Yusuf Gunerhan

Carcinosarcoma of the gallbladder: Report of a case

Gallbladder carcinosarcoma is one of the rarest subsets of gallbladder malignancies. To date, only 34 cases have been reported in the English literature. Therefore the knowledge and experience regarding this disease is limited. This report describes a 70-year-old male patient who was diagnosed by documenting the epithelial and mesenchymal components with histopathological and immunohistochemical methods, and treated by a radical cholecystectomy. The pediculated polypoid tumor had filled the lumen, originating from the gallbladder fundus. The tumor infiltrated the surrounding connective and adipose tissue overlapping the muscular layer of its primary site, but had not perforated the serosa nor invaded the liver. The patient, who was treated only surgically, has remained healthy after 54 months of follow-up, which is the longest documented survival for this disease. This case indicates that curative treatment of a tumor confined to the gallbladder without liver or serosa invasion, or lymph node involvement, is therefore possible.

Intestinal obstruction due to spontaneous intramural hematoma of the small intestine during warfarin use: a report of two cases.

Warfarin-dependent spontaneous intramural hematoma of the small intestine is a rare complication. The first symptom is usually abdominal pain, frequently accompanied by nausea and vomiting. In some cases, concomitant gastrointestinal bleeding might be seen. Ultrasonography and computed tomography are the most useful radiographic methods for the diagnosis of an intramural hematoma of the intestines. Although it is usually treated conservatively, surgical intervention is required in cases involving active bleeding, intestinal obstruction, or acute abdominal symptoms. Here we present two patients who were treated surgically. Both patients had intestinal obstruction and ischemia, and one had concomitant gastrointestinal bleeding and intussusception due to an intramural hematoma.

Effects of N-acetylcysteine on regeneration following partial hepatectomy in rats with nonalcoholic fatty liver disease.

PurposeTo investigate the effect of N-acetylcysteine on regeneration following partial hepatectomy in rats with nonalcoholic fatty liver disease (NAFLD).MethodsN-Acetylcysteine was given to seven rats with NAFLD (group 1); physiological saline was given to seven rats with NAFLD (group 2); and physiological saline was given to seven rats with a normal liver (group 3). We performed two-thirds hepatectomy in all rats and removed the remnant liver tissue 48 h later to measure the mitotic index (MI), proliferating cell nuclear antigen, glutathione (GSH), and malondialdehyde (MDA) levels.ResultsMitotic index values were significantly higher in group 1 than in groups 2 and 3, and higher in group 3 than in group 2. Proliferating cell nuclear antigen values were significantly higher in group 1 than in group 2, but no significant difference was found in comparison with group 3. Glutathione values in group 1 were significantly higher than in group 2 and MDA values in group 1 were lower than in group 2. There was no significant difference between groups 1 and 3 in GSH and MDA values, in both the two-thirds hepatectomy and 48-h tissues.ConclusionsN-Acetylcysteine enhanced regeneration after partial hepatectomy in rats with NAFLD. We believe that it exerted this effect through its influence on oxidative stress.

The impact of preoperative immunonutrition and other nutrition models on tumor infiltrative lymphocytes in colorectal cancer patients.

AIM The importance of the alteration of tumor infiltrative lymphocytes (CD4(+), CD8(+), CD16(+), and CD56(+)) in colorectal cancer prognosis is well known. In this study, we analyzed the effect of preoperative immunonutrition and different nutritional models on the clinical condition of colorectal cancer patients. METHODS Twenty-eight colorectal cancer patients were grouped into 4 groups according to their nutrition regimens randomly and were given immunonutrition (IMN), standard enteral (SE), total parental nutrition (TPN), and normal nutrition (NN) regimens, all of which contained the same calorie-nitrogen content within a 7-day preoperative period. All patients had an endoscopic biopsy before and after the regimen, and the lymphocyte population infiltrating mucosal parts of the resected tumor tissue were evaluated. Immunohistochemical analysis of the tissue specimens was performed by staining with antihuman CD4(+), CD8(+), CD16(+), and CD56(+) antibodies. RESULTS After nutrition, there were significant increases in each of the 4 groups of CD4(+) and CD8(+) cells within the tumor. Comparing the rates of augmentation, the increased rates of the CD8(+) cells infiltrating the tumor after nutrition in the patients who were fed with IMN were significantly more than the ones in other groups (P = .01). CD16(+) cell infiltration was significantly higher in all groups except the SE and IMN groups. The SE group had increased CD56(+) cell infiltration compared with the other groups. CONCLUSIONS In the colorectal cancer patients who had nutrition in the 7-day preoperative period, except for the SE nutrition group, there were significant increases of infiltration of CD56(+) cells at the mucosal part of the tumor tissue within the CD4(+) and CD8(+) cell population. When postnutrition values were compared, there was a marked increase of CD8(+) cells in the IMN group.

