Tufan Egeli

Management of enteroatmospheric fistulae

A small‐bowel enteroatmospheric fistula (EAF) is an especially challenging complication for patients with open abdomens (OAs) and their surgeons. Manipulation of the bowel during treatment (e.g. dressing changes) is one of the risk factors for developing these openings between the atmosphere and the gastrointestinal tract. Unlike enterocutaneous fistulae, EAFs have neither overlying soft tissue nor a real fistula tract, which reduces the likelihood of their spontaneous closure. Surgical closure is necessary but not always easy to do in the OA environment. Negative pressure wound therapy (NPWT) has been used successfully as an adjunct therapy to heal the wound around EAFs. This review discusses many aspects of managing EAFs in patients with OAs, and presents techniques that have been developed to isolate the fistula and divert effluent while applying NPWT to the surrounding wound bed.

Comparison of Milan and UCSF criteria for liver transplantation to treat hepatocellular carcinoma

AIM To assess the validity of the Milan and University of California San Francisco (UCSF) criteria and examine the long-term outcome of orthotopic liver transplantation (OLT) in patients with hepatocellular carcinoma (HCC) in a single-center study. METHODS This study is a retrospective review of prospectively collected data. Between 1998 and 2009, 56 of 356 OLTs were performed in patients with HCC. Based on pathological examination of liver explants, patients were retrospectively categorized into 3 grou-ps: Milan + (n = 34), Milan -/UCSF + (n = 7) and UCSF - (n = 14). RESULTS Median follow-up period was 39.5 (1-124) mo. The 5-year overall survival rates in the Milan +, Milan -/UCSF + and UCSF-groups were 87.7%, 53.6% and 33.3%, respectively (P < 0.000). Within these groups, tumor recurrence was determined in 5.8%, 14.3% and 40% of patients, respectively (P < 0.011). Additionally, the presence of microvascular invasion within the explanted liver had a negative effect on the 5-year disease free survival (74.7% vs. 46.7%, P < 0.044). CONCLUSION The Milan criteria are reliable in the selection of suitable candidates for OLT for the treatment of HCC. For cases of OLT involving living donors, the UCSF criteria may be applied.

Microporous Polysaccharide Hemospheres and Seroma Formation After Mastectomy and Axillary Dissection in Rats

OBJECTIVE Seroma is the most common complication after breast surgery. Several methods have been proposed to prevent seroma, but none of these provided a significant effect. A prolonged wound healing process is the most important cause of seroma. Microporous polysaccharide hemospheres (MPH) are used to achieve hemostasis. They may also accelerate wound healing. In this study, the effects of MPH on seroma formation were investigated. MATERIAL AND METHODS Female Wistar rats weighing between 200 g and 250 g were used. There were eight rats in each of the control and study groups. Right breast mastectomy and axillary dissection were performed in all rats. While no application was performed after the operation in the control group, MPH was locally applied to the surgical site in the study group. Ten days after the operation, seroma fluid was aspirated and the total volume was recorded. The aspirates were analyzed and tissue samples were obtained from the surgical site. RESULTS Seroma was significantly lower in the study group (p=0.001). The mean albumin and lactate dehydrogenase levels were significantly lower in the study group (p=0.003). Pathological examination revealed that increase in fibrous tissue was significantly greater in the control group (p=0.032). CONCLUSION MPH may reduce seroma after mastectomy.

Validation of three breast cancer nomograms and a new formula for predicting non-sentinel lymph node status.

BACKGROUND The aim of the study was to evaluate the available breast nomograms (MSKCC, Stanford, Tenon) to predict non-sentinel lymph node metastasis (NSLNM) and to determine variables for NSLNM in SLN positive breast cancer patients in our population. MATERIALS AND METHODS We retrospectively reviewed 170 patients who underwent completion axillary lymph node dissection between Jul 2008 and Aug 2010 in our hospital. We validated three nomograms (MSKCC, Stanford, Tenon). The likelihood of having positive NSLNM based on various factors was evaluated by use of univariate analysis. Stepwise multivariate analysis was applied to estimate a predictive model for NSLNM. Four factors were found to contribute significantly to the logistic regression model, allowing design of a new formula to predict non-sentinel lymph node metastasis. The AUCs of the ROCs were used to describe the performance of the diagnostic value of MSKCC, Stanford, Tenon nomograms and our new nomogram. RESULTS After stepwise multiple logistic regression analysis, multifocality, proportion of positive SLN to total SLN, LVI, SLN extracapsular extention were found to be statistically significant. AUC results were MSKCC: 0.713/Tenon: 0.671/Stanford: 0.534/DEU: 0.814. CONCLUSIONS The MSKCC nomogram proved to be a good discriminator of NSLN metastasis in SLN positive BC patients for our population. Stanford and Tenon nomograms were not as predictive of NSLN metastasis. Our newly created formula was the best prediction tool for discriminate of NSLN metastasis in SLN positive BC patients for our population. We recommend that nomograms be validated before use in specific populations, and more than one validated nomogram may be used together while consulting patients.

