Is it safe to be calcified? Porcelain gallbladder perforation and review of literature.

Calcification of the gallbladder wall (porcelain gallbladder) is an intense structure and uncommon manifestation seen in chronic cholecystitis and resulting from chronic inflammation of the gallbladder wall. Patients with porcelain gallbladder are usually considered not at risk of acute cholecystitis. However, sporadic cases of cholecystitis on porcelain gallbladder have been described in literature. Gallbladder perforation is a rare entity and may complicate on acute or chronic cholecystitis in a non-calcified gallbladder. We report an unusual case of acute cholecystitis with perforation in a porcelain gallbladder.

Severe gastrointestinal burn with hydrochloric acid.

Inadvertantly or purposely, an oral intake of corrosive substances may cause life-threatening problems. Early admission to the hospital, clinical and endoscopic evaluation, and early surgery when required, may reduce morbidity and mortality. We report the case of a 49-year-old male patient, who had attempted suicide, by drinking about 800 mL of 25% hydrochloric acid, and who had severe intra-abdominal damage. The aim of this report is to state the fact that a good outcome is possible in severe burns caused by oral intake of corrosive substances, when fast, multidisciplinary, and appropriate management is provided on time.

Antithrombin prevents apoptosis by regulating inflammation in the liver in a model of cold ischemia/warm reperfusion injury.

BACKGROUND/AIMS: Hepatic ischemia-reperfusion injury is a major problem in liver surgery. To modulate the complex process of inflammation, additional drugs to add to well-defined organ preserving solutions have been sought. The aim of the current study was to investigate the additive potential of antithrombin (AT) in liver preservation. METHODOLOGY: Female Wistar rats were randomized into four groups: sham (Group I), experiment model (Group II), and treatment groups with AT (250U/kg) administration systematically (Group III) or locally (Group IV) before hepatectomy. UW solution was used for liver preservation for 24h at 4°C. The livers in group II, III and IV were reperfused 1h and histopathological parameters were evaluated microscopically. Apoptosis was assessed with TUNEL test. RESULTS: Karyorrhexis was lower in the local treatment with AT group. Sinusoidal desquamation and mononuclear cell infiltration was higher in the experimental model group. Sinusoidal enlargement was higher in the systemic AT treatment group and neutrophil infiltration to sinusoids was lowest in the local treatment group. Apoptosis of hepatocytes and sinusoidal cells were significantly suppressed in rats that were treated with AT via portal vein infusion. CONCLUSIONS: AT treatment obviously contributed to liver preservation in our model; the effects on apoptosis and inflammation were prominent. Therefore, AT should be considered as a potent agent although its clinical role has yet to be defined in ex-vivo hepatic preservation.

A tumor-like lesion mimicking mucinous (colloid) carcinoma in heterotopic pancreas of the prepyloric antrum: a formidable challenge for frozen examination.

CONTEXT: Heterotopic pancreas is defined as the presence of pancreatic tissue, outside its usual location, which lacks anatomical and vascular continuity with the pancreas proper. Despite the development of modern diagnostic procedures, it is still difficult to differentiate heterotopic pancreas from benign or malignant tumors and other tumor-like lesions. Frozen examination of mucinous lesions arising from heterotopic pancreas may represent a diagnostic problem. A decision may be very difficult and it is sometimes impossible to decide on the basis of the frozen sections whether a lesion is benign or malignant. CASE REPORT: We report a tumor-like lesion mimicking a mucinous (colloid) carcinoma arising in heterotopic pancreatic tissue in the prepyloric antrum of a 56-year-old woman which was found incidentally during an elective laparoscopic cholecystectomy for cholelithiasis. The tumor was treated by wedge resection and, in the frozen section examination, there were pancreatic ducts in the proper muscle layer, pancreatic acini with islets of Langerhans under the serosal surface and mucinous lakes close to the heterotopic pancreatic tissue and to a peripheral nerve. CONCLUSION: The significance of this unusual lesion is its potential confusion with mucinous (colloid) carcinoma or other mucous tumors. Such confusion is more likely to occur if the tissue sample is selective or limited, and the presence of pancreatic tissue cannot be verified. Therefore, we believe that a choice of local excision, wedge resection or more extensive eradication be determined only after intraoperative, pathological confirmation of the complete and accurate diagnosis.

Factors predicting outcome of balloon dilatation in achalasia.

