Is ultrasound guidance necessary to avoid complications in the implantation of venous access ports?

BACKGROUND: The aim of this study was to present demographic information of patients undergoing totally implantable venous access port (TIVAP) implantation and to investigate the rates of early and late complications, assessing the benefits of performing the procedure underUS guidance. METHODS: From May 2018 to December 2023, the outcomes of a total of 537 TIVAP implantation procedures were analyzed retrospectively. Data of the surgeons' experiences for both puncture methods (anatomical landmarks and ultrasound guidance) are presented in the study. RESULTS: The average age of the patients was 53.1±11.9 years, and 261 (48.6%) were female. The right subclavian vein was the preferred insertion site. Fourteen patients developed early complications and 11 developed late complications. Arterial puncture was the most common early complication, while catheter-related infection was the most common late complication. The age, sex, and body mass index of the patients were not independent risk factors for developing complications. Early complications increased as the number of puncture attempts did (p=0.034) and developed significantly less when ultrasound guidance was used during insertion (p=0.011). CONCLUSION: The risk of developing complications was not affected by patient's age or sex. In addition, body mass index was not shown to be an independent risk factor for patients developing complications. It may be concluded from the study that early complications in particular can be reduced with ultrasound-guided implantation.

Endovascular and surgical management of splenic artery aneurysms.

BACKGROUND: Although true splenic artery aneurysms (SAA) are rare, due to advancements in imaging techniques, they are seen more frequently. The aim of this study is to present our strategy of managing patients with SAA. METHODS: Retrospectively, 13 patients who were treated in a tertiary university care center between 2012 and 2020 were included. Their demographic, clinical information, and post-operative complications were analyzed. RESULTS: Seven male and six female patients were evaluated between the ages of 27 and 73. The mean age was 49.8±13.2. The diameter of the aneurysm was between 17 and 80 mm with a mean range of 31.5±16 mm. Seven patients were treated with endovascular interventions (EV). Two patients were referred to surgery with failed attempt of EV, but patients refused surgery and were followed up consequently. Patients who had larger aneurysms with an increased risk of rupture underwent aneurysmectomy and splenectomy. Conservative management was decided on two patients initially: A patient who was previously operated on for a sigmoid colon tumor, and had an aneurysm size of 15 mm and another patient with a surgical history of thoracic aortic dissection with an aneurysm size of 18 mm. One patient who underwent surgery had post-operative pancreatic fistula and was treated with percutaneous drainage. The treatment of the remaining 12 patients was completed without any further complications. CONCLUSION: Splenic artery aneurysm treatment should be individualized. Endovascular treatment can be considered for patients with stable aneurysms larger than 2 cm in the elective setting. Open surgical treatment should be considered in patients with ruptured SAA or hemodynamically unstable, complicated patients.

Pushing the Limits of Breast-Conserving Surgery with Extreme Oncoplasty.

Introduction: We aimed to report the long-term surgical outcomes of extreme oncoplasty techniques in selected patients with unifocal (UF)/cT3 or multifocal-multicentric tumors (MFMC). Material and Methods: Patients who were initially recommended to have mastectomy underwent extreme oncoplastic breast-conserving surgery (eOBCS) including therapeutic reduction mammoplasty, racquet, and round-block mammoplasty, Grisotti flap, or combined technique were included. Preoperative tumor parameters, clinical outcomes, rate of local recurrence, survival, and patients' satisfaction were assessed. Results: Eighty-six patients with a median age of 51 years were followed for a median follow-up of 75 (8-154) months; 31 (36%) had cT3 and 55 (64%) had MFMC tumors. The majority of patients (83.6%) had invasive cancer. The median UF tumor size was 58 mm (range 51-100) on imaging and 51 mm (range 50-60) on final pathology. The median tumor span for MFMC was 65 mm (range 53-95) on imaging, whereas the median of the largest tumor size was 30 mm (range 22-60) on final pathology. Seventy-one patients (82.5%) were ER-positive, 17 (19.7%) were HER2 positive, and 8 (9.3%) were triple-negative breast cancer. Four patients (4.7%) required further intervention for having positive margins (3 re-excisions, 1 completion mastectomy). Three local recurrences (3.4%) and 10 (11.6%) distant metastasis occurred. The cosmetic outcome was excellent in 37 (43%) patients. No major complications were observed. Conclusions: eOBCS can be a good option for patients who initially require mastectomy. Appropriate patient selection, a multidisciplinary approach, and patient consent are essential steps of the procedure.

