Granulomatous mastitis, watch and wait is a good option.

BACKGROUND: Idiopathic granulomatous mastitis (IGM) is a benign and rare chronic inflammatory disease of the breast with unknown etiology. While there is no consensus regarding its post-diagnosis management, there are different treatment alternatives. AIMS: In this study, it was aimed to question the effectiveness of follow-up strategy without administering any treatment. METHODS: One hundred eighteen female patients diagnosed with IGM were retrospectively evaluated. Patients with histopathologically confirmed IGM were included in the study. Medical treatment was given only to patients who did not accept the follow-up option without treatment. The protocol used in steroid therapy was 16 mg prednisolone twice daily for 2 weeks, and then the dose was gradually reduced, and the treatment was stopped after 2 months. Patients were followed up with a physical examination every 3 months. The effectiveness of the systemic corticosteroid treatment and the follow-up approach without any treatment was compared. The recurrence rates and pre-treatment and post-treatment methods of the patients were examined. RESULTS: While 30.5% of the patients recovered with corticosteroid treatment, 42.4% recovered under observation without any treatment. The mean recovery period of the patients in these two groups was calculated as 3.9 months and 5.6 months, respectively. However, no statistically significant difference was found in terms of recovery period (p = 0.064). The recurrence rate was 11.9%. CONCLUSION: For IGM, the "watch and wait" approach is an effective option. A chance should be given to the self-limiting nature of the disease with the addition of drainage when necessary.

Expression of nestin and chromogranin in regeneration zones of rat pancreas.

AIM: The particular signals that start and orchestrate the regeneration process in pancreas are not well understood yet. We aimed to investigate the expression of nestin and chromogranin A in pancreatic regeneration zones and a secondary objective, we assessed the efficiency of pancreatic duct ligation method in creation of a pancreatic regeneration model in rats. MATERIALS AND METHODS: Partial (90%) pancreatectomy and pancreatic duct ligation were performed in Wistar rats, in order to create pancreatic regeneration models. Pancreatic tissues were examined histologically. Expression profiles were investigated by immunohistochemistry for nestin and chromogranin A. RESULTS: Nestin and chromogranin A expressions were observed in regeneration zones. Pancreatic regenerations zones were seen in pancreatic duct ligation group samples as well as partial pancreatectomy group. Nestin was expressed prominently in acinoductular metaplasia cells in regeneration zones. This was best demonstrated in the samples of pancreatic duct ligation group. In the subsequent sections of nestin positive sites, cytoplasmic positivity with chromogranin A was observed. CONCLUSION: This study confirms that nestin and chromogranin A can be detected in neogenesis-evoked pancreatic tissue, particularly in the acinoductular epithelium. Nestin and chromogranin A may be important markers to identify pancreatic stem cells. Pancreatic duct ligation can be used for creating pancreatic regeneration model in rats. KEY WORDS: Chromogranin A, Nestin, Pancreas, Regeneration, Stem cells.

Comparison of laparoscopic primary and open primary repair of ventral hernias.

Prosthetic materials have gained popularity for ventral hernia repair. There are situations when the use of a mesh is either unnecessary or contraindicated. This study compares 51 patients with ventral hernia who underwent laparoscopic or open primary suture repair. Results were determined by a median follow-up of 33 months. Recurrence rates and operative time were the major parameters of outcome. Mean operative time was insignificantly shorter in the laparoscopic group (14.8 ± 4.3 vs. 15.6 ± 3.7 min). There were no short-term complications in groups. One patient in each group had recurrence. Conclusively, laparoscopic primary repair of small ventral hernias is simple and can be performed as an initial approach for small defects. Compared with open repair, it has the advantages of better exposure, reduced pain, and less morbidity. It can also be performed as a component of a combined laparoscopic operation. However, this technique is not recommended for repair of large ventral hernias.

A prospective comparative study of the efficacy of conventional Lichtenstein versus self-adhesive mesh repair for inguinal hernia.

PURPOSE: Lichtenstein repair has been the gold standard in inguinal hernia surgery. The aim of this study was to investigate the role of mesh fixation in terms of postsurgical chronic pain and recurrence. METHODS: Sixty patients with primary inguinal hernias were treated between March 2007 and December 2008. Thirty patients underwent conventional Lichtenstein repair while a self-adhesive mesh was used for the second group. The primary outcome parameters were the rate of recurrence and chronic pain. The operating time, postoperative pain, complications, and time when patients returned to work were recorded. RESULTS: Fifty-one patients completed the survey. Early pain scores were lower in the self-adhesive mesh group. The main advantage of the self-adhesive mesh was the shorter operating time (23.70 ± 5.57 vs 36.90 ± 11.36, P = 0.006). Both techniques were almost identical in terms of long-term chronic pain (P = 0.294), and the rates of recurrence at the end of a median of 31 months' follow-up were identical. CONCLUSION: Self-adhesive mesh repair of inguinal hernias is superior to the conventional Lichtenstein method in terms of shorter operative time and less pain in the early postoperative period. The rates of chronic pain and recurrence are similar with the suture-fixed repairs.