BACKGROUND: Balloon dilatation of the lower esophageal sphincter (LES) is one of the effective nonsurgical treatment options in the management of achalasia. We aimed to determine the long-term results of graded balloon dilatation and the factors predicting outcome. PATIENTS: Patients followed for more than 12 months between January 1995 to March 2005, without history of endoscopic or surgical therapy before the study, were included (n = 111, mean age 46.3 +/- 16.9 years; follow-up period 46.3 [12-150] months). Patients were evaluated by barium swallow contrast studies, upper endoscopy, and esophageal manometry. Pneumatic dilatation was performed with the use of polyethylene balloon system. Patient outcome was evaluated according to manometric studies and Van Trappen staging as determined following face-to-face interviews with the patients. RESULTS: We determined clinical response rates of 98%, 85.7%, and 75% at months 24, 48, and 60. According to receiver-operating characteristics (ROC) analysis, age or=30.5 mmHg, LESP after first balloon dilatation >or=17.5 mmHg, and balloon number >2 were found to negatively affect treatment response. Young age and higher esophageal body pressure at admission were determined to be negative predictive factors (P = 0.038, relative risk (RR) 2.6, 95% confidence interval [CI] 1.05-6.4 and P = 0.05, RR 1.069, 95% CI 0.99-1.14, respectively). CONCLUSION: Balloon dilatation is an effective treatment of achalasia. Young age, higher esophageal body pressure, and high LESP after first balloon dilatation are negative predictive factors. Patients with young age requiring more than two balloon dilatations are likely to be unresponsive to the treatment.

Laparotomy with a curative intent in patients with suspected locally recurrent gastric cancer.

AIMS AND BACKGROUND: Most recurrent gastric tumors are unsuitable for further resection or palliative surgery. The aim of the present study was to evaluate the role of re-resection in patients with local-regional recurrences of gastric cancer. METHODS AND STUDY DESIGN: Between 1998 and 2007, 26 patients underwent laparotomy for local-regional gastric cancer recurrence. Length of time to recurrence, recurrence patterns, operative procedures, morbidity, mortality and survival after re-resection were evaluated. RESULTS: Re-resection was possible in 13 patients (50%). Among patients with resectable tumors, survival times were markedly longer, with 2 patients reaching 60 months of survival and 2 other patients reaching 48 and 28 months, respectively. Among patients with early recurrence, peritoneal carcinomatosis was more common. After re-resection, morbidity and mortality were seen, each in one patient. CONCLUSIONS: Most of the re-resected recurrences were intraluminal. In patients with early recurrences of gastric cancer, peritoneal carcinomatosis was encountered most frequently. Re-resection was beneficial and long-term survival was achieved after re-resection.

Prognostic factors and clinicopathological characteristics of carcinoma of ampulla Vateri.

The aim of this study was to describe the clinicopathological characteristics and prognostic factors of carcinoma of ampulla Vateri. The medical records of 32 patients (24 men, 8 women) were evaluated. Median age was 59 years (range, 36-80 years). The performance status at the time of admission of (European Cooperative Oncology Group) 18 patients (56.3%) were ECOG-1; 8 patients (25.0%) were ECOG-2. Fifteen patients had early stage, 15 patients had locally advanced stage. Twenty-eight of 32 patients underwent curative surgery. Eleven, nine, and four patients had high-, moderate-, and low-grade histology, respectively. Fourteen patients received adjuvant treatment. Ten out of 14 patients were treated with chemotherapy. ECOG performance status (P = 0.06), stage (P = 0.05), perineural invasion (P = 0.01), tumor grade (P = 0.01), and treatment with chemotherapy, chemoradiotherapy, or only radiotherapy (P = 0.001) had a statistically significant impact on overall survival, whereas only tumor histopathology (P < 0.001) was shown to have a statistically significant effect on disease-free survival. Carcinoma of ampulla Vateri is a rare gastrointestinal tumor. Prospective trials with larger number of patients are needed to determine the prognostic factors to help select patients for adjuvant treatment.

Elimination of mucosectomy during restorative proctocolectomy in patients with ulcerative colitis may provide better results in low-volume centers.

BACKGROUND: To compare the outcomes of hand-sewn and double-stapling techniques among ulcerative colitis patients undergoing restorative proctocolectomy at a center that has limited experience with restorative proctocolectomy. METHODS: Forty-four patients with ulcerative colitis were divided into two groups according to the anastomosis techniques: hand sewing and double stapling. Postoperative early and late complications, postoperative hospital stay, and long-term functional results were compared. RESULTS: Pelvic sepsis (9% versus 36%, P = 0.03), operation time (median 240 minutes versus 270 minutes, P = 0.01), postoperative hospital stay (median 9 days versus 12 days, P = 0.04), and night incontinence (42% versus 80%, P = 0.07) were less common in the double-stapling group. CONCLUSIONS: We recommend the double-stapling technique to centers that do not have extensive experience with restorative proctocolectomy for ulcerative colitis. This technique provides a good postoperative course in most patients and provides satisfactory long-term results. The results of the double-stapling group were similar to the results of the high-volume centers.

The effect of recombinant growth hormone on intestinal anastomotic wound healing in rats with obstructive jaundice.