Is the increased ozone dosage key factor for its anti-inflammatory effect in an experimental model of mesenteric ischemia?

BACKGROUND: Ischemia/reperfusion injury of the intestines is a severe surgical condition. This study aimed to reveal ozone therapy effects with relatively increased ozone dosage in a created ischemia/reperfusion injury model. METHODS: In this study, 24 albino Wistar rats were examined in three groups. Rats in the control group (CG, n=8) underwent only a laparotomy. In the sham group (SG, n=8) and ozone group (OG, n=8), the superior mesenteric artery (SMA) of the rats was occluded for 1 h. After deoccluding the SMA, the abdomen was closed, physiological saline was infused intraperitoneally in the SG, and an increased ozone/oxygen mixture dose (from 0.7 mg/kg to 1 mg/kg) was infused intraperitoneally in the OG. Small intestine samples were obtained at the 24th h for histopathological examination of intestinal mucosal injury and evaluated according to the Chiu score. In addition, Malondialdehyde and Myeloperoxidase levels were evaluated for oxidant levels, whereas, Glutathione (GSH) enzyme activity was measured to evaluate the tissue antioxidant system. RESULTS: Histopathologically, the Chiu score was the lowest in the CG. It was lower in the OG compared to the SG showing the ameliorating effect of ozone on the intestinal mucosa. Chiu score in the OG was higher compared to that in the CG, but not statistically significant. A significantly higher GSH level was observed in the OG compared to the SG, proving antioxidant activity. CONCLUSION: In this experimental model of ischemia/reperfusion in rats, treatment with an increased ozone level decreased the inflammatory process through antioxidant mechanisms and reduced intestinal mucosal damage. However, the effectiveness of ozone therapy depends on its dosages.

A rare cause of intestinal obstruction in children: signet-ring cell adenocarcinoma of the colon.

BACKGROUND: Signet-ring cell adenocarcinoma of the colon is well-recognized in adult patients who are extremely rare and not well-documented in children. Our study aims to raise awareness about this rare disease and its long-term outcomes. METHODS: We retrospectively evaluated patients with signet-ring cell colon adenocarcinoma. RESULTS: Six patients, three boys and three girls, with a mean age of 14.83 (range, 13-17 years), presented with signs of intesti-nal obstruction and were diagnosed with signet-ring cell colon adenocarcinoma. All patients had air-fluid levels on abdominal X-ray. Abdominal ultrasonography of all patients revealed subileus. Abdominal computed tomography was performed in five patients, and pre-operative colonoscopy was conducted in two patients before the emergency intervention. All of the patients underwent emergent exploratory laparotomy with the preliminary diagnosis of acute abdomen. In two patients, debulking surgery followed by a stoma was performed. The remaining four patients were treated with anastomosis following intestinal resection. All girls had metastases on the ovary. One of the patients died due to the burden of multiple metastases in the early period, and three died in the sixth post-operative year. We have been following the remaining two patients since then. CONCLUSION: Although signet-ring cell carcinomas (SRCCs) are rare, they should be considered in the differential diagnosis of acute abdomen and intestinal obstruction in pediatric patients. Despite early diagnosis and treatment, SRCC has a poor prognosis in the pediatric population.

Comparison of hyperbaric oxygen and ozone treatment for ischemia/re-perfusion injury in an experimental testicular torsion model.

