Laparoscopic resection for Meckel's diverticulum causing intestinal obstruction.

Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal system with an estimated incidence of approximately 2% of the population. Although most cases are asymptomatic, it has the potential to create complications, such as hemorrhage, inflammation, intestinal obstruction, perforation, and intussusception. Meckel's diverticulum is generally diagnosed incidentally or upon investigation of unexplained gastrointestinal bleeding, perforation, inflammation, or obstruction for both pediatric and adult patients. Complications are often present as surgical emergencies and require resection of the diseased intestinal segment. In doubtful cases, laparoscopy should be the surgical method for both diagnosing and treating MD. Here we present a case of MD causing intestinal obstruction and that was treated by laparoscopic resection.

Laparoscopic splenectomy for a wandering spleen causing chronic pelvic pain.

Wandering spleen is a rare condition with a reported incidence of less than 0.5% in which the spleen migrates from its normal anatomical location to any other position in the abdomen. Women constitute 80% of cases and one third of the overall patients are children. It has different clinical presentations such as asymptomatic, painless mass in the abdomen, intermittent abdominal pain and acute abdomen due to torsion of the vascular pedicle. Here we present a case of wandering spleen causing chronic pelvic pain. Laparoscopic splenopexy was the treatment choice but it could not be performed due to huge size of the wandering spleen.

Tamoxifen citrate: a glimmer of hope for silicosis.

BACKGROUND: Inhalation of crystalline silica nanoparticles causes pulmonary damage resulting in progressive lung fibrosis. Currently, there is no effective treatment for silicosis. Tamoxifen citrate is a selective estrogen receptor modulator, which is one of the adjuvant treatment choices for breast cancer. It is also known with its inhibitory effect on the production of transforming growth factor-beta (TGF-ß) and studied for the anti-fibrotic effect in some fibrotic diseases. The aim of the study was to determine the effect of tamoxifen citrate on the prevention of pulmonary fibrosis and the treatment of silicosis. METHODS: A total of 100 adult female Wistar Albino rats (200-250 g) were used in this study. The rats were divided into five groups including 20 rats in each. Rats were exposed to silica for 84 d in all groups. In group 1, rats were sacrificed on the day 84 without receiving treatment. In group 2, rats received 1 mg/kg tamoxifen (tmx1 + 1), from the first day of the study for the whole 114 d of the study. In group 3, (tmx10 + 10) rats were given 10 mg/kg tamoxifen from the first day of the study for the whole 114 d of the study. In group 4 (tmx1), rats were started 1 mg/kg of tamoxifen on day 84 and were given until day 114. In group 5 (tmx10), rats were fed with 10 mg/kg tamoxifen starting from day 84 to day 114. All rats except group 1 were sacrificed on 114 day of the study. Lung inflammation and fibrosis scores, serum TGF ß levels, lung smooth muscle antigen and tissue transforming growth factor ß (t-TGF-ß) antibody staining levels, and number of silicotic rats were compared between groups. RESULTS: Silicosis was caused successfully in all rats in group 1. There were six silicotic rats in group 3 and it was the lowest number of all groups. Plasma TGF-ß levels and fibrosis score were significantly lower in all groups when compared with the control group. Tamoxifen could have preventive or treating effects in silicosis and found that lung fibrosis score was significantly lower in rats treated with tamoxifen. CONCLUSIONS: Tamoxifen treatment after and/or before induction of silicosis decreased lung fibrosis score with blood TGF-ß levels. We hope that this study may introduce a new indication as prophylactic use of tamoxifen in high-risk groups for silicosis and for treatment of silicosis.

Modified elliptical rotation flap for sacrococcygeal pilonidal sinus disease.