BACKGROUND/AIMS: Several clinical and experimental studies have shown that obstructive jaundice delays wound healing. Growth hormone may prevent delayed wound healing, since it has effects on the release of mediators in jaundice, as well as increasing the protein synthesis. METHODS: Forty male Wistar rats were allocated to four groups: Group I (n=10): intestinal anastomosis to normal small bowel, Group II (n=10): intestinal anastomosis to normal small bowel followed by growth hormone therapy (2mg/kg/day, subcutaneously), Group III (n=10): intestinal anastomosis to obstructive jaundice rat's small bowel, Group IV (n=10): intestinal anastomosis to obstructive jaundice rat's small bowel followed by growth hormone therapy at the same dosage The animals were observed for seven days then killed. Intraabdominal adhesions, anastomotic complications and anastomotic bursting pressures were recorded and tissue samples from the anastomotic site were obtained to measure hydroxyproline levels and for histopathologic examination. RESULTS: Growth hormone had a beneficial effect on the healing of intestinal anastomosis in both jaundiced and non-jaundiced rats. This was demonstrated by clinical and mechanical parameters such as a significant increase in anastomotic bursting pressure, hydroxyproline content and histopathological scores. CONCLUSION: Growth hormone reverses the adverse effects of obstructive jaundice on small bowel anastomotic healing. It can be hypothesized that this effect is due to augmentation of insulin-like growth factors, protection of hepatocytes, enhancement of intestinal epithelization, and reversal of the resultant malnutritional state caused by growth hormone in obstructive jaundice.

Polyarteritis nodosa presenting with necrotising appendicitis and hepatic aneurysm rupture.

Polyarteritis nodosa is a necrotizing vasculitis which affects small and medium-sized arteries. The clinical features of the disease vary according to the site and extent of involvement. Aneurysmal dilatation and thrombosis in the arteries of the liver and gastrointestinal tract have been reported in polyarteritis nodosa. However, rupture of the hepatic aneurysm and necrotizing appendicitis due to polyarteritis nodosa are uncommon; indeed a case in which these have occurred together has not been reported to date. In this case report, a patient with necrotizing appendicitis and hepatic aneurysm rupture due to underlying poliarteritis nodasa is presented. Extensive intraabdominal hematoma and appendicitis were treated surgically and complete recovery was achieved.

Short-term outcomes after surgery for colorectal cancer in Turkish patients aged 70 and above.

BACKGROUND/AIMS: We aimed to evaluate the impact of age on short-term surgical outcomes and to investigate the risk factors for postoperative mortality in 660 Turkish colorectal cancer patients. METHODS: Between January 2002 and January 2007, 660 consecutive patients who were operated for colorectal cancer at our institution were enrolled in this study. The patients were divided into two groups as: a younger group (<70 years) and an older group (≥70 years). Patient data were recorded prospectively with the use of specially designed forms. Variables and short-term patient results were compared. RESULTS: American Society of Anesthesiologists (ASA) scores were significantly higher and albumin levels were lower in the older group compared with the younger group (p<0.05). Morbidity and mortality rates were 16.8% (83/494) and 2.6% (13/494) in the younger group and 22.9% (38/166) and 3.0% (5/166) in the older group, respectively. These differences in rates were not statistically significant. ASA score (ASA 4) and non-resective procedures were found to be independent risk factors for mortality. CONCLUSIONS: Age should not be regarded as a reason for limited surgery. Elderly patients should undergo the same standard surgical approach as younger patients. The patient's general state of health is more effective on postoperative mortality.

Predictive factors for conversion to open surgery in patients undergoing elective laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy (LC) has become the standard surgical procedure for symptomatic gallbladder disease. The aim of this study was to identify factors that may be predictive of cases that would require a conversion to laparotomy. METHODS: In the period of 2002-2007, 2015 patients who underwent elective LC were included in the study. Patients were divided into two groups. Group 1 (n = 1914) consisted of patients whose operation was successfully completed with LC. Group 2 (n = 101) consisted of patients who had a conversion. A prospective analysis of parameters, including patient demographics, laboratory values, radiologic data, and intraoperative findings, was performed. Multivariate stepwise logistic regression was used to determine those variables predicting conversion. RESULTS: One-hundred and one (5.0%) patients required a conversion. Significant predictors of conversion to open cholecystectomy in univariate analysis were increasing age, male gender, previous upper abdominal or upper plus lower abdominal incisions, an elevated white blood cell count, high aspartate transaminase, alkaline phosphatase and total bilirubin levels, preoperative ultrasound findings of a thickened gallbladder wall and dilated common bile duct, preoperative endoscopic retrograde cholangiopancreatography (ERCP), high-grade adhesion, and scleroatrophic appearance of the gallbladder intraoperatively. Multivariate analysis revealed that a history of previous abdominal surgery, preoperative ERCP, high-grade adhesion, and scleroatrophic appearance of the gallbladder predicted conversion. CONCLUSIONS: Patient selection is very important for efficient, safe training in LC. Based on the presented data, pathways could be suggested that enable the surgeon to precisely decide, during LC, when to convert to open surgery.