BACKGROUND: This study aims to compare the effects of medical ozone (MO) therapy and hyperbaric oxygen (HBO) therapy in an experimental testicular torsion model by measuring the oxidant and antioxidant markers and examining the histopathological tissue damage findings. METHODS: Thirty-two Wistar rats are used and are divided into four groups; (1) sham group (SG), (2) only ischemia/reperfusion (I/R) by testicular torsion, (3) HBO administered group, and (4) MO administered group. No torsion was conducted in the SG. In all other groups, rats underwent testicular torsion followed by detorsion to create an I/R model. After I/R, HBO was injected in the HBO group, and in the MO group, intraperitoneal ozone was applied. At the end of 1 week, testicular tissues were obtained for biochemical analyzes and histopathological examinations. Biochemically, malondialdehyde (MDA) levels were measured for oxidant activity, and superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) levels were measured for antioxidant activity. Furthermore, the testicles were evaluated histopathologically. RESULTS: Both HBO and MO have significantly decreased MDA levels, compared with sham and I/R groups, resulting in decreased oxidation effects. The antioxidant GSH-Px levels in the HBO and MO groups were significantly higher than in the sham and I/R groups. In addition, the antioxidant SOD levels in the HBO group were significantly higher than sham, I/R, and MO groups. Therefore, the antioxidant effect of HBO was observed to be superior to MO, specifically considering SOD levels. Histopathologically, there was no significant difference between the groups (p>0.05). CONCLUSION: The study may extrapolate that both HBO and MO are antioxidant agents that can be used in testicular torsion. HBO treatment might improve the cellular antioxidant capacity due to increased antioxidant marker levels more than MO therapy. However, further studies are needed with a larger sample size.

The impact of intraoperative cavity shaving on re-excision rates in breast-conserving surgery.

BACKGROUND AND OBJECTIVES: This trial aimed to investigate the effects of circumferential shaving on reducing the reoperation rates during breast-conserving surgery (BCS). METHODS: In the study, before 2014, 404 (39.9%) breast cancers (BCs) out of a total of 1012 BCs underwent BCS without intraoperative cavity shaving (ICS) and constituted the no-ICS group. After this date, ICS was added to 608 (60.1%) BCSs (ICS group) and intraoperative margin analysis was not requested from pathologists during these second BCS procedures. RESULTS: The patient and BC characteristics in the no-ICS and ICS groups were similar. Carcinoma detection at the margin and reoperation rates were 13.9% in the no-ICS group and 7.6% in the ICS group (p = 0.001). No significant difference was detected between patients who underwent BCS with intraoperative frozen section analysis (FSA) and patients who underwent BCS with additional ICS (5.6% vs. 7.6%, p = 0.383). CONCLUSIONS: ICS decreased the rates of positive margins and reoperations among patients with BCS to an acceptable level compared with intraoperative FSA. It may be concluded that ICS is feasible to achieve BC margin control.

Report of Two Cases with Simultaneously Detected Tubular Carcinoma and Phyllodes Tumor of the Breast.

Tubular carcinoma (TC) is a subtype of invasive breast carcinoma with better prognosis, and phyllodes tumors (PT) are rare fibroepithelial lesions. Accurate preoperative pathological diagnosis allows for correct surgical planning and avoidance of reoperation for these breast neoplasms. A database was created by analyzing the archives of Department of General Surgery of the Istanbul Faculty of Medicine between September 2006 and November 2017, and a total of 105 PTs and 55 TCs were collected. Two cases with concurrence of TC and PT were identified and examined in detail. The first patient was a 33-year-old woman with a 20×12 mm2 TC and a 65×32 mm2 malignant PT in the left breast. The second patient was a 28-year-old woman with two masses in the right breast. The first mass was 38×16 mm2 on the upper outer quadrant, and the second mass was 10×8 mm2 in size in the lower inner quadrant, accompanied by a 16×10 mm2 TC and a 33×26 mm2 borderline PT. Both cases were treated by mastectomies due to patient's decisions or insufficient margin control. This study extrapolated that if two tumors are detected simultaneously, margin control can become more difficult, and breast-conserving surgery should be thoroughly reviewed.

