The Role of Different Molecular Markers in Papillary Thyroid Cancer Patients with Acromegaly.

PURPOSE: Prevalence of papillary thyroid cancer (PTC) is increased in patients with acromegaly. We aimed to determine the protein expression of BRAF, RAS, RET, insulin like growth factor 1(IGF1), Galectine 3, CD56 in patients with PTC related acromegaly and to compare the extensity of these expressions with normal PTC patients and benign thyroid nodules. METHODS: We studied 313 patients with acromegaly followed in Cerrahpasa Medical Faculty, Endocrinology and Metabolism Clinic between 1998 and 2015. On the basis of availability of pathological specimen of thyroid tissues, thyroid samples of 13 patients from 19 with acromegaly related PTC (APTC), 20 normal PTC and 20 patients with multinodulary goiter (MNG) were histopathologically evaluated. Protein expressions were determined via immunohistochemical staining in ex-vivo tumor samples and benign nodules. RESULTS: The incidence of PTC in acromegaly patients were 6% (n=19). Among patients with PTC, APTC and MNG, all the immunohistochemical protein expressions we have studied were higher in papillary thyroid cancer groups (p<0.01, for all). Between PTC group without acromegaly and APTC, galectin 3 and IGF1 expression was significantly higher in acromegalic patients (p<0.01 for all) while RAS was predominantly higher in PTC patients without acromegaly (p<0.01). CONCLUSION: BRAF expression was not higher in PTC with acromegaly patients compared to PTC patients without acromegaly. Galectine 3 and IGF1 were expressed more intensively in APTC. These positive protein expressions may have more influence on determining malign nodules among acromegaly patients.

Hyalinizing trabecular tumor of the thyroid gland.

Hyalinizing trabecular tumor was first described by Carney et al. (1) in 1987 and is a rare benign tumor of the thyroid gland that shares some of the microscopic features of medullary and papillary thyroid carcinoma. Hyalinizing trabecular tumor derives from follicular cells, and it is characterized by an apparent trabecular pattern and intratrabecular hyalinization. In this study, we present the case of a 40-year-old female patient with thyroid gland nodules, whose ultrasound results, clinical behavior, and fine-needle aspiration biopsy results were suspicious; the pathology after thyroidectomy indicated hyalinizing trabecular tumor. We aimed to show the role of clinical behavior, radiology, fine-needle aspiration, and histological and immunohistochemical analysis in the differential diagnosis of hyalinizing trabecular tumor. Hyalinizing trabecular tumor which can be confused with papillary and medullar carcinoma of the thyroid gland, is mostly benign but some malignant and metastatic cases have been reported. Therefore, diagnosis, treatment, and follow-up steps of Hyalinizing trabecular tumor should be planned in consideration of a malignant potential.

Combination Technique Is Superior to Dye Alone in Identification of the Sentinel Lymph Node in Male Breast Cancer.

Sentinel lymph node (SLN) biopsy is the main method in staging the axilla. There are insufficient data available regarding the accuracy of an SLN biopsy in male breast cancer. The aim of this study is to evaluate whether the combination of dye and radiotracer would improve the detection rate of SLNs versus dye alone in male breast cancer patients. From February 2009 to January 2012, our SLN biopsy database was retrospectively reviewed to identify male breast cancer cases. Of the 890 SLN procedures contained in the database, 10 male breast cancer patients were identified. Patient age, body mass index, SLN biopsy technique, SLN identification, number of SLN excised, and pathology reports were reviewed. Mean age was 57.2 (34-85) years with a mean tumor size was 2.2 (1.0-4.0) cm. SLN detection ratios were two in four with blue dye and six in six with the combination technique. Overall, SLNs were identified in 8 of the 10 patients. SLN biopsy is applicable in male breast cancer cases. The addition of a radiotracer to the dye in SLN biopsy increases the detection rate of sentinel nodes in male breast cancer patients.

Experience in totally implantable venous port catheter: Analysis of 3,000 patients in 12 years.

BACKGROUND: This study aims to present our experience with patients who were performed totally implantable venous port catheter. METHODS: Demographics-clinical features, surgical results and complications of 3,000 patients (1,824 males, 1,176 females; mean age 61.04±11.5 years; range, 18 to 88 years) who were performed totally implantable venous port catheter between March 2005 and March 2017 were evaluated retrospectively. Totally implantable venous port catheter indications, complications, catheter duration of stay, reasons for catheter removal and statistical analysis information were reported in detail by reviewing patient records. RESULTS: Of the cases, the Seldinger method was used in 98%, 1% (n=36) had the catheter inserted with superficial Doppler ultrasonography, while the veins were not found in 1% (n=29) and these patients were excluded from the study. Totally implantable venous port catheter was inserted via right internal jugular vein in 2,095 patients (70%), via right subclavian vein in 470 patients (16%), via left internal jugular vein in 290 patients (10%), and via left subclavian vein in 106 patients (3%). Mean duration of stay for totally implantable venous port catheter was 46.7 months (range, 1 to 78 months). Complications were detected in a total of 288 patients (9.6%), 153 (5.1%) being early and 135 (4.5%) being late. The most common oncologic indication was colorectal cancer. The rate of port removal was 298/3,000 (9.9%) and the main reasons were infection, thrombosis, pain, and end of treatment. Totally implantable venous port catheter was required to be inserted twice in 33 patients (1%) and thrice in 14 patients (0.5%). Totally implantable venous port catheter had malposition in eight patients and all were revised successfully with over the guide method. CONCLUSION: Totally implantable venous port catheter may increase the quality of life in cancer patients. Despite possible complications, totally implantable venous port catheter is safe and comfortable for long-term intravenous treatment. Possible complications may be prevented or managed when totally implantable venous port catheter is performed by surgeons with adequate experience.

