Nine years' experience of needle localized breast biopsy in a university hospital: results and evaluation of the role of the surgeon in decision making.

BACKGROUND: Needle localized breast biopsy is an effective means of detecting breast cancer in its early stages. We analysed the indications for needle localized biopsies, evaluated the results, and determined the surgeon's role in the decision-making process. METHODS: The needle localized open biopsy results of 350 patients were assessed. RESULTS: Malignancy was encountered in 7 of 56 patients in whom the radiologist suggested follow-up due to mammographical images, although a surgeon performed a biopsy with the assessment of the patient's historical and clinical findings (12.5%). Biopsy failure rates were higher for office-based ambulatory patients (9.1%) than for those patients who underwent biopsies in an operating theatre (1.9%; P < .05). Patients undergoing operating theatre biopsies under local anaesthesia showed statistically significant failure rates compared with those under general anaesthesia (p = .04). The rate of malignancy of micro-calcification was highest in patients younger than 40 years of age (64.3%), while spicular lesions were commonly malignant in patients over 50 years of age. CONCLUSIONS: From our experience, we suggest that needle localized biopsies should be performed in the operating theatre with the patient under general anaesthesia. Although both micro-calcifications and spicular lesions have a high rate of malignancy in all decades, micro-calcifications are more prevalent in younger patients while spicular lesions prevail in older patients. The final decision, to follow-up or biopsy, should be based on a patient's clinical and historical perspective and not only on the guidance of the mammography report.

A case of acute pancreatitis in a patient with systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) is an auto-immune disease which can affect multiple organs. It may also involve the pancreas and in rare cases may cause acute pancreatitis. The etiology of acute pancreatitis in SLE is a matter of controversy. We present a case diagnosed with SLE that developed acute pancreatitis while being treated with corticosteroids. During the course of the disease, pancreatic pseudocysts developed and were treated by percutaneous drainage. There are few reports in the literature about the therapy of acute pancreatitis and percutaneous drainage of pseudocysts in SLE. We discuss the pathogenesis and therapy for acute pancreatitis in SLE patients.

Gastritis cystica polyposa.

Gastritis cystica polyposa was diagnosed in five patients between ages 29 and 61 years. All five had been operated on for peptic ulcer disease three to 26 years earlier, when gastroenteric anastomoses had been made. The presenting complaint was abdominal pain, nausea and vomiting, or gastrointestinal bleeding. The lesions, located on the gastric side of the anastomosis, consisted of polypoid mucosal changes associated with hyperplasia and cystic dilatation of glands. Radiologic and endoscopic findings were often nondiagnostic, and surgical intervention was necessary to relieve obstruction and to rule out carcinoma. Resection of the gastrojejunostomy site and choosing anastomotic techniques to minimize bile reflux into the stomach appear to be the preferred methods of treatment.

Effect of hydrogen peroxide on permeability of the main pancreatic duct and morphology of the pancreas.

BACKGROUND: The direct effect of free oxygen radicals, if any, on the morphology of the pancreas has never been studied in vivo. This study was designed to evaluate the effects of hydrogen peroxide (H2O2) on permeability of the main pancreatic duct (MPD) and morphology of pancreas in cats when administered intraductally or intraarterially. METHODS: Thirty-six mongrel cats were randomly allocated into three groups, and all groups were divided into two subgroups. In group I and III, MPD was perfused with either standard perfusate (group IA and IIIA) or H2O2 at a concentration of 150 microM (group IB and IIIB) for 3 hours. In group II, the splenic artery was infused either with 0.9% sodium chloride (group IIA) or H2O2 (group IIB) for 3 hours. After 3 hours, in group I and II, MPD was perfused with 99mTc labelled dextran, and the percentage of the dextran permeated from the MPD into the portal vein was calculated for the evaluation of the pancreatic duct permeability. Then, tissue samples were obtained for the examination of early histopathological changes in pancreas. In group III, following ductal perfusion studies, the cats were allowed to recover. After 24 hours animals were killed, and samples were taken for the examination of late histological changes in pancreas. In all groups, an inflammatory score was created for each animal based on the pathological changes in pancreas: edema, leukocyte infiltration, parenchymal necrosis, and hemorrhage. RESULTS: Group I: All cats developed acute edematous pancreatitis with significantly higher inflammatory scores than controls (P < 0.01). Desquamation of the single layer of columnar epithelium that normally lined the duct and leukocyte infiltration around the MPD duct were found. Pancreatic duct permeability was found to be increased significantly (P < 0.01). Group II: There were no statistical differences in inflammatory scores and pancreatic duct permeability between experimental and control groups (P > 0.05). Group III: All animals developed gross acute edematous pancreatitis after 3 hours of intraductal H2O2 perfusion. Histopathological changes at 24 hours were much more pronounced in group IIIB than in group IIIA including focal necrosis and hydropic degeneration of acinar cells. CONCLUSION: This study has shown that intraductal H2O2 perfusion induced acute edematous pancreatitis with marked histopathological changes and increased pancreatic duct permeability in cats. Intraarterial H2O2 infusion, however, has no effect on the permeability of the MPD and morphology of pancreas in our model.