A report of a case: unusual portosystemic shunt in a hernia sac who has portal hypertension due to cirrhosis.

BACKGROUND: Variations in the origin and branching pattern of splenic vein (SV) are relatively rare and asymptomatic. We describe here only the first case in the literature of accessory SV in hernia sac due to previous operation and increased portal pressure because of cirrhosis. CASE PRESENTATION: This report describes a 66-year-old female, with a history of total abdominal hysterectomy (TAH) due to uterine myomatosis, signs of cirrhosis onset due to hepatitis B, who had been presented with recurrent abdominal pain attacks. Ultrasonography (USG) findings were nothing pathologic except a gallstone in the gallbladder without cholecystitis signs. Incisional hernia was found to contain an accessory SV in the hernia sac arising from a branch of main SV in the hilum, ongoing to the subcutaneous fat tissue and draining to the superficial femoral vein on computed tomography (CT). Videoendoscopy showed wide gastritis and multiple ulcers. The patient's symptoms diminished with proton pump inhibitor (PPI) treatment and they then underwent a hernia repair surgery with Prolene mesh patch as elective surgery. CONCLUSIONS: A thorough knowledge of the normal anatomy, most frequent variations and congenital or acquired anomalies of the spleno-portal axis has great importance for hepatopancreaticobiliary and emergency surgical procedures. It is, therefore, essential for preoperative evaluation of the anatomical details of the spleno-portal venous axis and should be evaluated with imaging methods in detail.

The role of histopathologic testing on apocrine carcinoma of the breast.

BACKGROUND: Apocrine carcinoma is a rare primary breast tumor characterized by the apocrine morphology. The purpose of this article is to report a review of cases with apocrine carcinoma and draw physicians' attention to the benefits of immunphenotypic techniques in cases with suspected apocrine morphology in diagnosing this uncommon breast tumor. METHODS: In this study, authors report a case series of 15 cases with apocrine carcinoma from totally 4123 breast cancer cases. Data collected between years 2008 and 2016 from Istanbul School of Medicine department of surgery archive by analyzing surgical approach to cases and immunphenotypic features of tumors according to the date of examining in our pathology department. RESULTS: In this study, Androgen, "gross cystic disease fluid protein-15" (GCDFP-15), estrogen (ER), progesterone (PR) and Her-2 neu receptor status supported evidence of apocrine carcinoma has been reviewed. As a result, HER-2 neu, GCDFP-15, androgen receptor positivity in general are useful in the diagnosis of apocrine carcinoma. In addition of these data our study revealed that GCDFP-15 positive patients are more prone to have local recurrence and distant metastases. CONCLUSIONS: We briefly describe and discuss the molecular features and new diagnostic biomarkers for this rare mammary malignancy. The importance of comprehensive profiling is highlighted due to synergistic and potentially antagonistic molecular events in the individual patients.

Pinch-Off Syndrome, a Rare Complication of Totally Implantable Venous Access Device Implantation: A Case Series and Literature Review.

BACKGROUND: Pinch-off syndrome (POS) is a rare complication after totally implantable venous access device (TIVAD) implantation. In cancer patients, it is important to prevent this rare complication and to recognize it early if it does occur. We present a case series of POS after TIVAD implantation and the results of a literature search about this complication. METHODS: From July 2006 to December 2015, 924 permanent implantable central venous catheter implantation procedures were performed. The most common indication was vascular access for chemotherapy. RESULTS: POS occurred in 5 patients in our clinic. Two patients experienced POS within 2 weeks, and the other 3 patients were admitted to department of surgery, Istanbul Faculty of Medicine at 6 to 14 months following implantation. The catheters were found to be occluded during medication administration, and all patients complained of serious pain. The transected fragments of the catheters had migrated to the heart. They were successfully removed under angiography with a single-loop snare. CONCLUSION: POS is a serious complication after TIVAD implantation. It is important to be aware of this possibility and to make an early diagnosis in order to prevent complications such as drug extravasation and occlusion events.

