Varlık Erol

Spontaneous intestinal intramural hematoma: What to do and not to do

OBJECTIVE Spontaneous intestinal intramural hematoma is a rare complication of anticoagulant treatment. In this study, we retrospectively evaluated 14 patients with the diagnosis of intramural hematoma of the small intestine who were followed-up and treated in our clinic, and we aimed to determine current approaches in the diagnosis and treatment of intramural hematoma. MATERIAL AND METHODS Between February 2010-October 2012, 14 patients diagnosed with small intestinal intramural hematoma were retrospectively analyzed. Nine patients were followed due to clinical findings and 5 patients underwent operation with a histopathological diagnosis of intramural hematoma. RESULTS Abdominal computed tomography demonstrated ileal and jejunal wall thickening in 10 patients, while findings were consistent with mesenteric vascular disease in four. Five patients were operated due to mechanical bowel obstruction and acute abdomen. The other 9 patients were followed up with medical treatment and 8 of these patients were already using warfarin due to cardiac bypass and valve replacement. CONCLUSION Spontaneous intestinal intramural hematoma is a rare cause of small bowel obstruction due to intramural hematoma, which is encountered even more rarely. An intramural hematoma should be considered among differential diagnosis of patients who present with abdominal pain and symptoms of obstruction with a history of anticoagulant drug use and elevated International Normalized Ratio (INR) levels. Early diagnosis and medical follow-up can provide a good response to treatment in the majority of patients without requiring surgery.

Tiroid papiller mikrokarsinomlarında multisentrisite

Tiroid kanseri, endokrin organ kaynakli kanserler arasinda en sik gorulenidir (1,2). Tiroid kanserlerinin yaklasik %85’ini papiller tiroid kanseri olusturmaktadir. Papiller kanserlerin bir alt grubu olarak siniflandirilan ve ≤10mm tumorler olan ‘papiller mikrokarsinomlar’ tum papiller kanserlerin %30’unu olusturmakta ve daha az agresif davrandiklari kabul edilmektedir (2-5). Yuksek sagkalim oranlarina ragmen bazi hastalarda lokal nuks ve metastazlar ortaya cikmakta ve bu durum daha agresif bir cerrahi tedaviyi gerektirebilmektedir. Her ne kadar literaturde tanimlamasi konusunda kargasa mevcut ise de ‘tiroid kanserinde multisentrisite’, tiroid kanserinin, ayni tiroid lobunda veya iki lob icerisinde birden fazla yerde bulunmasi olarak tanimlanir (6). Gunumuzde yaygin olarak kullanilan tani yontemleri ile papiller mikrokarsinom tanisini ve multisentrik ozelligini belirlemek kolay degildir. Mikrokarsinomlar genellikle palpe edilemez ve klinik olarak sessiz seyretmektedir. Otopsi calismalarinda papiller mikrokarsinom gorulme orani bolgesel olarak degismekle birlikte %0.01-%35 arasinda bildirilmektedir ve bu oranlar cogu papiller mikroarsinomun benign davranisli oldugunu desteklemektedir (2,3,7,8). Cogu mikrokarsinom tanisi ise ‘tesadufi’ olarak benign davranisli tiroid hastaligi nedeniyle ameliyat edilen hastanin piyesinin patolojik incelemesi sonucu ortaya cikmaktadir. Gunumuzde daha yuksek cozunurluklu ultrasonografi ve ultrasonografide kusku duyulan, capi 1 cm’den kucuk nodullere uygulaARAŞTIRMA YAZISI

Complicated Meckel's diverticulum and therapeutic management.