Incidence of Late Acute Rejection in Living Donor Liver Transplant Patients, Risk Factors, and the Role of Immunosuppressive Drugs.

INTRODUCTION Late acute rejection (LAR) is a clinical manifestation that occurs 6 months after liver transplantation, shows histopathologic features different from those of acute rejection, and is the cause of a high prevalence of morbidity and mortality. METHODS In this study, hospital records of 211 living donor liver transplantation (LDLT) patients who underwent surgery in our clinic between June 2000 and February 2014 were reviewed retrospectively. The patients were ≥ 18 years old and were followed for ≥ 6 months. RESULTS Of the 211 patients, 21 (9.9%; 16 males, 5 females) developed LAR. The mean age of the patients was 46 years (range, 33-58). The mean follow-up period was 61.2 months (range, 6-152) and the median time to development of LAR was 26.4 months (range, 7-77). In our study, patients who received cyclosporine and mycophenolate mofetil (MMF) treatment developed more LAR than did patients who received tacrolimus and MMF therapy (P = .05). In addition, the incidence of LAR in patients who underwent LDLT was significantly greater in the ABO-matched groups than in the ABO identical group (P = .028). CONCLUSIONS Development of LAR and serious complications related to it can be avoided if liver transplant recipients are followed regularly and closely in outpatient clinics after transplantation.

Complications in Donors Using Right Liver Graft: Analysis of 280 Consecutive Cases

INTRODUCTION Living donor liver transplantation (LDLT) is performed with increasing frequency worldwide due to the shortage of donated organs. It is a life-saving procedure for the recipient, but, on the other hand, a major surgical procedure for healthy donors and it may cause morbidity and even mortality. PATIENTS AND METHODS This research was completed at Dokuz Eylül University Faculty of Medicine Hospital General Surgery Department Liver Transplant Unit and included 280 cases (4 with simultaneous liver and kidney transplants from living donors) who underwent donor right hepatectomy for LDLT from June 2000 to June 2016. We analyzed the data of patients retrospectively. RESULTS Of 280 donor right hepatectomies for LDLT, 181 were male (M; 64.6%) and 99 were female (F; 35.4%) (M/F: 1.82). Mean donor age was 31.2 ± 0.9 years (range, 18-56). Mean donor monitoring duration was 45 ± 2.4 months (range, 3-192 months). Mean body mass index (BMI) was 24.28 ± 2.96 kg/m2 (range, 18.1-32.42 kg/m2). In our study 72 cases (25.7%) developed postoperative complications. There were 17 Clavien grade 3A, 1 grade 3B, and 5 grade 4A complications and also 1 death due to pulmonary embolism. CONCLUSION Together with the increase in living donor surgery, the morbidity and mortality of these cases are becoming controversial. Full donor safety is only possible with appropriate donor choice requiring very detailed studies, a problem-free hepatectomy process, and close postoperative donor monitoring.

Evaluation of Pregnancy Outcomes After Liver Transplantation

Liver transplantation is increasing worldwide. Pregnancy after liver transplantation is considered to be well tolerated with favorable neonatal outcomes in cases of stable and sufficient graft function. In this study, our aim was to determine pregnancy and neonatal outcomes of patients after liver transplantation. Data for patients who had been followed-up by the liver transplantation clinic at the Dokuz Eylül University Medical Faculty Hospital, Turkey, between 2002 and 2016, and who had pregnancy after the transplantation were evaluated retrospectively. The earliest post-transplantation conception occurred after 22 months and the latest conception occurred after 108 months (mean, 55.4 months). Twenty-one pregnancies concluded with live births (100%). The mean birth week was 37.09. The earliest birth occurred at 27 weeks and the latest at 40 weeks. Mean birth weight was 2993 g (10th to 25th percentiles). No pregnancy-induced hypertension, pre-eclampsia, or gestational diabetes were observed in any patient. Five pregnancies concluded with premature birth. In conclusion, several complications may occur during pregnancy (such as hypertension or pre-eclampsia, etc) in patients with liver transplantation, but it seems that pregnancy has good effects on graft functions and the neonatal outcomes are favorable.