The effect of ursodeoxycholic acid on liver regeneration after partial hepatectomy in rats with non-alcoholic fatty liver disease

Aim:  To investigate the effect of ursodeoxycholic acid (UDCA) on liver regeneration following partial hepatectomy in rats with non‐alcoholic fatty liver disease (NAFLD).

Effects of Unfractionated Heparin and Low-Molecular-Weight Heparin on Colonic Anastomoses in the Presence of Experimental Peritonitis

Background: We aimed at investigating the effects of unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) on the healing process of colonic anastomoses in the presence of peritonitis which is known to adversely affect the healing process. Study Design: Three groups of Wistar albino rats (n = 15 in each group) with experimental fecal peritonitis were studied. A 1-cm colonic segment was resected, and an end-to-end anastomosis was performed. The control group (group 1) was given no treatment; group 2 animals received 50 IU/kg s.c. UFH twice a day, and group 3 rats received LMWH at a dose of 1.5 mg/kg daily for 7 days postoperatively. Relaparotomy was done on day 7 in the surviving rats. The rats were sacrificed by resection of the colonic segment. The anastomosis bursting pressures were measured and the tissue samples from anastomosis lines were histopathologically examined. Results: The bursting pressures were significantly higher in UFH and LMWH groups as compared with the controls (p = 0.021 and p < 0.001, respectively), while there was no statistically significant difference between UFH and LMWH groups. Positive bacterial culture results were more common in controls (90%) than in the other two groups (p = 0.029 and p = 0.002, respectively). Also the polymorphonuclear leukocyte counts were higher (p = 0.005) and the fibrin formation more common (p = 0.007) in the controls. On the other hand, the number of fibroblasts was higher (p = 0.002) and collagen formation and revascularization more frequent (p = 0.001 and p = 0.001, respectively) in the UFH and LMWH groups. Conclusion: UFH and LMWH may have positive effects on the healing process of colonic anastomoses in the presence of peritonitis.

A rare ileal tumor causing anemia and intussusception: inflammatory fibroid polyp.

To the editor, A 41-year-old female patient with symptoms of severe abdominal pain, vomiting, diarrhea, rectal bleeding, and weight loss was sent to our endoscopy unit for a colonoscopy. The full blood count revealed hemogram 8.6 g/dL and hematocrit 28%. Colonoscopic investigation revealed a fragile and bleeding tumoral mass at the level of the cecum that obstructed the lumen completely (Figure 1a). At surgery, an ulcerated mass that localized at the final section of the ileum and invaginated to the colon was found. When the specimen was opened, an ulcerative 5-cm mass located 12 cm from the ileocecal valve was seen (Figure 1b). The histopathology evaluation of the specimen led to a diagnosis of inflammatory fibroid polyp (IFP) (Figure 2). Microbiological evaluation showed Actinomyces israelii in the tissue. The anemia recovered during postoperative follow-up.

