In the Experimental Model of Acute Mesenteric Ischemia, The Correlation of Blood Diagnostic Parameters with the Duration of Ischemia and their Effects on Choice of Treatment.

Purpose/Aim: Acute mesenteric ischemia is a syndrome characterized by sudden onset abdominal pain followed by intestinal necrosis. Morbidity and mortality increase with delayed diagnosis. Even with the latest radiological diagnostic methods, early diagnosis and initiation of treatment can be delayed. Using an experimental model, here we aim to determine the relationship between the laboratory parameters used to detect acute mesenteric ischemia and the duration of irreversible ischemia. Materials and Methods: A total of 30 male Wistar albino rats were divided into five groups, all of which underwent general anesthesia: (i) Superior mesenteric artery (SMA) dissection with laparotomy was performed, and blood samples and intestinal segment samples were taken after 2 hr (Sham group); (ii) volvulus of one-third of the small intestines was performed manually by laparotomy, and blood samples and intestinal segment samples were taken after 2 hr (Volvulus group); (iii) SMA was ligated with laparotomy, and blood samples and intestinal segment samples were taken after 2 hr (SMA+ligated 2-hr group); (iv) SMA was ligated with laparotomy, and blood samples and intestinal segment samples were taken after 4 hr (SMA+ligated 4-hr group); and (v) SMA was ligated with laparotomy, and blood samples and intestinal segment samples were taken after 6 hr (SMA+ligated 6-hr group). Results: The mean lactate dehydrogenase (LDH) activities of the SMA+ligated 2-hr and SMA+ligated 6-hr groups were statistically higher than the control group (p = .004). Compared to the Sham and Volvulus groups, the mean lactate level of the SMA+ligated 6-hr group was significantly higher (p = .004). Compared to the Sham and Volvulus groups, the mean D-dimer levels of the SMA+ligated 4-hr and SMA+ligated 6-hr groups were significantly higher (p = .004 and .003, respectively). By histopathological evaluation, we found that pathological damage increased as the ischemia lengthened. Conclusions: Mesenteric ischemia leads to an irreversible loss of intestinal perfusion and an increase in parameters of ischemia. Irreversible tissue damage occurs after 4 hr of ischemia and peaks after 6 hr, whereas parameters of ischemia (D-dimer, LDH, and L-Lactate levels) are highest at 2 hr after the onset of ischemia.

Importance of Spontaneous Choledochoduodenal Fistulas Detected During ERCP Procedure.

Choledochoduodenal fistula (CDF) is an abnormal passage between the choledochus and duodenum. The most common causes of CDF are cholelithiasis, duodenal ulcer, and tumors. There are mainly two types of fistulas depending on the location. Type 1 is usually present on the longitudinal fold just close to the papilla. Type 2 is present at the duodenal mucosa adjacent to the longitudinal fold and probably caused by larger stones, duodenal ulcer penetration, impacted cystic duct stones, and as a complication of laparoscopic cholecystectomy. In this study, we investigate the characteristics of our patients those were diagnosed with CDF. This is a descriptive study. We retrospectively obtained the data of 21 patients with spontaneous CDF out of 2430 endoscopic retrograde cholangiopancreaticography (ERCP) patients between 2000 and 2014. We analyzed the laboratory results, demographic and etiological features, major clinical presentations, diagnostic methods, and treatment modalities of the patients. The mean age of the 21 patients was 66.6 ± 2.2 years and a female to male ratio was 12:9. In ten patients, interventional procedures were performed via fistulotomy, not through the papilla. The eventual diagnosis was tumor in five patients and stone or sludge in bile ducts in 14 patients. In the remaining two patients, no reason was found as a cause of CDF. Whipple operation was performed in one patient and stents were placed in three patients for malignacy. Among the 14 patients with sludge or stone in bile ducts, ERCP has been therapeutic in ten. One of the remaining patients has been operated for proximal fistula and underwent choledochus exploration and repair of fistula over a T-tube. In the second patient, stone extraction and T-tube drainage were performed. In patients who had bile duct obstruction and got over of jaundice afterwards, one of the most important reasons of this recovery is the development of spontaneous choledochoduodenal fistula. Even if it is very rare, malignancy can be observed in this area. Therefore, it is extremely important to evaluate the papillary area with ERCP and to conduct biopsy; this will make early diagnosis possible in many patients. In these patients, ERCP can both be diagnostic and therapeutic.