BACKGROUND: Although various surgical procedures have been described for pilonidal sinus disease, the best surgical technique is still controversial. The aim of this study was to evaluate the short-term results of modified elliptical rotation flap (MERF) for pilonidal sinus disease in terms of post-operative complications, recurrence and quality of life. METHOD: Data of 121 patients (10 women, 111 men) who were operated on for sacrococcygeal pilonidal sinus disease between 2011 and 2013 were analysed. Elliptical rotation flap procedure which was described by Nessar et al. was modified. Complications, quality of life and recurrence were evaluated. RESULTS: The mean operating time was 31 (range, 20-55) min. The mean time for complete healing was 2.26±0.72 weeks. The mean time for returning to daily activities was 9.0±2.2 days. There were no flap necrosis and recurrence. Post-operative infection developed in five (4.1%) patients, which was managed by removal of a few skin sutures, drainage and prolonged antibiotic use. Four patients (3.3%) developed a seroma, three of them having a partial wound dehiscence (2.5%). Neither haematoma formation nor complete dehiscence were observed. CONCLUSION: MERF seems to be an effective and reliable procedure having low morbidity rates and no recurrence. Further prospective randomized studies comparing the MERF with other flap techniques will provide better information about the technique.

Unclassified diffuse ductal cholangiocarcinoma; report of a case.

Cholangiocarcinoma (CCA) is the second most common malignant tumor of the liver. It is simply classified as intrahepatic and extrahepatic CCA (including perihilar and distal extra hepatic CCA) according to the anatomic localization. Various classification systems were described for staging cholangiocarcinoma. We represent an interesting case of cholangiocarcinoma which is in the shadow area of classification by involving intrahepatic, hilar, and distal extra hepatic bile ducts. To our knowledge, this is the first case in the literature with diffuse bile duct involvement.

Laparoscopic Appendectomy versus Mini-Incision Appendectomy in Patients with Lower Body Mass Index and Noncomplicated Appendicitis.

Laparoscopic appendectomy has become favored over open surgical methods for its association with decreased postoperative pain, more rapid return to daily activities, and improved cosmetic results. Mini-incision appendectomy was being performed in our clinic for a long time especially in patients with noncomplicated appendicitis and in patients with appropriate body mass index. Although laparoscopy presents obvious advantages especially for obese patients and young women, with respect to the results of our study, mini-incision appendectomy seems to be an alternative for selected patient groups.

Effects of tamoxifen citrate on postoperative intra-abdominal adhesion in a rat model.

BACKGROUND/AIMS: The aim of this study was to evaluate the effects of oral tamoxifen citrate on postoperative intra-abdominal adhesions. MATERIALS AND METHODS: Forty five rats were randomly separated in to 3 groups. Group 1: Control group (15 rats), Group 2: tmx 1 group (15 rats) and Group 3: tmx 10 group (15 rats). The cecum was abraded with a sterile gauze until subserosal hemorrhage had developed. Full- thickness 4-0 silk sutures were also placed in the traumatized anterior cecal wall to increase the adhesive reaction. In Group 1 (control group), adhesion induction was performed and no treatment was given. In Group 2 (tmx 1 group), after adhesion induction, 1 mg/kg/day tamoxifen citrate was given by orogastric gavage. In Group 3 (tmx 10 group), adhesion induction was performed and 10 mg/kg/day tamoxifen citrate was given by orogastric gavage. Rats were sacrificed on postoperative day 30. At the time of second surgery, after the abdominal fascia had been opened blood samples were collected to evaluate serum TGFß-1 levels and following the macroscopic adhesion scoring, tissue specimens of the bowel and adhesions were subjected to histopathological investigation. RESULTS: In group 1 and group 2 we detected higher scores for the macroscopic classification (2.25 ± 1.13 vs. 1.53 ± 0.77) and histopathological scores (2.72 ± 0.64 vs. 2.53 ± 0.87) for fibrosis and serum TGFß-1 levels (42000 ± 2935 vs. 32988 ± 10804). In group 3 we have detected decreased scores for macroscopic classification (0.91 ± 0.51) and histopathological scores (1.58 ± 0.90) for fibrosis and serum TGFß-1 levels (22847 ± 4976). There were no significant differences between group 1 and group 2 according to the macroscopic classification and pathological scores for fibrosis. There were statistically significant difference between tamoxifen 10 mg/kg group and the other groups according to macroscopic classification ( P: G1-3: 0.004; G2-3: 0.046), pathological scores for fibrosis (P: G1-3: 0.004; G2-3: 0.011) and serum TGFß-1 levels (P: G1-3:<0.001). CONCLUSIONS: In conclusion tamoxifen citrate seems to be useful for preventing postoperative intra-abdominal adhesions. Its effects are in a dose and time dependent manner. Further studies must be carried out to use tamoxifen for preventing intra-abdominal postoperative adhesions in clinical practice.

