Amyloid goiter associated with amyloidosis secondary to rheumatoid arthritis.

Amyloidosis refers to a variety of conditions in which amyloid proteins are abnormally deposited in organs and/or tissues. The most common forms of systemic amyloidosis are primary amyloidosis (PA) of light chains and secondary amyloidosis (SA) caused by chronic inflammatory diseases such as rheumatoid arthritis (RA). Although involvement of the thyroid gland by amyloid is a relatively common phenomenon, clinically significant enlargement of the thyroid owing to amyloid deposition is a rare occurrence. In SA, the deposition of amyloid associated (AA) protein is associated with atrophy of thyroid follicles. The clinical picture of these patients is characterized by rapid, painless thyroid gland enlargement which may be associated with dysphagia, dyspnea, or hoarseness. Thyroid function is not impaired in most cases. Although amyloid goitre secondary to systemic amyloidosis due to chronic inflammatory diseases is relatively common, specifically related to RA is much more uncommon one and it is reported less in the literature. In this report, A 52-old-year female patient with amyloid goiter associated with amyloidosis secondary to rheumatoid arthritis is presented.

A modified method in laparoscopic peritoneal catheter implantation: the combination of preperitoneal tunneling and pelvic fixation.

Introduction. Continuous ambulatory peritoneal dialysis (CAPD) is widely accepted for the management of end-stage renal disease (ESRD). Although not as widely used as hemodialysis, CAPD has clear advantages, especially those related to patient satisfaction and simplicity. Peritoneal dialysis (PD) catheter insertion can be accomplished by several different techniques. In this study, we aimed to evaluate our results obtained with peritoneal dialysis catheter placement by combination of pelvic fixation plus preperitoneal tunneling. Material and Methods. Laparoscopic peritoneal catheter implantation by combining preperitoneal tunneling and pelvic fixation methods was performed in 82 consecutive patients with end-stage renal disease. Sex, age, primary disease etiology, complications, mean duration of surgery, mean duration of hospital stay, morbidity, mortality, and catheter survival rates and surgical technique used were assessed. Analysis of catheter survival was performed using the Kaplan-Meier method. Results. Mean follow-up period was 28.35 ± 14.5 months (range of 13-44 months). Mean operative time was 28 ± 6 minutes, and mean duration of hospital stay was 3 ± 1 days. There were no conversions from laparoscopy to other insertion methods. None of the patients developed serious complications during surgery or the postoperative period. No infections of the exit site or subcutaneous tunnel, hemorrhagic complications, abdominal wall hernias, or extrusion of the superficial catheter cuff was detected. No mortality occurred in this series of patients. Catheter survival was found to be 92% at 3 years followup. Conclusions. During one-year followup, we had seven patients of migrated catheters due to separation of pelvic fixation suture from peritoneal surface, but they were reimplanted and fixated again laparoscopically with success. Over a three-year followup period, catheter survival was found to be 92%. In the literature, similar catheter survival rates without combination of the two techniques are reported. As a conclusion, although laparoscopic placement of PD catheters avoids many perioperative and early complications, as well as increasing catheter free survival period and quality of life, our results comparing to other studies in the literature indicate that different laparoscopic placement methods are still in debate, and further studies are necessary to make a more accurate decision.

Duodenal somatostatinoma: a case report and review of the literature.

INTRODUCTION: About 70% of well-differentiated endocrine tumors arise from the gastrointestinal tract. Duodenal well-differentiated endocrine tumors account for only 2.6% of all neuroendocrine tumors. Following the first two case reports of somatostatin-secreting tumors in 1977, fewer than 200 cases of somatostatinoma have been reported. These tumors of the duodenum are usually silent and asymptomatic, but can cause gastrointestinal symptoms. Depending on the localization of the tumor, multiple surgical procedures can be performed, ranging from local resection to pancreaticoduodenectomy. CASE PRESENTATION: Here, we report a case of a submucosal duodenal mass in a 42-year-old Turkish White man presenting with nausea, vomiting, fatigue and abdominal pain. The treatment decision of pancreaticoduodenectomy made preoperatively was later altered to intraoperative removal via local resection with sphincteroplasty. CONCLUSION: Tumors of the periampullary region are considered highly malignant, and the Whipple operation is usually the only procedural treatment. In the current case, we decided not to perform pancreaticoduodenectomy but to excise the mass intraoperatively, and consequently avoided unnecessary resection of the pancreas and anastomosis to undilated hepatic and pancreatic ducts. This protective strategy prevented duodenum- and pancreas-related morbidity.