Laparoscopic primary repair of ventral hernias: early results of a new technique.

Epigastric, umbilical, incisional, parastomal, and trocar site hernias are all classified as "ventral" hernias, which constitute a great portion of the surgery in a general surgical practice, and debate still continues regarding the optimal surgical strategy to correct these anatomical defects. Although repairing these hernias using a synthetic material, whether placed open or laparoscopically, has gained wide popularity, there are some situations where the use of a mesh is either unnecessary or contraindicated. This article presents the cases of 10 patients with some kind of ventral hernia which were all repaired laparoscopically with a primary suturing technique.

Cleft lift procedure for sacrococcygeal pilonidal disease.

PURPOSE: The surgical treatment of sacrococcygeal pilonidal disease varies widely. This study reports outcomes of cleft lift procedure combined with pit excision performed both in primary and recurrent pilonidal disease. METHODS: A total of 76 consecutive patients with primary or recurrent pilonidal disease who received cleft lift procedure or combined (cleft lift with pit excision) procedure in our clinic between March 2005 and May 2007 were investigated prospectively. Rate of postoperative complications and disease recurrence were the primary outcomes. RESULTS: Mean follow-up was 16.4 months (SD 7.0, range 5-34). The most common early postoperative complications were minor wound dehiscence (11 patients, 14.5 percent), followed by infection (10 patients, 13.2 percent), and wound break (4 patients, 5.3 percent). One recurrence (1.3 percent) was observed during the follow-up. CONCLUSIONS: The results of the current study supported that cleft lift procedure fulfills the requirements of an ideal operation for pilonidal disease. The cleft list procedure was a relatively simple procedure that was easy to learn, to teach, and perform under either spinal or local anesthesia. The procedure can be performed as a "day-surgery" procedure with low postoperative morbidity, acceptable time to return to work, and low recurrence rate.

Xanthogranulomatous inflammation of the colon: a rare cause of cecal mass with bleeding.

Xanthogranulomatous inflammation is a well-defined disease most frequently reported in the kidney and gallbladder. The occurrence of this disease in the colon is extremely rare, with only five cases of appendix vermiformis involvement in the literature. Its clinical importance is that it can be misinterpreted as a malignant process clinically and intraoperatively as well as in the imaging studies. In this report, a 57-year-old patient presented with a cecal mass that caused recurrent lower gastrointestinal bleeding and anemia, mimicking colon cancer. This is the first report of this lesion involving the cecum with typical macroscopic and microscopic features but with atypical clinical symptoms and findings.

Coexistence of gastrointestinal stromal tumor (GIST) of the rectum and adenocarcinoma of the prostate in a patient with familial GIST.

BACKGROUND: Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal system. The rectum is a rare location for GIST. Prostate adenocarcinoma is the most common malignancy in geriatric men. Rarely, rectal GIST mimics prostate pathologies. CASE REPORT: We describe a 58-year-old male patient who was admitted with signs and symptoms of prostatism. A presumptive diagnosis of primary prostate sarcoma was made based on imaging studies and a trucut biopsy. Removal of the mass compressing both the prostate and the rectum revealed the final diagnosis of synchronous prostate adenocarcinoma and high-grade GIST originating from the rectum. The patient also had a family history of GIST. CONCLUSION: According to our knowledge, there are 5 more reported cases of rectal GIST, which were misdiagnosed as prostate malignancy. Rectal GIST may simulate prostate carcinoma clinically, and should always be kept in mind in the differential diagnosis of prostate pathologies.

Wegener's granulomatosis with massive gastrointestinal hemorrhage due to jejunal and colonic involvement: report of a case.

Wegener's granulomatosis (WG) is a systemic necrotizing vasculitis of unknown etiology characterized mainly by the involvement of the upper airways, lungs, and kidneys. Although most organ systems can be involved, gastrointestinal involvement in WG is notably uncommon. We herein present the case of a WG patient who developed two massive gastrointestinal hemorrhages treated respectively by surgery and angiographic embolization of the bleeding artery. The present case indicates that gastrointestinal manifestations might thus be considered in the natural history of WG.