Solid-Pseudopapillary neoplasm of the pancreas: A clinicopathological review of 20 cases including rare examples

AIMS Solid-pseudopapillary neoplasm (SPN) is an uncommon malignant tumor of the pancreas with a favorable prognosis unlike other pancreatic neoplasms. We investigated the clinicopathological features of 20 patients with SPN in details. METHODS The patients diagnosed as SPN in Dokuz Eylul University Hospital between January 2005 and March 2016 were reviewed in terms of clinical and histopathological data. RESULTS Mean age of the patients was 33. Three of our cases were male and 4 were children. Some patients had synchronuous malignancies. Nine patients were diagnosed by fine needle aspiration cytology (FNAC). One of our tumors had 2×1mm of pancreas endocrine neoplasm in addition to SPN. One case had foci of atypical and multinucleated giant cells. All cases were positive for vimentin and CD10 antibodies and most were positive for PR and β-catenin. The mean follow-up duration was 40 mo (range 2-110 mo). Only one case showed liver metastasis. CONCLUSION Herein we present a series of 20 patients with 3 male and 4 pediatric cases, almost half of which were diagnosed with FNAC findings, and most of which are clinically being followed with one patient showing progression. Our series includes rare examples like collision tumor of SPN and pancreas endocrine neoplasm, SPN with multinucleated giant cells. Also cases with no surgical treatment and no progression, as well as cases with synchronous malignancies are presented. We believe that FNAC findings of any pancreatic mass should be investigated in detail for the designation of a therapy plan especially for the patients with high operation risks. The findings in our series also show that extensive necrosis, angioinvasion, perineurial invasion and larger tumor size might be predictive for worse prognosis and these patients should be more closely followed up.

Xanthogranulomatous appendicitis causing an endometrial abscess: radiological findings

SummaryXanthogranulomatous inflammation (XGI) is a rare chronic inflammatory condition most commonly involving the kidneys and gallbladder. The condition is histopathologically characterized by the presence of foamy histiocytes, lymphocytes, and plasma cells. A few reports describing appendicitis caused by XGI have appeared in the English-language literature. However, no study has yet focused on the imaging features of xanthogranulomatous appendicitis (XGA). We present a pathologically confirmed case of XGA with an endometrial abscess; the patient underwent ultrasonography, computed tomography, and magnetic resonance imaging. To the best of our knowledge, this is the first case of XGA with uterine and right adnexal involvement presenting as a complicated pelvic abscess on radiological imaging.ZusammenfassungDie xanthogranulomatöse Entzündung (XGE) ist eine seltene chronische Entzündung, die meist im Bereich der Nieren und der Gallenblase vorkommt. Histopathologisch ist sie durch schaumige Histiozyten, Lymphozyten und Plasmazellen charakterisiert. In der Englisch-sprachigen Literatur gibt es einige wenige Berichte über durch eine XGE ausgelöste Appendicitis. Allerdings liegen bis jetzt keine Berichte vor, die sich mit den bildgebenden Charakteristika dieser Erkrankung auseinandersetzen.Wir stellen einen histopathologisch gesicherten durch XGE ausgelösten Fall einer Appendicitis mit einem Abszess des Endometriums vor. Die Patientin wurde mittels Sonographie, Computertomographie und Magnetresonanz untersucht. Soweit wir wissen, ist dies der erste Fall einer durch XGE ausgelösten Appendicitis mit Befall des Uterus und der rechten Adnexe, wobei sich diese in der radiologischen Bildgebung als komplizierter Beckenabszess darstellte.

Mechanical Bowel Obstruction Due to Localized Extensive Amyloidotic Involvement in the Left Colon

Amyloidosis is a disorder caused by extracellular deposition of insoluble protein fibrils in various tissues. Colonic amyloidosis is a rare clinical manifestation which can mimic tumor, inflammatory bowel disease, or ischemic colitis. The most common symptoms of colonic amyloidosis include bleeding, ulceration, diarrhea, and abdominal pain. However, colonic obstruction due to extensive submucosal amyloidosis is extremely rare. Considering the wide variety of symptoms and potentially effected organs, the diagnosis can be challenging particularly in emergent conditions. In this paper, a case with mechanic bowel obstruction due to extensive amyloidotic involvement of the left colon is presented.