Is there any effect of pneumoperitoneum pressure on coagulation and fibrinolysis during laparoscopic cholecystectomy?

BACKGROUND: Laparoscopic cholecystectomies (LC) are generally performed in a 12 mmHg-pressured pneumoperitoneum in a slight sitting position. Considerable thromboembolism risk arises in this operation due to pneumoperitoneum, operation position and risk factors of patients. We aim to investigate the effect of pneumoperitoneum pressure on coagulation and fibrinolysis under general anesthesia. MATERIAL AND METHODS: Fifty American Society of Anesthesiologist (ASA) I-III patients who underwent elective LC without thromboprophlaxis were enrolled in this prospective study. The patients were randomly divided into two groups according to the pneumoperitoneum pressure during LC: the 10 mmHg group (n = 25) and the 14 mmHg group. Prothrombin time (PT), thrombin time (TT), International Normalized Ratio (INR), activated partial thromboplastin time (aPTT) and blood levels of d-dimer and fibrinogen were measured preoperatively (pre), one hour (post1) and 24 h (post24) after the surgery. Moreover, alanine amino transferase, aspartate amino transferase and lactate dehydrogenase were measured before and after the surgery. These parameters were compared between and within the groups. RESULTS: PT, TT, aPTT, INR, and D-dimer and fibrinogen levels significantly increased after the surgery in both of the groups. D-dimer level was significantly higher in 14-mmHg group at post24. CONCLUSION: Both the 10-mmHg and 14-mmHg pressure of pneumoperitoneum may lead to affect coagulation tests and fibrinogen and D-dimer levels without any occurrence of deep vein thrombosis, but 14-mmHg pressure of pneumoperitoneum has a greater effect on D-dimer. However, lower pneumoperitoneum pressure may be useful for the prevention of deep vein thrombosis.

Predictive value of fine needle aspiration biopsy of axillary lymph nodes in preoperative breast cancer staging.

OBJECTIVE: Diagnosis of axillary nodal involvement is significant in the management of breast cancer as well as in predicting prognosis. In this prospective study, we evaluated the efficiency of US-guided fine needle aspiration biopsy (FNAB) in preoperative axillary staging of early breast cancer. MATERIAL AND METHODS: Between January 2011 and July 2013, 46 women were prospectively enrolled in the study. Ultrasound guided-FNABs for axillary assessment were performed preoperatively. Cytology results were compared with histopathology reports to determine its sensitivity, specificity, negative and positive predictive value and accuracy. RESULTS: Nineteen cases that had malignant cytology on FNAB also had axillary involvement in axillary lymph node dissection (ALND) without any false-positive results. The sensitivity and specificity of US-guided FNAB were 63.3% and 100%, respectively. US-guided FNAB was accurate in predicting the status of the axilla in 76.1% of patients. CONCLUSION: Although this technique is favorable due to its minimally invasive nature, it is not as effective as sentinel lymph node biopsy (SLNB) in terms of detecting axillary metastasis preoperatively. The low sensitivity and low accuracy rates decrease the usefulness of the technique. Therefore, it seems that US-guided FNAB alone could not replace SLNB. Nevertheless, combining some other molecular studies may be useful in increasing the technique's sensitivity. These issues should be determined by comprehensive clinical trials.

The predictive value of elastography in thyroid nodules and its comparison with fine-needle aspiration biopsy results.