Intermittent pneumatic sequential compression of the lower extremities restores the cerebral oxygen saturation during laparoscopic cholecystectomy.

BACKGROUND: Pneumoperitoneum causes intracranial pressure elevation and blood stasis at lower extremities. This study investigates cerebral oxygen saturation changes during laparoscopy and the effects of intermittent sequential compression (ISC) of the lower extremities in patients during elective laparoscopic cholecystectomy. PATIENTS AND METHOD: Sixty patients were randomly divided into two groups according to the application of ISC to the lower extremities. Group I served as control group whereas ISC was applied to group II. Cerebral oxygen saturation, peripheral blood oxygen saturation, heart rate, mean blood pressure, and associated changes have been recorded during the operation. RESULTS: Peripheral blood oxygen saturation and mean blood pressure values did not change significantly after pneumoperitoneum. Cerebral oxygen saturation levels of the group II patients were higher in than the group I patients and the difference between the groups was statistically significant (p = 0.0001). The difference became more prominent following the 35(th) minute of the operation. Mean heart rate of the patients in group II was lower than the patients in group I and the difference was also statistically significant (p = 0.0001). CONCLUSION: In this study, it was found that the decrease in cerebral oxygen saturation was recovered with ISC application. This simple and reliable technique helps to restore cerebral oxygen saturation levels while increasing blood return from the lower extremities.

Polytetrafluoroethylene prosthesis migration into the bladder after laparoscopic hernia repair: a case report.

Mesh migration after laparoscopic inguinal hernia repair is an unusual and late complication. We report a 50-year-old man with persistent painless hematuria and urinary infection who underwent bilateral laparoscopic intraperitoneal onlay mesh 4 years ago. Polytetrafluoroethylene (PTFE) prosthesis was used and fixed with tackers. The patient underwent cystoscopy and laparotomy for excision of the migrated PTFE prosthesis into the bladder. This is the first case of PTFE prosthesis migration into the bladder after laparoscopic hernia repair. We also reviewed the literature involving migration of mesh after all inguinal hernial repairs.

Total thyroidectomy for the treatment of Hashimoto's thyroiditis coexisting with papillary thyroid carcinoma.

The coexistence of Hashimoto's thyroiditis (HT) and papillary thyroid carcinoma (PTC) is controversial. This study was conducted to evaluate the correlation between HT and PTC and to identify predictive factors for the coexistence of PTC and HT. A total of 922 patients underwent surgery for thyroid disorders between January 2001 and August 2005. In all, 199 patients had been diagnosed with PTC, 37 of whom had coexistent HT; in 689 patients, benign thyroid disease had been diagnosed. Patients' age and sex, as well as histopathology, tumor size, nodal involvement status, multicentricity, presence of metastasis, and serum thyroglobulin levels, were retrospectively reviewed. A significant correlation was observed between HT and PTC, although no statistical significance was noted between PTC and HT type (nodular or diffuse). Most patients with PTC+HT were female and younger (<40 y old) than those with PTC only. The rate of occult tumor in patients with PTC+HT was higher than that in patients with PTC alone. Data indicate the coexistence of PTC and HT and suggest that PTC may develop even in cases of diffuse HT. Total thyroidectomy is the surgical procedure of choice, especially in young, female patients with HT.

Potential benefit of oral calcium/vitamin D administration for prevention of symptomatic hypocalcemia after total thyroidectomy.

OBJECTIVE: To evaluate routine oral calcium and vitamin D administration for preventing symptoms of hypocalcemia after total thyroidectomy. SUBJECTS AND METHODS: A total of 487 consecutive patients were prospectively randomized into two groups in terms of routine oral calcium and vitamin D supplementation: In the control group (244 patients) the treatment was not routinely started after surgery, whereas the treated group (243 patients) received routine supplementation that started on postoperative day 1. RESULTS: Patients of treated group had only minor hypocalcemia symptoms, whereas 7 patients of control group experienced carpopedal spasm as a major symptom (p<0.001). None of the patients in the treated group required intravenous calcium administration. Average hospital stay of the treated group patients was significantly shorter than that of control group (p<0.001). CONCLUSIONS: Routine postoperative calcium and vitamin D supplementation therapy may be useful for the prevention of symptomatic hypocalcemia after total thyroidectomy and may allow for a safe and early discharge from the hospital.

Anaplastic thyroid carcinoma with long term survival after combined treatment: case report.