Regional Clinical and Biochemical Differences among Patients with Primary Hyperparathyroidism.

BACKGROUND: Environmental habitat may play a role in clinical disparities of primary hyperparathyroidism (pHPT) patients. AIMS: To compare preoperative clinical symptoms and associated conditions and surgical findings in patients with pHPT, living in different geographical regions from the Black Sea, Mediterranean and Anatolia regions. STUDY DESIGN: Retrospective, clinical-based multi-centric study of 694 patients with pHPT. METHODS: Patients from 23 centers and 8 different geographical regions were included. Data related to baseline demographics, clinical, pathologic and treatment characteristics of 8 regions were collected and included age, gender, residential data, symptoms, history of fracture, existence of brown tumor, serum total Ca and p levels, serum parathormone (PTH) levels, serum 25-OH vitamin D levels, bone mineral density, size of the resected abnormal parathyroid gland(s), histology, as well as the presence of ectopia, presence of dual adenoma, and multiple endocrine neoplasia (MEN)- or familial-related disease. RESULTS: The median age was 54. Asymptomatic patient rate was 25%. The median PTH level was 232 pg/mL and serum total Ca was 11.4 mg/dL. Eighty-seven percent of patients had an adenoma and 90% of these had a single adenoma. Hyperplasia was detected in 79 patients and cancer in 9 patients. The median adenoma size was 16 mm. Significant parameters differing between regions were preoperative symptoms, serum Ca and p levels, and adenoma size. All patients from South-East Anatolia were symptomatic, while the lowest p values were reported from East Anatolia and the largest adenoma size, as well as highest Ca levels, were from Bulgaria. CONCLUSION: Habitat conditions vary between geographical regions. This affects the clinicopathological features of patients with pHPT.

Changes in the elasticity of fibroadenoma during the menstrual cycle determined by real-time sonoelastography.

OBJECTIVE: Shear-wave elastography (SWE) presents quantitative data that thought to represent intrinsic features of the target tissue. Factors affecting the metabolism of the breast parenchyma as well as age, menstrual cycle, hormone levels, pregnancy and lactation, pre-compression artifact during the examination could affect these elastic intrinsic features. Aim of our study is to determine variation of fibroadenoma elasticity during the menstrual cycle (MC) by means of real-time shear-wave elastography (SWE) and identify the optimal time for SWE evaluation. METHODS: Thirty volunteers (aged 20-40 years) who had biopsy-proven fibroadenoma greater than 1cm in diameter, with regular menstrual cycle and without contraceptive medication underwent SWE (ShearWave on Aixplorer, France) once weekly during MC. Statistical data were processed by using the software Statistical Package for the Social Sciences (SPSS) 19.0. A repeated measures analysis of variance was used for each lesion where the repeated factor was the elastographic measurements (premenstrual, menstrual and postmenstrual). Pillai's trace test was used. Pairwise correlation was calculated using Bonferroni correction. Values of p<0.05 were considered statistically significant. RESULTS: The mean elasticity value of fibroadenomas in mid-cycle was 28.49 ± 12.92 kPa, with the highest value obtained in the third week corresponding to the premenstrual stage (32.98 ± 13.35 kPa) and the lowest value obtained in the first week corresponding to the postmenstrual stage (25.39 ± 10.21 kPa). Differences between the elasticity values of fibroadenomas in premenstrual and postmenstrual periods were statistically significant (p<0.001). There were no significant differences in lesion size between the different phases of the menstrual cycle (p>0.05). CONCLUSION: In this study, we found that there is significant difference between the elasticity values of fibroadenomas on premenstrual and postmenstrual period. We propose that one week after menstruation would be appropriate time to perform breast SWE.

The investigation of foxe1 variations in papillary thyroid carcinoma.