The identification of recurrent laryngeal nerve by injection of blue dye into the inferior thyroid artery in elusive locations.

Introduction. Thyroidectomy creates a potential risk for all parathyroid glands and the recurrent laryngeal nerve (RLN). The identification and dissection of the RLN is the gold standard for preserving its function. In some cases, it may be quite difficult to identify the nerve localization. In such elusive locations, we aimed to identify RLNs using peroperative injection of a blue dye into the inferior thyroid artery. Materials and Methods. This study included 10 selected patients whose RLN identification had been difficult peroperatively during the period from April 2008 to June 2009. When the RLNs became elusive in location, the branches of the inferior thyroid artery (ITA) on the capsule of the thyroid lobe were isolated, and then 0.5 mL isosulphan blue dye was injected into the artery. Results. RLN was carefully dissected in the tracheoesophageal groove. RLN was clearly visualized, in all patients. All RLNs were identified along their course in the dyed surrounding tissue. No RLN palsy was encountered. Conclusion. The injection of blue dye into the ITA branches can be used as an alternate method in case of difficulty in identification of RLNs.

Abdominal wall endometrioma; a 10-year experience and brief review of the literature.

BACKGROUND: Abdominal wall endometrioma is a rare condition, which usually develops in a surgical scar of Cesarean section or hysterectomy. Certain factors relating to knowledge of the clinical pattern of this disease make correct diagnosis and treatment difficult. The aim was to identify the different forms of presentation of this disease entity through publishing the results from our experience of surgical management of such lesions. METHODS: Patients diagnosed with abdominal wall endometrioma over a period of 10 y were identified from the comprehensive surgical database of our institution. The age, parity, symptoms, previous surgeries, initial diagnosis, diagnostic modalities, current operation, and recurrences were surveyed and analyzed. RESULTS: There were 40 patients with a mean age of 32.3 ± 5.2 y. All of the patients (100%, n = 40) had an abdominal mass in or adjacent to surgical scars. The main symptom was pain, noncyclic (45%, n =18), or cyclic (40%, n = 16) in nature. The mean duration of symptoms was 18.2 ± 23.4 mo. The preoperative diagnosis was correct in 47.5% (n = 19) of the cases. Surgical treatment failed in 3 cases (3/33, 9.1%), and the operations were performed once again. CONCLUSIONS: Abdominal wall endometriosis may be difficult to diagnose as it is comparatively an unfamiliar entity that has not received its due attention among general surgeons, so far. Therefore, in patients with a palpable subcutaneous mass in or around surgical scars with a history of violation of uterus, a thorough history and physical examination is necessary, and usually sufficient to make correct diagnosis of endometrioma.

MALT lymphoma of the rectum, presenting with rectal prolapsus: a case report.

Up to now, there have been only a few reported cases of Mucosa-associated lymphoid tissue (MALT) lymphomas arising in the rectum. Its clinical presentation is indistinguishable from that of rectal carcinoma but the treatment is apparently different. Symptoms of primary lymphomas involving the rectum include; anorexia, weight loss, change in bowel habits, obstruction, and bleeding. These symptoms are not disease specific and can be seen in many other gastrointestinal disorders. Patients with polypoid masses may present with obstruction symptoms. In this rare case, a female patient admitted to the emergency service with prolapsus of a rectal mass.The optimal treatment of rectal MALT lymphoma is not well defined yet, given the rarity of the disease. Surgical resection of the localized lesion and following adjuvant chemotherapy has proved to be an effective treatment option. However, a close and long-lasting follow-up is important.

Choice of the optimal pancreaticojejunal anastomosis technique: how can we improve patient safety in pancreatic surgery?