A case of type 3 choledochal cyst masquerading as acute abdominal pain.

A type 3 choledochal cyst, presenting with acute abdominal pain attacks, was diagnosed in a 24-year-old man. Previously he had undergone exploratory laparotomy for acute abdominal pain, which had proved negative. An internal drainage procedure was chosen as the surgical procedure. The patient is under constant follow-up because of the risk of a malignancy developing.

The usefulness of intra-operative endoscopy in Peutz-Jeghers syndrome: a case report.

The Peutz-Jeghers syndrome is an autosomal dominant inherited disease manifested by a combination of mucocutaneous pigmentation and gastrointestinal hamartomatous polyps that usually cause intussusception and intestinal hemorrhage. We report a case in which the patient has been followed-up on for 14 years and who underwent surgical and endoscopic polyp removal several times as well as one intestinal resection. This time, with the use of combined surgery and perioperative endoscopy, 27 polyps were removed, performing only 3 enterotomies. This is the highest number in one session to be reported in the literature. The usefulness of this technique is providing a "clean small intestine" that allows the patient a longer time interval between laparotomies and reduces the complications associated with multiple laparotomies and resections.

Periampullary carcinoma detected after sphincterotomy.

BACKGROUND/AIMS: Although periampullary carcinoma can often be diagnosed at an early stage because of its strategic location, in a substantial number of cases (23% to 25% of periampullary carcinoma cases), the papilla can be prominent, but without an identifiable mass or ulceration. As a result, duodenoscopy alone can miss the tumor. In this series, the usefulness of sphincterotomy in establishing a diagnosis of periampullary carcinoma is documented. MATERIALS AND METHODS: A total of 664 patients, who had clinical, biochemical and/or sonographic evidence of pancreaticobiliary disorders underwent endoscopic retrograde cholangiopancreaticography (ERCP) at Hacettepe University Hospital between March 1985 and September 1994. All identified lesions were biopsied. RESULTS: In sixty-six of the 664 patients, a specific periampullary or pancreatic diagnosis could be made. These included 30 cases of pancreatic carcinoma (14 in the head, 15 in the corpus, and 1 in the tail), 10 cases of chronic pancreatitis, 15 cases of periampullary carcinoma and 11 miscellaneous. None of the 15 periampullary carcinomas was demonstrable by abdominal computed tomography, sonography or pancreatic angiography. In 12, the diagnosis was established immediately by endoscopic visualization of the tumor and biopsy. In the remaining 3, the tumor was visualized as a protruding mass only after a papillatomy was performed. All cases were treated surgically with a pylorus preserving pancreaticoduodenectomy. No symptoms of dumping were experienced postoperatively. The survival of these 15 patients was good with a mean survival of 24.2 months. CONCLUSIONS: Careful endoscopic examination of the periampullary mucosa before and after sphincterotomy is required to identify periampullary carcinoma. A pylorus preserving pancreaticoduodenectomy revealed excellent post-surgical outcome with no post operative symptoms of the dumping syndrome.

Congenital hepatic fibrosis associated with cavernous transformation of the portal vein.