Effects of previous abdominal surgery incision type on complications and conversion rate in laparoscopic cholecystectomy.

For laparoscopic cholecystectomy, previous abdominal operations are seen as a relative contraindication. The purpose of this study was to investigate the effects of the incision type of previous abdominal surgery on laparoscopic cholecystectomy in terms of complications and conversion to open surgery. Data from 677 patients who had previously undergone abdominal surgery before undergoing laparoscopic cholecystectomy were prospectively collected and evaluated. From the previous operations, the incisions were upper abdominal in 66 patients, lower abdominal in 567, and upper plus lower in 44. Conversion rates in the upper, lower and upper plus lower groups were 27.27%, 2.82%, and 25%, respectively. Intraoperative major complications were bile duct injury (1 patient, upper plus lower incision group), small bowel mesentery injury, and aortic injury (1 patient each, both in the lower incision group). Postoperative major intra-abdominal complications were duodenal injury (1 patient, upper incision group) and small intestine injury (1 patient, lower incision group). The lower abdominal incision group had fewer adhesions in the upper abdomen than did the other 2 groups, and as a result had a much lower conversion rate.

Surgical outcomes and survival after multiorgan resection for locally advanced gastric cancer.

BACKGROUND: Multiple organ resection for locally advanced (assumed T4) gastric cancer is associated with high morbidity and mortality. Our aim was to evaluate the efficacy of these surgeries with regard to surgical morbidity, mortality, and survival. METHODS: Fifty-six patients underwent potentially radical gastrectomy combined with invaded organ resection. Early and late results of multiorgan resection and clinicopathologic factors influencing these results were evaluated. RESULTS: Forty patients (71.4%) received 1 additional organ resection and 16 patients (28.6%) received 2 or more additional organ resections. Postoperative morbidity and mortality was 37.5% and 12.5%, respectively. Resection of 2 or more additional organs increased postoperative morbidity and advanced age increased mortality. The 1- and 3-year survival rates were 53.3% and 28.1%, respectively. Advanced age, lymph node metastasis, and resection of more than 1 additional organ were significant prognostic factors for survival. CONCLUSIONS: For patients with locally advanced gastric carcinoma, multiple organ resection is worthwhile with careful patient selection.

Spontaneous hepaticoduodenal fistula functioning like a bilioenteric anastomosis following bile duct injury: case report.

Bile duct injury is a serious complication of laparoscopic cholecystectomy. We report a case of spontaneous hepaticoduodenal fistula following bile duct injury. Initially, Roux-en-Y hepaticojejunostomy had been planned for the patient, but as the patient did not show any symptoms or findings of biliary obstruction, we preferred a non-operative management. The fistula allowed adequate biliary drainage, and the patient has been followed regularly by the outpatient clinic with good clinical results for approximately five years.

Effects of exopolysaccharide-producing probiotic strains on experimental colitis in rats.

PURPOSE: Inflammatory bowel disease is suggested to result from a dysregulated immune response toward intestinal microflora, which may be restored by probiotic therapy based on the concept of healthy microflora. Ideal probiotic bacteria may be beneficial in inflammatory bowel disease; however, the mechanism of action and the clinical efficacy of probiotic usage are still unclear. In the present study, the effect of exopolysaccharide producing probiotics was evaluated on an experimental colitis model in rats. METHODS: Colitis was induced by intracolonic administration of acetic acid. Then, rats were treated daily with two probiotic strains, Lactobacillus delbrueckii subsp. bulgaricus B3 strain (exopolysaccharide of 211 mg/l: high-EPS group) or Lactobacillus delbrueckii subsp. bulgaricus A13 strain (EPS of 27 mg/l: low-EPS group), which were given into the stomach. The non-colitis-fed control group was only treated with high-exopolysaccharide strain. The model-control and control groups were treated only with tap water. Rats were killed after a seven-day treatment period. Disease activity was quantified by use of histologic scores and colonic myeloperoxidase activity, which is a marker of neutrophil infiltration during inflammation. RESULTS: The enhanced inflammatory response was accompanied by a higher level of myeloperoxidase activity in the colitis group. Histologic scores of colonic damage and myeloperoxidase activity were lower in both probiotic-treated groups compared with those of the colitis control group (P<0.001), although the mentioned scores improved significantly more in the high-EPS group than in the low-EPS group (P<0.001). CONCLUSIONS: Exopolysaccharide-producing probiotics significantly attenuate experimental colitis, which may be mediated by exopolysaccharide in a dose-dependent manner. Therefore, exopolysaccharide-producing probiotics may be a promising therapeutic role in inflammatory bowel disease.