Anaplastic thyroid carcinoma (ATC) is associated with an almost uniformly rapid and lethal clinical course. ATC grows rapidly and invades surrounding tissues at an early stage. Despite surgery, chemotherapy and radiotherapy, few patients with ATC live more than 1 year follow-up diagnosis. The mean survival is reported to be only 7.2 months. Treatment of ATC is still controversial because of its rarity and advanced stage at the time of diagnosis. We report herein an unusual case of ATC, 35 year old woman. She is alive without evidence of recurrence more than 36 months after combined therapy.

Intraportal endovascular ultrasound for portal vein resection in pancreatic carcinoma.

BACKGROUND/AIMS: Intraportal endovascular ultrasound (IPEUS) has been reported to be the most precise diagnostic procedure for the accurate diagnosis of portal vein/superior mesenteric vein (PV/SMV) invasion in patients with pancreatic cancer. In this study, we evaluated the clinical significance of the length of PV/SMV invasion measured by IPEUS METHODOLOGY: Twenty-six consecutive patients who underwent the pancreatic resection and IPEUS using an autopull-back device between January, 1997 and September, 2000 were retrospectively evaluated. The length of PV/SMV invasion was measured by reviewing the videotapes recorded during the operation. Clinicopathological data and survival were analyzed. RESULTS: The percentage of PV/SMV invasion was 46%, all of which were treated by PV/SMV resection. The cases without PV/SMV invasion showed significantly longer survival rate. The cases with < or = 18mm PV/SMV invasion, however, achieved a comparable 2-year survival rate of 28% whereas no patient with > 18mm PV/SMV invasion survived more than 18 months after the resection. CONCLUSIONS: Involvement of the PV/SMV by pancreatic carcinoma seems to be related to the extent of the disease and the PV/SMV involvement > 18mm is associated with a poor prognosis due to high rate of tumor positive margin even with radical operation.

Clinical significance of intraportal endovascular ultrasonography for the diagnosis of extrapancreatic nerve plexus invasion by pancreatic carcinoma.

BACKGROUND/AIMS: The extrapancreatic nerve plexus (PL) invasion is a common feature of pancreatic cancer and affects the outcome of the patients after surgical resection. IPEUS with high-resolution probes can visualize the PL invasion with high overall accuracy rate. The aim of this study is to evaluate the clinical significance of the PL invasion diagnosed intraoperatively by intraportal endovascular ultrasonography (IPEUS). METHODS: IPEUS was performed in 64 patients who underwent the pancreatic resection. Several clinicopathological factors were studied in patients with or without PL invasion. RESULTS: There were 18 cases in which PL invasion was confirmed pathologically. IPEUS showed 94% sensitivity, 98% specificity and 97% accuracy for the diagnosis of the PL invasion with the false-positive rate of 5.6%. The 1-, 2- and 3-year survival in 18 patients with PL invasion was 30, 6 and 0% in comparison to 52, 32 and 18% in those 46 patients without PL invasion and the difference was statistically significant (p = 0.008). A significant correlation was found between PL invasion and the portal vein invasion, invasion of the margins or pTNM stage. CONCLUSIONS: According to current results, the prognosis of the cases with PL invasion is very poor and indication for resection is doubtful. We conclude that the cases in which PL invasion is diagnosed by IPEUS are not indicated for extended resection and correct diagnosis of PL invasion is important not only to predict the outcome but also to decide the surgical procedure for obtaining negative margins while improving the quality of life after surgery.

REG I as a marker for human pancreatic acinoductular cells.

BACKGROUND/AIMS: Several studies have suggested that pancreatic exocrine cells are able to differentiate into endocrine cells. REG I has been shown to be crucial for induction of ductal epithelial cells to differentiate into insulin producing cells. To date, however, there has been no study which examined the expression of REG I along with other differentiation markers in patients with chronic pancreatitis. METHODOLOGY: Six cases with chronic pancreatitis and the pancreata from the age-matched autopsy cases of unrelated diseases (n=2) were included in this study and examined by immunostaining methods using antibodies against human REG I protein, trypsin, insulin, chromogranin A, cytokeratin 19 and Ki-67. RESULTS: In chronic pancreatitis, REG I was found in acinar and acinoductular cells and the latter were also characterized by cytokeratin 19 positivity. The acinoductular cells showed the budding of REG I-positive cells which were also trypsin- and chromogranin A-positive. MIB-1 antibody against Ki-67 was found negative in the ductal, acinoductular and islet cells reflecting low proliferation in these cells. CONCLUSIONS: The current study revealed that acinoductular cells characterized by dual expression of REG I and cytokeratin 19 also express insulin, chromogranin A and trypsin and therefore supports the hypothesis that transdifferentiation of fully differentiated (acinar) cells may be the main source of islet neogenesis in patients with chronic pancreatitis. However, low proliferation rate in these cells limits the regeneration capacity of the pancreatic tissue in these cases. The present results of double staining of REG I with cytokeratin 19, chromogranin A and insulin in the acinoductular cells indicate that REG I may be used as a marker for these cells.

