associated with menopause and menarche.13,14 Lim et al. investigated the incidence and binding characteristics of the cytosol estrogen receptor and found that estrogen receptors were present in 33% of the desmoid tumors assayed.15 The signs and symptoms of mesenteric fibromatosis are insidious and usually manifest when there is a large palpable tumor resulting in abdominal discomfort or pain. Weight loss and symptoms of ureteral obstruction, mesenteric ischemia, or intestinal obstruction were observed in this patient. Mechanical intestinal obstruction is extremely rare, and we have seen only one previous case in the literature. Gastrointestinal stromal tumors, lymphomas, carcinoid tumors, fibrosarcomas or inflammatory fibroid polyps should be considered in the differential diagnosis.16 Histologically, desmoid tumors are composed of long sweeping fascicles of differentiated fibroblastic cells with ill-defined cytoplasmic borders, delicately staining nucleoli, and rare mitosis. Unfortunately in some cases, the differential diagnosis between fibromatosis and well-differentiated fibrosarcoma (Grade I) is difficult.17 A variety of treatments, including wide surgical excision, non-steroidal anti-inflammatory drugs, antiestrogens, radiotherapy and cytotoxic chemotherapy have been attempted, but the efficacy of most of these is unpredictable. Treatment modalities other than surgical excision are controversial. Surgery should be performed by radical resection with wide margins, but these tumors are often unresectable because of massive involvement of adjacent vital structures. Wide excision is recommended, as these tumors have a tendency toward local recurrence.1,3–7,10,12,16 The principal chemotherapy drugs used are vinblastine, methotrexate, doxorubicin, dacarbazine and carboplatin. In addition, it has been shown that tamoxifen, either alone or in combination with indomethacin, has produced a good response.1,18 Despite radical surgery and adjuvant radiotherapy, recurrence rates in most studies can be in the range of 25–50%.19 However, recurrent disease can be resected, and patients may live for extended periods with recurrent disease, especially in cases of sporadic desmoids. In addition, Kollevold et al. have reported that a desmoid tumor temporarily regressed after salpingo-oophorectomy in a patient with breast cancer.20 Moreover, Baliski et al. have proposed that neoadjuvant treatment with doxorubicin and radiotherapy with delayed surgery is a better option than surgery alone.19 To the best of our knowledge, this is the first documented case of successful margin-negative resection of jejunal mesenteric intraabdominal fibromatosis by combined partial duodeno-jejunectomy and right hemicolectomy. The effects of radiation therapy on treatment are not obvious, but several reports have advocated that complete regression may be achieved using dose levels greater than 50 Gy. Furthermore, Nuyttens et al. have also reported that radiotherapy or surgery with radiotherapy results in a significantly lower local recurrence rate.12,21 Objective response was seen in 52% of patients with desmoid tumors treated with endocrine therapy.16 These tumors infiltrate the surrounding tissue and lead to severe morbidity and death. The frequency of local recurrence following excision is high, ranging from 10–90%. The significance of margins is a very controversial topic. Some studies suggest that margins are significant for predicting recurrence, while others claim that they are of no prognostic value.22,23 The patient presented in this report had a small bowel obstruction caused by mesenteric fibromatosis and underwent only an aggressive surgical operation without any postoperative adjuvant therapy. The patient has shown no signs of recurrence at present, 30 months after surgery. As a result, we may say that intra-abdominal desmoids are very rare and benign tumors but are very aggressive and should be considered in the differential diagnosis of mechanical intestinal obstruction.

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.

Internal herniation through the foramen of Winslow: a rare cause of bowel obstruction

An 80-year-old male patient was admitted with nausea, vomiting and abdominal pain persisting for 1 week. The patient’s medical history showed no malignancies, previous surgery, trauma or weight loss. The physical examination showed peritoneal tenderness and widespread abdominal distention. Laboratory examinations showed no sign of pathologies, except leukocytosis (14 000/mm). Abdominal computed tomography showed widespread small intestine dilation and intra-abdominal free air, and the patient underwent emergency surgery (Fig. 1). Intra-abdominal exploration showed that the terminal ileum and cecum (in part) were herniated into the bursa omentalis through the foramen of Winslow. Kocher’s manoeuvre was used to reduce herniated loops. Perforation foci secondary to ischaemia were detected in the 10-cm herniated small bowel loop (Fig. 2). Perforated intestinal loops were resected, and right colonic fixation was performed. The patient did not have any complications in the post-operative period, and was discharged on day 8. Herniation through the foramen of Winslow (HFW) is a rare type of herniation, and is usually not considered in the differential diagnosis in the preoperative period; still, it causes significant morbidity and mortality. HFW constitutes 0.1% of all abdominal hernias, and 8% of all types of internal herniation. The rate of preoperative diagnosis is quite low, and the diagnosis is usually made intraoperatively. Because of delays in diagnosis and treatment, mortality rates up to 50% have been reported. HFW was described for the first time in 1834 by Blandin, and is an extremely rare type of internal herniation. To date, approximately 200 cases have been reported. Under normal conditions, the foramen of Winslow is closed due to intra-abdominal pressure. The predisposing factors in