OBJECTIVE This study aimed to investigate the treatment options and compare patient management with the literature for patients operated on for an acute abdomen who had complications due to inflammation of the Meckels diverticulum at our clinics. MATERIAL AND METHODS This study retrospectively evaluated 14 patients who had been operated on for acute abdomen and had been diagnosed with Meckels diverticulitis (MD) in Ege University Medical Faculty Department of General Surgery, between October 2007 and October 2012. RESULTS Fourteen patients with a diagnosis of Meckels diverticulitis (MD) were retrospectively analyzed. Radiologically, the abdominal computer tomography showed pathologies compatible with mechanical intestinal obstruction, Meckels diverticulitis and peridiverticular abscess, as well as detection of free air within the abdomen on direct abdominal X-ray. Among patients diagnosed with complicated Meckels diverticuli (obstruction, diverticulitis, perforation) 10 patients had partial small bowel resection and end-to-end anastomosis (71.5%), three patients underwent diverticulum excision (21.4%), and one patient underwent right hemicolectomy+ileotransversostomy (7.1%). CONCLUSION Meckels diverticulum is a vestigial remnant of an omphalomesenteric channel in the small bowel. It is a real congenital diverticular abnormality that contains all three layers of the small bowel. Surgical excision should be performed if Meckels diverticulum is detected in order to avoid incidental complications such as ulceration, bleeding, bowel obstruction, diverticulitis or perforation. Meckels diverticulitis does not have specific clinical and radiological findings. Delayed diagnosis can lead to lethal septic complications. Complications associated with Meckels diverticulitis, especially if a definite diagnosis is not made during the preoperative period, should be considered in the differential diagnosis. In the presence of a complicated diverticulum the appropriate treatment should be emergent surgical intervention.

Reliability of fine needle aspiration biopsy in large thyroid nodules

OBJECTIVE Fine needle aspiration biopsy provides one of the most important data that determines the treatment algorithm of thyroid nodules. Nevertheless, the reliability of fine needle aspiration biopsy is controversial in large nodules. The aim of this study was to evaluate the adequacy of fine needle aspiration biopsy in thyroid nodules that are four cm or greater. MATERIAL AND METHODS We retrospectively examined 219 patients files who underwent thyroidectomy for thyroid nodules that were greater than four centimeter between May 2007 and December 2012. Seventy-four patients with hyperthyroidism, and 18 patients without preoperative fine needle aspiration cytology were excluded from the study. Histopathologic results after thyroidectomy were compared with preoperative cytology results, and sensitivity and specificity rates were calculated. RESULTS False-negativity, sensitivity and specificity rates of fine needle aspiration biopsy of thyroid nodules were found to be 9.7%, 55.5%, and 85%, respectively. Within any nodule of the 127 patients, 28 (22.0%) had thyroid cancer. However, when only nodules of at least 4 cm were evaluated, thyroid cancer was detected in 22 (17.3%) patients. CONCLUSION In this study, fine needle aspiration biopsy of large thyroid nodules was found to have a high false-negativity rate. The limitations of fine-needle aspiration biopsy should be taken into consideration in treatment planning of thyroid nodules larger than four centimeters.

A rare cause of mechanical obstruction: Intestinal myeloid sarcoma

Myeloid sarcoma is a rare aggressive tumour that originates from immature extramedullary myeloid cells. It can be seen as a relapse in patients with acute myeloid leukaemia. Sometimes it can be seen in the form of a solid tumour without any evidence of leukaemia. A case of a 44-year-old male patient who was admitted with symptoms and signs of mechanical intestinal bowel obstruction was operated on. The operation findings showed small bowel obstruction due to a mass. The mass was then resected with end-to-end intestinal anastomosis. The resected mass pathology results were consistent with myeloid sarcoma. The post-operative period was uneventful and adjuvant therapy was applied. In this case report we aimed to evaluate the clinical signs and treatment modalities of small intestinal myeloid sarcoma.

Papillary thyroid cancer, macrofollicular variant: the follow-up and analysis of prognosis of 5 patients.

Objective. The main aim of this study was to comparatively analyze the recurrence and prognosis of this rare variant with the literature by analyzing the follow-up data of 5 patients diagnosed with papillary cancer macrofollicular variant. Methods. The demographic data, radiological and pathological data, and prognostic data of 5 patients who underwent surgery for thyroid cancer and were diagnosed with papillary cancer macrofollicular variant pathologically were retrospectively analyzed. Results. The mean age of patients whose mean follow-up period was determined as 7.2 years was 41, and the male/female ratio was 4/1. All patients underwent total thyroidectomy. The pathology report of 2 patients (40%) revealed macrofollicular variant of papillary microcancer, and 3 patients papillary cancer macrofollicular variant. Central dissection was performed in one patient (20%) due to macroscopic pathologic lymph node and 4 metastatic lymph nodes were reported. Also, locoregional recurrence was present in 3 out of 5 patients (60%). Conclusions. Although an impression of earlier and increased risk of recurrence in papillary carcinoma with macrofollicular variant has been documented, more studies with extensive follow-up times and large populations are required.