BACKGROUND/AIMS: Congenital hepatic fibrosis (CHF), which is one of the fibropolycystic diseases, occurs in various forms. Portal hypertension, a very common clinical feature of this condition, has been attributed to the compression of portal vein radicles in the fibrous bands. We investigated whether there are any other contributing factors in the development of portal hypertension in patients with CHF. METHODOLOGY: A total of 1285 patients with portal hypertension of different etiologies were studied using ultrasonography as the screening test. Forty-seven (including portal vein involvement and/or CHF) of these 1285 patients were prospectively studied to evaluate the etiology of the portal hypertension by portography, abdominal computed tomography, exploratory laparotomy, peritonoscopy, liver biopsy and laboratory tests. The patients with CHF were divided into two groups, according to whether or not they had portal vein involvement. RESULTS: Eleven (0.8%) of the 1285 patients with portal hypertension had CHF, and 41 (3.2%) had cavernous transformation of the portal vein (CTPV), resulting from different or unknown etiologies. Five patients had both pathologies (CTPV and CHF). In the 11 patients with CHF, there was CTPV in 5 patients, Caroli's disease in 2 patients, cholangiocarcinoma in 1 patient, inferior vena caval obstruction in 1 patient, and CHF in only 2 patients. There were statistically significant differences in the age of the CHF patients at clinical onset, the incidence of bleeding from esophageal varices, and laboratory findings between the 2 groups with and without CTPV. Despite a thorough investigation, we could not distinguish any predisposing factor in 25 of the 41 patients with CTPV. The incidence of CTPV was 48% in patients with CHF and 3.2% in patients with portal hypertension. CONCLUSIONS: These results suggest that the association of CTPV with CHF is not coincidental, but that CTPV may be associated with CHF and a new possible factor in portal hypertension, and that it can be a major factor in the manifestation of esophageal bleeding from varices.

Internal hernia in adults.

BACKGROUND: Congenital bands, congenital anomalies of the intestinal rotation and congenital defects in the mesentery or omentum, postsurgical or traumatic defects of the mesentery and omentum are important factors that predispose to internal herniation. In this retrospective study, 18 cases of internal herniation were evaluated and the factors that effect the prognosis were investigated. METHODS: The records of 609 patients who underwent laparotomy due to acute intestinal obstruction were retrospectively reviewed. The cause of intestinal obstruction was internal herniation in 18 patients. The patients were evaluated with respect to signs and symptoms, radiological findings, time elapsed between the onset of symptoms and surgery, findings, in surgery, type of operation performed, postoperative complications and postoperative stay. RESULTS: Postoperative complications were encountered more frequently in the patients with bowel strangulation (p=0.045) in our series. Time elapsed between the onset of symptoms and laparotomy was found to be significantly longer in the patients with strangulation than in those without strangulation (p=0.046). Additionally, postoperative hospital stay was shorter in the patients without strangulation (p=0.03). CONCLUSIONS: Since preoperative diagnosis of an internal herniation is very difficult because of the lack of specific signs and symptoms, postoperative complications can only be decreased with early surgical intervention in the patients with acute intestinal obstruction.

Surgical treatment of substernal goiter.

BACKGROUND: Substernal goiter differs from its cervical counterpart in regard to its clinical presentation, surgical management, pathological analysis and postoperative complication. METHODS: Retrospective analysis of 1320 thyroidectomies performed at the Hacettepe University Hospital between 1990 and 1997. RESULTS: 30 (2.3%) of 1320 thyroidectomies underwent operation for removal of substernal goiters in an 8-year period. The most common symptom was cervical mass (67%) and 33% of the patients were asymptomatic. Computerised tomography was the most accurate pre-operative test for detecting substernal extension. Substernal goiters were removed by collar incisions in 93% of the cases. The pathology was generally found to be benign (94%), but follicular carcinoma was present in two (6%) patients. There was no mortality and no complications were observed in 73% of the patients. CONCLUSIONS: The presence of substernal goiter is an indication for removal given the lack of any effective medical therapy, low surgical morbidity, risk of malignancy and acute obstructing symptoms.

Factors affecting postoperative mortality in abdominal trauma.

Records of 345 patients in whom laparatomies were performed because of blunt and penetrating abdominal trauma were reviewed retrospectively with respect to factors affecting mortality. One hundred and twenty-eight patients had blunt abdominal trauma (Group I), 114 patients had gunshot wounds of the abdomen (Group II), and 103 patients had stab wounds of the abdomen (Group III). Mortality rates were 14.8%, 12.3% and 1.9% in groups I, II and III respectively. The presence of head trauma especially if accompanied by hypotension in group I, and the presence of chest trauma (hemothorax and/or pneumothorax) and hypotension (less than 90 mmHg) in group II were associated with a high mortality rate (p less than 0.05). Of the two patients who died in group III, one had septic shock due to massive intestinal necrosis and the other had hemorrhagic shock due to multiple organ injury and bleeding from an injured internal thoracic artery as the cause of death.

Biliary enteric fistulas.