Results of the open surgery after endoscopic basket impaction during ERCP procedure

AIM To report the results of open surgery for patients with basket impaction during endoscopic retrograde cholangiopancreatography (ERCP) procedure. METHODS Basket impaction of either classical Dormia basket or mechanical lithotripter basket with an entrapped stone occurred in six patients. These patients were immediately operated for removal of stone(s) and impacted basket. The postoperative course, length of hospital stay, diameter of the stone, complication and the surgical procedure of the patients were reported retrospectively. RESULTS Six patients (M/F, 0/6) were operated due to impacted basket during ERCP procedure. The mean age of the patients was 64.33 ± 14.41 years. In all cases the surgery was performed immediately after the failed ERCP procedure by making a right subcostal incision. The baskets containing the stone were removed through longitudinal choledochotomy with the stone. The choledochotomy incisions were closed by primary closure in four patients and T tube placement in two patients. All patients were also performed cholecystectomy additionally since they had cholelithiasis. In patients with T-tube placement it was removed on the 13(th) day after a normal T-tube cholangiogram. The patients remained stable at postoperative period and discharged without any complication at median 7 d. CONCLUSION Open surgical procedures can be applied in patients with basket impaction during ERCP procedure in selected cases.

Kolesistektomi sonrası kolestaz nedeni olarak Dubin-Johnson sendromu; Olgu sunumu ve literatür incelemesi

Dubin Johnson syndrome (DJS), also known as Sprinz-Nelson syndrome is a hereditary disease characterized by conjugated hiperbillirubinemi induced by chronic mild stress. DJS are frequently diagnosed during late adolescence and early adulthood. The patients apply with an itching jaundice, vague abdominal pain, nausea and vomiting. Physical examination is usually accompanied by jaundice, but sometimes hepatomegaly can find out. The disease is usually indolent and does not cause chronic liver failure. Although rifampicin and usodeoksikolik acid may be used in a therapy, the optimal treatment is not still found out. In this article we presented DJS to cause of persistent conjugated hiperbillirubinemi in patient undergoing laparoscopic cholecystectomy because of symptomatic cholelithiasis with literature data

Our results of lower gastrointestinal endoscopy: evaluation of 700 patients.

OBJECTIVE Although radiological imaging modalities like barium enema and computed tomography provide some clues, endoscopic methods still maintain superiority in assessment and differential diagnosis of large intestinal symptoms and complaints that require biopsy. We aimed to present the results of colonoscopic procedures performed in our general surgery clinic in detail. MATERIAL AND METHODS Seven hundred patients who presented to Afyon Kocatepe University, Faculty of Medicine, Department of General Surgery Endoscopy Unit between January 2011 and July 2012 with an indication for colonoscopy were retrospectively evaluated. RESULTS Out of the 700 patients enrolled in the study 356 (50.8%) were male while 344 patients (49.2%) were female. The mean age of the patients was found to be 49 years. Within the group of 700 patients who underwent colonoscopic examinations, the terminal ileum and cecum have been reached on the first attempt in 432 patients (61.7%) and colonoscopic success has been achieved. Results of colonoscopies performed on 700 patients in our clinic revealed malignancy in 42 (6%) patients, and all of these patients were treated surgically in our clinic. Mortality was not observed in this series. Procedure-related bleeding and perforation developed in 6 patients. One patient developed respiratory arrest due to sedation and patient was responsive to resuscitation. The complication rate in our series was 1%. CONCLUSION In the study where we revised our own clinical experience, we found that our success rate was lower than the literature, and our complication rate was higher. The main reasons are accepted as our colonoscopy units being young and the low patient volume.