Comparison of short-term results of modified Karydakis flap and modified Limberg flap for pilonidal sinus surgery.

The aim of this study was to compare and analyze the short term results of modified Karydakis flap reconstruction (MKF) and modified Limberg flap reconstruction (MLF). This is a retrospective analysis of 81 patients operated for pilonidal sinus disease. There were 46 patients in MLF group and 35 patients in MKF group. We compared patients age, BMI, operation time, removal time of suction drain, time of feeling completely healed, type of presentation, complications, postoperative 1., 3., 5. Days VAS scores, time to stop analgesic drugs and time to sit on chair or throne without pain. Complication rate, analgesic drug stopping time, postoperative 5. days VAS score were lower in MLF group and there were significant difference between groups. MLF group patients feel better (P: 0.010), they recommended this operation to other pilonidal sinus patients (P: 0.010) and 36 of them rated their satisfaction excellent and 10 of them good (P: 0.010). MLF procedure was more comfortable for patients. Lesser pain, lower complication and recurrence rates and higher patient satisfaction were detected in MLF group.

External validation of Lintula score in Turkish acute appendicitis patients.

PURPOSE: The aim of this study was to evaluate the predictive accuracy of Lintula score in Turkish appendicitis patients. MATERIALS AND METHODS: Data from a total of 156 patients operated with the diagnosis of acute appendicitis were collected retrospectively. The Lintula score was constructed from nine variables (gender, intensity of pain, relocation of pain, pain in the right lower abdominal quadrant, vomiting, body temperature, guarding, bowel sounds and rebound tenderness) with independent diagnostic value in 156 patients. Lintula score was calculated for all patients. Pathological results of the resected specimen were determined and the diagnostic performance of the Lintula score was compared. RESULTS: Hoshmer-Lemeshow and ROC curve analysis was performed and area under the curve was 0.922. Predictive accuracy of Lintula score among Turkish appendicitis patients was statistically significant. CONCLUSION: Lintula score seems to be useful method to diagnose acute appendicitis among Turkish patients and may reduce the rate of negative appendectomy.

Artificial neural networks in the diagnosis of acute appendicitis.

The aim of the study was to assess the role of artificial neural networks in the diagnosis of acute appendicitis in patients presenting with right lower abdominal pain. Data from 156 patients presenting with suspected appendicitis over a 12-month period to a rural hospital were collected prospectively. The sensitivity, specificity, and positive and negative predictive values of the artificial neural network were 100%, 97.2%, 96.0%, and 100% respectively. Artificial neural networks can be an effective tool for accurately diagnosing acute appendicitis and may reduce unnecessary appendectomies.

Diagnosis and treatment of multiseptate gallbladder with recurrent abdominal pain.

Laparoscopic cholecystectomy is usually performed for gallstones or polyp of the gallbladder. Multiseptate gallbladder is a rare congenital malformation. Although several asymptomatic cases have been described, patient usually present with right upper abdominal pain. We present a 29-year-old female patient with multiseptate gallbladder, cholecystectomy was performed, and her abdominal pain and gastrointestinal complaints have resolved.

Receiver operating characteristic analysis of leukocyte counts in operations for suspected appendicitis.