BACKGROUND/PURPOSE: The cause of the morbidity and mortality following pancreaticoduodenectomy (PD) in the surgical treatment of benign and malignant diseases of the periampullary region is leakage from the pancreaticojejunal anastomosis. The size of the main pancreatic duct and the texture of the remnant pancreas are very important factors for a secure pancreaticojejunal anastomosis. METHODS: A new technique was developed for patients having pancreatic ducts smaller than 3 mm and a hard remnant pancreas. RESULTS: Pylorus-preserving PD was performed for 28 patients who underwent PD at our hospital between January 2004 and January 2007, without mortality. The new technique was used in the 8 patients who had pancreatic ducts smaller than 3 mm and a hard remnant pancreas. With our new technique, different from other previously described techniques, the anastomosis was performed with the sutures passing from the cut-surface of the parenchyma of the pancreas. All patients were operated on by the same surgeon and surgical team. None of the patients developed a fistula. CONCLUSIONS: We believe that this anastomosis technique can be performed securely in patients having a hard remnant pancreas and a main pancreatic duct smaller than 3 mm.

H pylori: Treatment for the patient only or the whole family?

AIM: To compare the effects of treatment of H pylori-infected individuals with the effects of treatment of individuals as well as all H pylori-infected family members. METHODS: H pylori-positive patients with similar demographic specifications were prospectively randomized with respect to treatment, with a triple regimen of either patients and all H pylori-positive family members living togetherI (group I) or patients only (group II). Nine months after treatment, all patients were assessed for H pylori positivity. RESULTS: There were 70 H pylori-positive patients in each group; patients in groups I and II lived with 175 and 190 H pylori-positive relatives, respectively. Age, sex and H pylori positivity rate were similar in both groups of relatives. Nine months after 14 d standard triple therapy, H pylori positivity was 7.1% in group I patients and 38.6% in group II patients [P < 0.01, OR = 8.61 95% confidence interval (CI): 2.91-22.84]. CONCLUSION: The present results indicate bad environmental hygienic conditions and close intra-familial relationships are important in H pylori contamination. These findings indicate all family members of H pylori-positive individuals should be assessed for H pylori positivity, particularly in developing countries where H pylori prevalence is high; they also suggest patients, their spouses and all H pylori-positive family members of H pylori-positive individuals should be treated for H pylori infection.

Endolaparoscopic approach in the management of gastroesophageal reflux disease: an experimental study in pigs.

INTRODUCTION: Chronic reflux of gastric content to the esophagus causes retrosternal burning, pain, and regurgitation, and results in histopathologic changes that may culminate in adenocarcinoma. Insufficiency of the lower esophageal sphincter and hiatal hernia are the two principal causative factors. In this paper, we present the early results of a new antireflux operation in pigs. MATERIALS AND METHODS: The status of physiologic reflux was determined in 5 pigs (approximately 40-45 kg) with 24-hour pH monitorization. Under endoscopic guidance, a trocar was inserted into the stomach (similar to the percutaneous endoscopic gastrostomy technique). The endoscope was put into the retroflexed position; a mucomuscular pursestring suture was placed around the endoscope at the cardia and tied. Ten days later, pH monitorization was repeated to evaluate the effectiveness of the method. Late postoperative results have been reevaluated by 24-hour pH monitorization in the sixth month. RESULTS: The procedure achieved statistically significant improvements in total reflux time, number of reflux periods, number of long reflux periods, the longest reflux period, and the DeMeester score. The preoperative and postoperative DeMeester scores of the individual animals were 179.24-0.94, 11.48-0.98, 68.4-3.74, 132.2-46.49, and 38.72-5.86, respectively. Even though there appeared to be a slight increase in the pH monitorization levels after 6 months, these results did not reach significant degrees, and compared to the physiological reflux, the results were remarkable. CONCLUSIONS: The results obtained showed considerable decreases in physiologic reflux in all animals. We believe that this endoluminal, laparoendoscopic operation can be used in the treatment of gastroesophageal reflux disease as a minimally invasive method.