Comparison of Meperidine Versus Hyoscine During Colonoscopy in the Elderly: A Prospective Randomized Study

BACKGROUND Colonoscopy is the gold standard in diagnosis of diseases of the colon. Sedation and antispasmodic agents are recommended during colonoscopy. Age is a limiting factor when the surgeon is deciding whether to use these medications or not. SUBJECTS AND METHODS One hundred twenty patients older than 65 years of age were randomized into two groups. The first group (n=60) received 2 mg of midazolam and 25 mg of meperidine intravenously. The second group (n=60) received 2 mg of midazolam and 20 mg of hyoscine N-butylbromide intravenously. The data collected were colonoscopy procedure time, time to cecum, visual analog pain scale, systolic blood pressure before and after the procedure, pulse, partial oxygen pressure, comfort of the endoscopist, the modified observers assessment of alertness/sedation scale, and morbidity. RESULTS Total colonoscopy and cecal reach times were shorter in Group 2 (19.58±4.82 minutes and 10.57±2.54 minutes, respectively) than in Group 1 (25.05±5.93 minutes and 13.78±3.37 minutes, respectively) (P<.001). The sedation score of Group 2 (4.52±0.50) was better than that of Group 1 (3.45±0.75) (P<.001). Nine patients (15%) in Group 1 experienced diaphoresis, temporary memory loss, or lip smacking. Three patients in Group 1 and 1 patient in Group 2 had hypoxia. Three patients in Group 1 had hypotension; this was seen in 1 patient in Group 2. One patient had perforation in Group 1. The visual analog scale score was 4.37±1.38, and the endoscopist satisfaction was 6.72±0.99 in Group 1, while these values were 3.95±0.81 and 7.75±0.89, respectively, in Group 2 (P>.05). CONCLUSIONS Use of midazolam and hyoscine N-butylbromide during colonoscopy is safe in the elderly and significantly reduces procedure time while increasing comfort for the endoscopist.

A comparison of single-port laparoscopic cholecystectomy and an alternative technique without a suspension suture

OBJECTIVE Many surgeons face difficulties during single-incision laparoscopic cholecystectomy (SILC) surgery and are forced to use an additional port. We compared the results of a technique that we developed with SILC. MATERIAL AND METHODS Fifty-four patients who were diagnosed with chronic cholelithiasis were prospectively randomized and divided into two groups. An additional 5-mm port (MCAP: with an additional port using a multi-channel device through the umbilicus) was placed in the subxiphoid area instead of a transabdominal suspension suture in one group of patients. The other group was operated on with the SILC technique. The demographic and surgical data of the patients were compared. RESULTS The MCAP technique shortened the surgery duration by more than half (MCAP: 35.0±12.3, SILC: 79.1±27.7 min) (p<0.05). No difference was found between the two methods in terms of estimated blood loss, length of hospitalization, postoperative day 1 and 7 visual analog scale scores, need for analgesia in the postoperative period, and rate of changing to another technique due to inadequacy of the surgical technique. CONCLUSION MCAP is as safe as SILC for cholecystectomy and is easier for the surgeon to perform.

Effects of hemoperitoneum on wound healing and fibrinolytic activity in colonic anastomosis.

BACKGROUND We aimed to test whether hemoperitoneum has adverse effects on colonic anastomosis healing by increasing fibrinolytic activity. METHODS After colonic intersection and anastomosis, 20 Wistar Albino rats received intraabdominal injections of either 25 mg/kg blood (10, Group 1) or physiologic saline (10, Group 2). Anastomotic bursting pressures were measured after sacrifice on the fifth day. Following histopathological evaluation of the anastomotic line, hydroxyproline, tissue plasminogen activator (tPA), plasminogen activator inhibitor-1 (PAI-1), and tPA/PAI-1 complex levels were determined in the omentum, lung and anastomotic colon. RESULTS Mean anastomotic bursting pressures of Groups 1 and 2 were 224.5 mmHg and 254.4 mmHg (p=0.121), and mean hydroxyproline levels were 45.89 and 65.959 mg/g protein, respectively (p=0.257). Histopathology was insignificant. There was a significant difference between groups in omental tPA levels (0.962 ng/ml and 0.27 ng/ml, p=0.041), but not in PAI-1 and tPA/PAI-1. Anastomotic line and lung levels of tPA, PAI-1 and tPA/PAI-1 complex were not significantly different between groups. The relation between anastomotic line tPA level and bursting pressure was highly significant in Group 2 (r=0.778; p=0.008). CONCLUSION In this first study on the effect of hemoperitoneum on colonic anastomosis, we observed no significant effect on anastomotic healing or fibrinolytic activity, except in the omentum. Further studies with different blood volumes and assessment times are needed.