Thirty-one patients with biliary enteric fistula who were operated on over a 19-year period (1976-1994) with an incidence of 0.74% in all biliary tract operations were reviewed retrospectively to identify etiologic factors, types of fistulas, signs and symptoms, methods of diagnosis, management and prognosis of the cases. Most common symptoms were abdominal pain, nausea, vomiting and jaundice. Two patients had gallstone ileus. The majority of the patients had severe concomitant medical illnesses. The exact preoperative diagnosis of a biliary enteric fistula was established in only five (16%) patients. In 81% of the cases fistula was secondary to chronic calculous biliary tract disease. Postoperative complications included wound infection in six (19%), biliary fistula in two (6%) and erosive gastritis in one (3%) patient. Two patients died of intra-abdominal sepsis and two of cardiac failure, with an operative mortality of 13%. Early elective cholecystectomy is recommended to avoid complications of chronic calculous cholecystitis such as bilioenteric fistulas and their increased mortality and morbidity.

Pylorus preserving pancreaticoduodenectomy.

We have performed 9 pylorus preserving pancreaticoduodenectomies (PPPD) for periampullary malignancies. In these 9 patients, six had been diagnosed as having carcinoma of the ampulla of Vater, two pancreatic carcinoma and one duodenal carcinoma. We have no operative mortality and a 44 per cent rate of morbidity. Complications include wound infections (3), pleural effusion (1), intraabdominal abscess (1), delayed gastric emptying (1). There was neither biliary nor pancreatic leakage in these patients. None of the patients had gastrointestinal haemorrhage and marginal ulceration. We have complete follow-up for all cases. Eight of 9 patients are alive, one patient who had been operated for carcinoma of ampulla of Vater died the 14th month postoperatively. During the follow-up, in 7 patients we have observed neither recurrence nor metastasis but in one patient, who is still alive, operated for carcinoma of the pancreas, recurrence in the pancreatic remnant was detected 27 months after the operation. In four months, all patients regained 90 per cent of the weight lost prior to operation. During the follow-up period no patients had gastrointestinal dumping, diarrhoea, or delayed gastric emptying. We concluded that PPPD, technically easier and faster, can therefore be performed with a much lower morbidity and mortality than the standard Whipple procedure. Preservation of the pylorus reduces the incidence of marginal ulceration, and patients undergoing PPPD are more likely to regain their preoperative weight. The antrum and pylorus were structurally preserved in the first successful radical pancreaticoduodenectomy performed by Kausch in 1912 (13) and Whipple in 1935 (28).(ABSTRACT TRUNCATED AT 250 WORDS)

Portomesenteric gas due to intestinal obstruction: a case report.

A case of mesenteric vein gas as a nonfatal complication of intestinal obstruction is reported. A 48-year-old woman presented postoperatively signs and symptoms of acute abdomen on the eighth day following a gastric pull-up surgery due to an oesophageal carcinoma. The abdominal tomography findings revealed dilated jejunal segments and free gas in the superior mesenteric vein and end branches of the portal vein in the left hepatic lobe. The patient underwent a second laparotomy with a provisional diagnosis of intestinal ischaemia. Intraoperative gross appearance of the intestines revealed no ischaemic finding, the pathology was the dense adhesions between the jejunal segments and previous incision site. On the basis of these findings, the operation was ended with adhesiolysis. One month after the operation, the patient was well, there were no complications. As the authors, we think that the main reason for portomesenteric gas is mucosal destruction and that these case may be followed conservatively as long as intestinal ischaemia is excluded.

Laparoscopic splenectomy for haematological diseases.

PURPOSE: To show the utility of laparoscopic splenectomy for hematologic diseases. PATIENTS AND METHODS: Ten patients with hematologic diseases who were operated between February 1997 and October 1998 were analysed retrospectively. TECHNIQUE: The operations were performed by four trocars, hilar vessels were divided by clips and bag was used for splenic retrival. RESULTS: All operations were completed successfully. No accessory spleens were found. Intraoperative complication, other than a bag tear in one operation did not occur. Postoperative complications occurred in two patients. The first one was a portal vein thrombosis and the second one was a peritonitis. All patients responded hematologically to the operation. CONCLUSION: With appropriate surgical technique and patient follow up, laparoscopic splenectomy is a safe, adventageous and efficaceus operation for hematologic diseases.

Pyloric stenosis with esophageal involvement in Behçet's syndrome.

A 43-yr-old man with a diagnosis of Behçet's syndrome since 1977 developed esophageal aphthous ulcerations, duodenal ulcer, and pyloric stenosis. The pyloric stenosis was due to edematous hypertrophy of the pyloric ring. The evidence strongly suggested that these findings were complications of Behçet's syndrome.

Antegrade jejunojejunal intussusception after Roux-en-Y esophagojejunostomy as an unusual cause of postoperative intestinal obstruction: report of a case.