Breast-Conserving Surgery Under Local Anesthesia in Elderly Patients with Severe Cardiorespiratory Comorbidities: A Hospital-Based Case-Control Study.

INTRODUCTION: We report the feasibility and safety of local anesthesia (LA) in patients having breast-conserving surgery (BCS). METHODS: 37 patients with American Society of Anesthesiologists (ASA) score of 4 having BCS under LA and 54 age-matched subjects with ASA score of 3-4 having BCS under general anesthesia (GA) were included. Patients were retrospectively evaluated for the follow-up duration, duration of surgery, postoperative satisfaction scores (1-10), complication and survival time for locoregional recurrence and overall survival rates. RESULTS: The mean follow-up duration was 55.09 ± 13.49 months (range 38-104) in GA group, and 58.7 ± 15.5 months (range 20-99) in LA group. There was a significant difference in the duration of surgery (p < 0.001). In the LA group, 5 patients (13.5%) had minor complications including seroma, wound infection or hematoma, whereas 6 patients (11.1%) had minor complications in the GA group (p > 0.05). The re-excision rate due to positive tumor margins was 5.4% (2 patients) in the LA group and 5.5% in the GA group, respectively. The locoregional recurrence-free survival and overall survival rate was not different between 2 groups (p = 0.192, p = 0.93). CONCLUSION: BCS under LA seemed to be effective and safe in selected high-risk elderly patients.

Rare Complication of Stomas: Peristomal Necrotizing Fasciitis.

INTRODUCTION: A stoma formation is a frequently performed procedure in patients undergoing colorectal surgery. Although stoma formation is a simple process, it should be performed with caution. The aim of this study was to attract physicians' attention to this rare disease and also to identify the surgical and medical treatment options for peristomal necrotizing fasciitis as a rare complication. MATERIALS AND METHODS: Risk factors including age, sex, additional diseases, previous surgical procedures, source of infection, physical findings, and vital signs of 14 patients with peristomal necrotizing fasciitis over a period of 10 years from 2005 to 2015 were retrospectively evaluated. RESULTS: Of the 14 patients, 9 were men and 5 were women. The average age was 63.28 years (range, 45-85 years). Risk factors were also observed: diabetes mellitus, 4 (28.57%); obesity, 3 (21.42%); alcoholism, 1 (7.14%); and malignancy, 10 (71.42%). Prophylactic antibiotic treatment was given to all patients, and they all underwent debridement and stoma replacement. CONCLUSION: Peristomal necrotizing fasciitis is an urgent and mortal disease. Risk factors, physical findings, and infection sources should be determined, and treatment modalities should be applied immediately. Medical treatment and surgical options should be performed, and vacuum devices should also be considered when treating this complication.

Axillary arch may affect axillary lymphadenectomy.

BACKGROUND: The aim of this study was to identify the axillopectoral muscle anomaly commonly known as Langer's axillary arch, and to understand its importance in surgical procedures of the axilla. PATIENTS AND METHODS: Between 2009 and 2011, 758 patients underwent sentinel lymph node biopsy, axillary dissection, or both. Patients with Langer's axillary arch were identified and assessed retrospectively. The decision to cut or preserve the axillary arch was made based on clinical judgment, and patients were followed-up accordingly to monitor for adverse outcomes. RESULTS: Of the 758 patients who underwent axillary procedures, 9 (1.2%) were found to have a Langer's axillary arch. In 2 patients the arch was cut, and in 7 patients it was preserved. No adverse outcomes were identified in any of the patients upon follow-up. CONCLUSION: Langer's axillary arch is a unique anatomic anomaly of the axillary region that may be problematic due to the potential risks of lymphedema and vascular or nerve compression. It is important for surgeons and radiologists alike to be aware of this anatomic variation in order to properly identify it and respond appropriately based on clinical judgment, and to complete close follow-up of the patient due to the potentially increased risk of adverse outcomes.