STUDY OBJECTIVE: There has been no clear-cut value of the white blood cell (WBC) count in differential diagnosis of acute appendicitis in emergency medicine. Therefore, the aim of this study was to assess the preoperative WBC counts in 3 groups of patients operated on for a clinical suspicion of acute appendicitis with different findings at appendectomy: uninflamed appendix, uncomplicated acute appendicitis, or complicated acute appendicitis. METHODS: The medical records of 540 patients who underwent appendectomy for suspected acute appendicitis during a 17-month period were retrospectively reviewed. Data for 3 groups of patients were analyzed to calculate the sensitivity and specificity of the WBC count in the diagnosis of acute appendicitis, and we calculated likelihood ratios for 2 cut-points with either high sensitivity or high specificity. Receiver operating characteristic curves were used to evaluate the WBC count in relation to the true diagnosis and severity of acute appendicitis. RESULTS: We were able to identify patients with appendicitis on a statistically significant level using receiver operating characteristic curves of WBC counts (area under the curve = 0.756, P < .001), but the WBC count had no diagnostic value in differentiating between uncomplicated and complicated groups (area under the curve = 0.55, P = .086). Likelihood ratio ranged from 1.79 (95% confidence interval, 1.17-2.3) for WBC count of more than 10,500 cells/mm(3) to 3.20 (95% confidence interval, 2.72-3.24) for WBC count of more than 14,300 cells/mm(3). CONCLUSION: White blood cell count is helpful in the diagnosis and exclusion of appendicitis. However, there is no value to differentiate advanced appendicitis.

Bilateral ductal carcinoma in situ of the breast after radiation therapy for Ewing's sarcoma of the vertebra in a young woman: report of a case.

Thoracic radiation in the early years of life is a known risk factor for breast cancer later in life. A 21-year-old woman who had received thoracic radiation therapy for Ewing's sarcoma of the vertebra 9 years earlier was referred to our hospital for investigation of a palpable mass in her left breast. Ultrasonography and excisional biopsy showed ductal carcinoma in situ (DCIS) of the left breast, with no detectable pathology in the right breast except that it was more hypoplastic than the left breast. Considering the known risk factors for invasive breast cancer in both breasts, we performed bilateral skin-sparing mastectomy with immediate breast reconstruction using subpectoral implants. The final histopathological diagnosis was bilateral DCIS.

Can biliary-cyst communication be predicted before surgery for hepatic hydatid disease: does size matter?

BACKGROUND: The aim of this study was to determine if there is any predictive factor indicating the risk of bile leakage before surgery for hepatic hydatid disease in clinically asymptomatic patients. METHODS: The data of 116 patients who underwent surgery for hepatic hydatid disease were reviewed retrospectively. There were 43 men (37%) and 73 women (63%) with a mean age of 45 +/- 15 years. Because of high preoperative serum bilirubin and liver function test levels, 12 patients were excluded from the study. These patients underwent preoperative endoscopic retrograde cholangiopancreatography. In addition, 2 medically treated patients were excluded from the study. The following variables were analyzed as potential predictors of biliary-cyst communication: age, sex, physical examination findings, leukocyte count, liver function test results, and ultrasonographic cyst features (type, diameter, number, and localization). RESULTS: Bile leakage was detected in 24 out of 102 patients. There were no differences in age, sex, cyst type, alkaline phosphatase level, gamma-glutamyl transpeptidase level, alanine aminotransferase level, aspartate aminotransferase level, bilirubin level, and number of cysts and cyst locations between the patients with and without bile leakage. The mean cyst size in patients with biliary leakage was 10.2 cm as compared with 6.1 cm in patients with no biliary leakage (P < .05). When the cut-off value of cyst diameter was accepted as 7.5 cm, the specificity and sensitivity for biliary-cyst communication were 73% and 79%, respectively. CONCLUSIONS: These data suggest that cyst diameter is an independent factor that is associated with a high risk of biliary-cyst communication in clinically asymptomatic patients. Preoperative endoscopic retrograde cholangiopancreatography should be performed in these asymptomatic patients to reduce the incidence of postoperative complications.

External validation of prognostic models among cancer patients undergoing emergency colorectal surgery.

BACKGROUND: The aim of this study was to evaluate the predictive accuracy of different scoring systems on patients undergoing emergency colorectal surgery. METHODS: The Acute Physiology and Chronic Health Evaluation II or III, the Simplified Acute Physiology Score II, the Mortality Probability Model II, and the Colo-rectal POSSUM scoring systems were applied to 102 patients who underwent colorectal resection for cancer. Validation of scoring systems was tested by assessing calibration and discrimination. Calibration was assessed using Hosmer-Lemeshow goodness-of-fit test and the corresponding calibration curves. Evaluation of the discriminative capability of both models was performed using receiver-operating characteristic curve analysis. RESULTS: Overall, 17 deaths occurred. The Simplified Acute Physiology Score II showed good calibration (x(2) = 1.079, P = .982) and discrimination (areas under the receiver-operating characteristic curve .83). CONCLUSIONS: These data suggest that the SAPS II scoring system was accurate in predicting outcome for patients undergoing emergency colorectal surgery.