Postoperative intestinal obstruction in adults is rarely caused by intussusception. A case of antegrade jejunojejunal intussusception that occurred after Roux-en-Y esophagojejunostomy is described, followed by a discussion of the literature on this unusual entity.

Bile duct varices or "pseudo-cholangiocarcinoma sign" in portal hypertension due to cavernous transformation of the portal vein.

A total of 832 patients with portal hypertension resulting from different etiology was studied by ultrasonograph as a screening test. In 17 of the 832 patients, cavernous transformation of the portal vein was detected by means of ultrasonography. We have prospectively studied these 17 patients, and the diagnosis of cavernous transformation was confirmed by portography in all patients. To evaluate how much biliary tract has been affected from cavernous transformation of the portal vein, and to explain the cause of mildly increased alkaline phosphatase and serum bilirubin levels, endoscopic retrograde cholangiopancreatography (ERCP) was performed in 16 of the 17 patients. There were narrowing, irregularity, undulation and nodular extrinsic defects resulting from compression of thrombosis of the portal vein and the collateral vessels, mimicking cholangiocarcinoma spreading along the common bile duct on the extrahepatic biliary tract in all 16 patients who underwent ERCP. Similar ERCP findings were not found in six patients with portal hypertension due to liver cirrhosis. The ultrasonographic, portographic, and ERCP findings corresponded to surgical findings in six patients who had undergone splenectomy for either hypersplenism or bleeding from esophageal varices. The results indicate that cavernous transformation of the portal vein cause the above-mentioned radiographic findings that we propose to call "pseudo-cholangiocarcinoma sign."

The "pseudo-cholangiocarcinoma sign" in patients with cavernous transformation of the portal vein and its effect on the serum alkaline phosphatase and bilirubin levels.

OBJECTIVES: The goal of this study was to identify the underlying disorder responsible for portal venous thrombosis and cavernous transformation of the portal vein (CTPV). All patients with this finding underwent a thorough medical examination with intent to determine the cause and biochemical consequences of CTPV. METHODS: During an 8-yr period, a total of 1247 patients with clinical evidence of portal hypertension were examined using ultrasonography. Forty four of these 1247 patients were found to have CTPV. In each case, the finding of CTPV was confirmed by portography using either splenoportography or arterial portography, with digital subtraction angiography. These 44 patients were studied in an effort to determine the etiology of the cavernous transformation. In addition, the specific reason for the increased serum bilirubin and alkaline phosphatase levels in 35 of the 44 cases was evaluated by endoscopic retrograde cholangiopancreatography (ERCP) (34 patients), percutaneous transhepatic cholangiography (one patient), and by CT in 19. The surgical findings in 10 of these 44 patients, who ultimately underwent splenectomy and portal venous decompression for bleeding, were reviewed in light of the ultrasonographic, portographic, and ERCP findings in the same 10 patients. RESULTS: The underlying disorder responsible for cavernous transformation was found to be Behcet's disease in seven patients, chronic liver disease in four, congenital hepatic fibrosis in five, congenital protein C deficiency in one, and a prior abdominal operation for cholelithiasis in one patient. Despite a full clinical, radiological, hematological, and chemical evaluation, no etiology for CTPV was found in the remaining 26 patients. All of these later cases had no indication for liver biopsy or evidence for parenchymal liver disease. In these 26 patients, the serum levels of bilirubin and alkaline phosphatase ranged from mild to moderately increased compared with the moderately to markedly increased levels present in the 18 patients having an identifiable underlying liver disease. Irregular, undulating narrowing and nodular extrinsic defects, the so-called "pseudo-cholangiocarcinoma sign" was present in 33 of the 35 patients who underwent either ERCP or percutaneous transhepatic cholangiography. No such findings were observed in 10 control cirrhotic patients with portal hypertension but without CTPV, who also underwent ERCP. CONCLUSION: The results of this study indicate that mildly increased serum alkaline phosphatase and direct reacting bilirubin levels occur in cases with CTPV associated with a pseudo-cholangiocarcinoma sign. Presumably, these enzyme elevations are a result of compression of the biliary tree by the venous collaterals that run along the extrahepatic biliary tree. None of the 33 cases with this sign had cholangiolar carcinoma. Thus, when a patient with splenomegaly but without documentable parenchymal liver disease demonstrates an increase in the serum direct reacting bilirubin and alkaline phosphatase levels, CTPV and the presence of large extrahepatic venous collaterals partially obstructing the biliary tree should be suspected.