OBJECTIVE: We aimed to evaluate the predictive value of elastography in determining malignancy during preoperative investigation of thyroid nodules and to compare its results with preoperative fine-needle aspiration biopsy (FNA) and postoperative histopathology results. MATERIAL AND METHODS: Among the group of patients who had indications for thyroidectomy between January 2013- September 2013 in the department of general surgery 86 euthyroid patients were prospectively included in the study. Informed consent was obtained from all patients. All patients received simultaneous thyroid ultrasonography and elastography by an experienced radiologist. The patients were classified into five scores according to Tsukuba scoring. Score 1 and 2 were evaluated as soft nodules (benign), score 3 as medium consistency (usually benign), and scores 4 and 5 as hard nodules (malignant). For statistical purposes, the FNA results were classified as benign, probably benign or malignant. The histopathological results were classified as benign or malignant. The results were compared with FNA and elastography findings. RESULTS: The fine-needle aspiration biopsy of the nodules revealed 60.5% benign, 17.4% high probability of benign, and 22.1% malignant cases; and the elastography diagnosed 38.4% benign, 23.3% high probability of benign, and 38.4% malignant nodules. The postoperative pathology evaluation diagnosed 67.4% of patients as benign, and 32.6% as malignant. The rate of detection of thyroid cancer cases (sensitivity) by elastography was 67.9%, the ability to distinguish healthy individuals (specificity) was 75.9%, and the overall adequacy of the method (accuracy) was determined as 73.3%. CONCLUSION: Elastography overlaps with especially benign cytology-pathology at a high rate, and provides definite diagnosis in 58% of malignant cases. In our study, elastography provided more reliable results than FNA, in terms of diagnosing malignancy.

Cinical Significance of Androgen Receptor, CK-5/6, KI-67 and Molecular Subtypes in Breast Cancer.

OBJECTIVE: To detect the relationship between molecular subtypes of breast cancer with expressions of androgen receptor, cytokeratin 5/6 (CK5/6)and Ki-67. MATERIALS AND METHODS: Expressions of androgen receptor, CK-5/6 and Ki-67 were determined by immunohistochemistry in paraffin-embedded sections obtained from 86 invasive breast cancer cases of stages I/IIa/IIb in 4 molecular subtypes. Patients treated for recurrent disease and locally advanced disease were excluded. RESULTS: Forty one luminal A cases, ie. positive estrogen receptor(ER) and/or progesteron receptor (PR) with negative epidermal growth factor receptor (HER2), 14 luminal B, ie. positive ER and/or PR and positive HER2, 14 HER2-enriched (HER2+), ie. negative ER and PR with positive HER2, and 17 triple negative (negative ER and PR and HER2) invasive breast cancers were included. Mean follow-up was 17.46±11.70 mo. Androgen receptor-negativity and CK5/6-positivity were significantly more common in HER2+ and triple negative groups. Ki-67 and histological grade were higher in HER2+ group, significantly. Two deaths were triple negative (P=0.04). Androgen receptor-negativity, CK5/6 and Ki-67 status did not affect survival or systemic metastases, significantly. All groups had local recurrences. Local recurrence was significantly associated with androgen receptor-negativity in luminal A and high Ki-67 value in HER2+ groups. Systemic metastases were significantly more common in triple negative and HER2+ groups. CONCLUSION: Molecular subtypes of breast cancer are prognostic and predictive. Androgen receptor is expressed more commonly in luminal subtypes with better prognosis and androgen receptor negativity is associated with development of local recurrence in luminal A cancers.

Repair of a postappendectomy massive ventral hernia using tissue expanders.

Reconstruction of large abdominal wall defects is a challenging problem. Various reconstructive techniques have been described in the surgical literature each with its advantages and disadvantages. In this report we describe our experience in treating a patient with large abdominal wall defect by staged abdominal wall reconstruction utilizing prosthetic mesh in conjunction with tissue expanders. A 41-year-old male presented with abdominal pain. Exploratory laparotomy showed perforated appendicitis with intraabdominal abscess of 1,500 mL. Postoperatively, he developed intraperitoneal sepsis. To prevent abdominal compartment syndrome, he was reoperated and left with "open abdomen". After several open abdomen lavages, his abdominal wall defect was allowed to granulate. After epithelization of the defect, the abdominal wall was reconstructed using prosthetic mesh and tissue expanders. The tissue expansion process was well tolerated. We suggest that the use of tissue expanders provides reliable and well-vascularized soft-tissue coverage in abdominal wall reconstruction.