Doppler ultrasonography for postoperative hepatofugal portal blood flow of the intrahepatic portal vein.

BACKGROUND/AIMS: The clinical significance of the hepatofugal portal blood flow after abdominal surgery involving other than portosystemic shunt was investigated in our hepatobiliary pancreatic surgical division. METHODOLOGY: Preoperative and postoperative Color and pulsed Doppler ultrasonography was performed on 101 consecutive patients who underwent abdominal surgery. Preoperative Doppler ultrasonography was performed within one week before surgery. Basically, postoperative Doppler ultrasonography was performed every other day within one week after surgery and once a week 2 weeks after surgery. The portal flow direction was assessed in the right portal branch or the umbilical portion of the left portal branch. RESULTS: Of the 101 patients, 9 showed a hepatofugal flow in the intrahepatic portal vein, 5 of which showed a total hepatofugal flow, and 4 of these 5 patients died of hepatic failure. The remaining 4 patients showed a partial hepatofugal flow and postoperative hyperbilirubinemia, but all 4 survived. CONCLUSIONS: Postoperative total hepatofugal flow indicated a serious prognostic sign of critical liver damage. Postoperative partial hepatofugal flow induced postoperative hyperbilirubinemia which was not critical.

Differentiation of acinar cells into acinoductular cells in regenerating rat pancreas.

BACKGROUND/AIMS: Several lines of experimental data suggest that acinar cells have the potential to differentiate into ductular-like cells, and these newly formed acinoductular cells may act as (facultative) stem cells. The purpose of this study was to test this hypothesis in a model of pancreatic regeneration in rats. METHODS: In the current study, using a 90% pancreatectomy as a rat model for pancreatic regeneration, we serially examined the pancreatic tissues in a time-dependent manner by conventional histology and immunostaining. Cell proliferation was assessed by in vivo bromodeoxyuridine (BrdU) labeling. RESULTS: By 24 h after surgery, acini showed depleted granules with more dilated lumens (acinar ectasia). By day 2, focal regions of regeneration appeared which were separated by fibrosis and composed of ductular-like cells (tubular complexes) and acinar cells with dilated lumina. Double immunofluorescent staining revealed that both amylase and CK19 were positive in the same cells localized to the focus of regeneration from the animals on day 2, the phenotype of cells from those regions apparently reverted to acinar cells, and the regions completely disappeared by day 7. By 48 h after surgery, the number of BrdU-positive cells increased 4.3-fold in ductular cells, and 2.5-fold in acinar cells compared with control tissue. CONCLUSION: Acinar cells through acinoductular metaplasia may be a source of pancreatic regeneration.

Earlier hepatic vein transit-time measured by contrast ultrasonography reflects intrahepatic hemodynamic changes accompanying cirrhosis.

BACKGROUND/AIMS: Non-invasive diagnosis of cirrhosis by transit-time analysis of an ultrasound contrast agent has been reported, even though the mechanism by which contrast arrives to the hepatic vein earlier in cirrhosis than in normal controls is unknown. The aim of this study is to assess whether the earlier appearance of contrast in the hepatic vein depends on intrahepatic or extrahepatic causes. METHODS: There were 15 participants: six volunteers, three patients with hepatitis, and six with cirrhosis. The contrast agent was given intravenously, and transit-time analysis of the hepatic artery, portal vein and hepatic vein was performed. The time-acoustic intensity curves in the three vessels were analyzed by an image and cineloop display and quantification software package. RESULTS: The hepatic artery and portal vein arrival times were not significantly different among the three groups. On the other hand, hepatic vein arrival times were significantly earlier in cirrhosis (median 18 seconds) compared with arrival times in hepatitis patients (median 30 seconds, P < 0.001) and in healthy volunteers (median 31 seconds, P < 0.001). These results give support to a previous pilot study and indicate that most of the time delay in hepatic vein arrival time between cirrhosis and the other groups originated from intrahepatic circulation abnormalities. CONCLUSIONS: This study confirms that the earlier appearance of contrast in the hepatic vein observed in cirrhosis is due to intrahepatic, and not extrahepatic, hemodynamic changes.