Comparison and validation of scoring systems in a cohort of patients treated for perforated peptic ulcer.

BACKGROUND AND AIMS: The aim of this study is to evaluate the predictive accuracy of different scoring systems on surgery for perforated peptic ulcer referred to an academic department of general surgery in a tertiary reference center. PATIENTS AND METHODS: Seventy-five consecutive patients (Male/female ratio = 64:11; mean age, 44 years; range, 16-85) with perforated peptic ulcer disease were investigated. Disease severity scores and mortality predictions were calculated using the collected data during admission. Discrimination and calibration characteristics of each system, namely, the acute physiology and chronic health evaluation II and III, the simplified acute physiology score II, and the mortality probability models (MPM) II, were determined by using the area under receiver operating characteristics curve and the Hosmer-Lemeshow goodness-of-fit test, respectively. RESULTS: Among the 75 patients included, there were eight (10.6%) mortalities. All systems had a reliable power of discrimination and calibration. Among the systems tested, MPM II was the best performing as far as discrimination and calibration characteristics were considered. The parameters of MPM II system that were related to systemic perfusion of the patient were significantly positive in patients who died compared to those who survived. CONCLUSIONS: MPM II that predicted mortality at admission is better than the other systems in predicting mortality. Results also indicate the importance of maintenance of systemic perfusion of the patient at the early phases of peptic ulcer perforation.

A prospective randomized trial comparing the harmonic scalpel with conventional knot tying in thyroidectomy.

Currently, thyroidectomies are performed with very little morbidity. This study was undertaken to investigate whether the use of the harmonic scalpel during thyroid surgery has any advantage over the conventional technique. Eighty patients were randomly assigned to 2 groups. The patients in group 1 (n=40) underwent thyroidectomy performed with conventional knot tying and the electrocautery technique; in patients in group 2 (n=40), the harmonic scalpel was used for the procedure. Significant differences were observed between these 2 surgical techniques in terms of operative time, number of ligatures used, amount of bleeding, average length of incision, total amount of drainage fluid, and cosmetic satisfaction (P<.05). With the harmonic scalpel technique, there was a nearly 18% reduction in operative time. No significant differences were noted between mean hospital stay and postoperative pain (P>.05). No patient in either group had permanent recurrent laryngeal nerve palsy or hypoparathyroidism. The harmonic scalpel significantly shortens the duration of thyroidectomies; it can be used safely and effectively in thyroid surgery with no additional morbidity.

Comparison and validation of scoring systems in a cohort of patients treated for biliary acute pancreatitis.

OBJECTIVES: There are a few prospective studies assessing the severity of acute pancreatitis with exclusive criteria for biliary etiology. The aim of this study was to assess the reliability of prediction of the severity and mortality of acute biliary pancreatitis by using the Ranson, Acute Physiology And Chronic Health Evaluation II and III, Simplified Acute Physiology Score II, and Mortality Probability Model (MPM) II systems. METHODS: Fifty-eight patients with acute biliary pancreatitis were studied prospectively. Disease severity scores and mortality predictions were calculated using the collected data in the first 24 hours of admission and for Ranson score in the first 48 hours. Discrimination and calibration characteristics of each system were determined by using area under receiver operating characteristics curve and Hosmer-Lemeshow goodness-of-fit test, respectively. RESULTS: Among 58 patients included, there were 4 mortalities (6.8%). Fifteen patients (25.8%) had severe disease, and 5 patients (8.6%) had systemic and local complications. All systems had reliable power of discrimination and calibration. Among systems tested MPM II was the best performing as far as discrimination, and calibration characteristics are considered. The items of MPM II that were positive in patients with severe pancreatitis were those related to systemic perfusion. CONCLUSIONS: Mortality Probability Model II predicted mortality at admission is better than the other systems in predicting the severity of pancreatitis. Results also indicate the important role of systemic perfusion at the early phases of acute pancreatitis in the progression of disease.