Treatment of hepatic hydatid disease complications using endoscopic retrograde cholangiopancreatography procedures.

BACKGROUND: Liver hydatidosis may lead to serious morbidity due to biliary complications, the management for which endoscopic sphincterotomy (ES) and biliary drainage are very efficient. We evaluated the effectiveness of endoscopic treatment for complications of hepatic hydatid disease. METHODS: We retrospectively reviewed endoscopic retrograde cholangiopancreatography (ERCP) procedures performed between January 2000 and December 2009 and compared laboratory findings, localization of the lesions and ERCP procedures applied between patients with and without jaundice. RESULTS: In all, 70 ERCP procedures were performed in 54 patients (24 men, 30 women). Of the 70 procedures, 24 were performed to treat jaundice. All patients with biliary fistulas and jaundice were managed with endoscopic procedures. The 70 ERCP procedures included sphincterotomy only (n = 40); sphincterotomy and stent placement (n = 7); stent placement only (n = 4); sphincterotomy and membrane extraction (n = 9); sphincterotomy, membrane extraction and pus drainage (n = 5); and sphincterotomy and pus drainage (n = 5). Laboratory results improved in 3-7 days, and bile leakage ceased in 2-21 days. CONCLUSION: Endoscopic retrograde cholangiopancreatography is a safe and effective way to manage biliary complications of hepatic echinococcal disease. In most patients, ES is the most efficient treatment of postoperative external biliary fistulas, jaundice and accompanying cholangitis, as it enables clearing the bile ducts of hydatid remnants; ES should be performed since it accelerates the healing process by decreasing pressure in the choledochus.

Corticosteroid treatment and timing of surgery in idiopathic granulomatous mastitis confusing with breast carcinoma.

Idiopathic granulomatous mastitis (IGM) is an uncommon chronic inflammatory lesion of the breast with an uncertain optimal treatment regimen, the physical examination, and radiologic features of which may be confused with breast carcinoma. In this study, we aimed to describe the clinicopathologic characteristics of 33 patients who admitted to our breast policlinic and took the diagnosis of granulomatous (idiopathic and non-idiopathic) mastitis, and report the place of corticosteroids and the timing of surgery in the treatment of patients with IGM. The clinical features of 33 patients who presented to our breast policlinic with the complaint of breast mass and reached the final diagnosis of GM between March 2005 and October 2009 were reported. The most common symptoms were mass (n: 27) and pain (n: 11). Ultrasonography (USG) and biopsy were performed in all of the patients. Mammography (MMG) was performed in 9, and magnetic resonance imaging (MRI) in 10 patients. The diagnosis of idiopathic lobular granulomatous mastitis (ILGM) was made in 25 patients and tuberculous mastitis (non-idiopathic GM) in the remaining 8 patients. Twenty-four patients received steroid treatment except one who was pregnant. After giving birth, she also received steroids. One of the patients who developed recurrence after 11 months repeated the steroid therapy. Eight patients with tuberculous mastitis were placed on a regimen of antituberculosis therapy for 6 months. In the diagnosis of IGM, physical examination, USG, MMG, and even MRI alone may sometimes not be enough. They should be discussed altogether and the treatment should begin after definitive histopathologic result. Fine needle aspiration biopsy for cytology will result in a high level of diagnostic accuracy, however, core biopsy will reinforce the exact result. Corticosteroid therapy has been shown to be efficacious for IGM, but in the existence of complications such as abscess formation, fistulae, and persistent wound infection, surgical treatment has been the first method of choice.