BACKGROUND: Recent reports indicated that incidence of thyroid carcinoma is increasing throughout the worldwide. The aim of our study was to determine a possible relationship between Forkhead box E1 (FOXE1) gene variants and histopathological features of papillary thyroid carcinoma. METHODS: FOXE1 gene variations; rs894673, rs1867277 and rs3758249 were analyzed in 57 Papillary thyroid carcinoma patients and 51 age matched healthy control subjects. Restriction fragment length polymorphism (RFLP) technique was used to specifically detect the variations. RESULTS: There was a significant difference in the distribution of rs894673 genotypes in Papillary thyroid carcinoma cases (P=0.01). AA genotype presence of rs1867277 was more significantly associated with several histopathological parameters such as focal and diffuse capsular invasion, lymphatic invasion, P3 with P4 tumor grade and surgical margins. AA genotype presence in rs1867277 variation was significantly associated with the classical variant which is subtype of papillary thyroid carcinoma. Furthermore, the presence of the allel A was found to be related with lymph node invasion risk by 2.46 fold, capsular invasion risk by 2.97 fold, and pT3 with pT4 pathological stage risk by 4.13 fold and the presence of allele A in rs1867277 was significantly associated with classic variants. The presence of allele A in rs1867277 was more significantly associated with several histopathological parameters in classic variant in papillary thyroid carcinoma cases such as, the presence of the A allele was found relationship with lymph node invasion risk by 2.0 fold, capsular invasion risk by 2.39 fold , and pT3 with pT4 pathological stage risk by 3.57 fold. In addition, AATT, AAAA and GATT haplotypes (rs1867277 and rs894673) were evaluated for association with papillary thyroid carcinoma cases. Our results indicate that the significant difference according to two-allele haplotype distribution between papillary thyroid carcinoma cases and control groups. CONCLUSION: Our findings suggest that FOXE1 variations generate a higher risk for poor histopathological features of papillary thyroid carcinoma.

Recurrent bleeding of parastomal varices: case report.

Bleeding of parastomal varices is an unusual complication of portal hypertension. We report a case with recurrent parastomal variceal bleeding who had chronic liver disease secondary to autoimmune hepatitis and who had undergone abdominoperineal resection for rectal cancer. She presented four episodes of parastomal variceal bleeding in one month and was successfully treated with combined polidocanol and cyanoacrylate glue.

A rare complication of jejunostomy tube: Enteral migration.

Feeding jejunal tubes provide an excellent method for enteral nutritional support in cases where the oral route is impossible or insufficient for use. However, several complications may result from the placement of the tube. Detachment of the tube and migration through the intestine is a very rare complication. We report herein a 65-year-old male patient in whom a jejunal feeding tube (28-F Pezzer catheter) was placed two months before due to unresectable gastric cancer. He presented with disappearance of the tube and abdominal pain. Radiological investigations showed the tube localized in the lumen of the small intestine and its advancement through the gut. Conservative measures were taken as there was neither intestinal obstruction nor peritonitis. The tube passed spontaneously through the rectum 18 days later. One should be careful during the placement of jejunostomy tubes, and health care providers and patients should be instructed well in the care of feeding enterostomy tubes in order to prevent this complication.

Single-port laparoscopic sphincter-saving mesorectal excision for rectal cancer: report of the first 4 human cases.

HYPOTHESIS: Single-port laparoscopic rectal surgery can be performed using the principles of oncologic surgery in institutes experienced in laparoscopy with the advantages of minimally invasive surgery. DESIGN: Sphincter-saving mesorectal excision in 4 human cases via a single laparoscopic port. SETTINGS: A university hospital and a private hospital. PATIENTS: A series of 4 patients who underwent single-port laparoscopic sphincter-saving rectal resection for rectal cancer. Two of them were total and 2 were partial mesorectal excisions. INTERVENTIONS: An umbilical incision was made to place the multichannel single port. The sigmoid colon was hung to the left lateral abdominal wall using an intracorporeal stitch passing through its appendices epiploicae to achieve medial dissection and vascular ligation. The mesorectum was sharply dissected down to the pelvic floor. Endoscopic linear roticulating staplers were used to divide the rectum and proximal colon. A specimen was retrieved using an extraction bag through the umbilicus. Anastomosis was performed using a circular stapler, or pull-through hand-sewn anastomosis was performed. MAIN OUTCOME MEASURES: Duration of the operation, length of hospital stay, surgical complications, wound size, and histopathologic data. RESULTS: There were no perioperative or postoperative complications. Mean operative time was 347 minutes (range, 240-480 minutes). Mean hospital stay was 4.25 days (range, 4-5 days). Mean wound size was 3.5 cm (range, 3-4 cm). Mean number of harvested lymph nodes was 15 (range, 8-28). CONCLUSIONS: With the help of sophisticated surgical technology and techniques, single-port laparoscopic surgery for rectal cancer will be feasible while also maintaining oncologic principles and patient safety.

Amelogenin (an extracellular matrix protein) application on ischemic colon anastomosis in rats.

BACKGROUND: Ischemia is a troublesome problem that can cause intestinal emergencies and complicate the treatment. Identification of a chemical agent with beneficial effects on the healing process in risky colon anastomosis with the aim of reducing leakage rates is a popular topic in the era of surgical research. Data is lacking about the role of amelogenin, an extracellular matrix protein, during the healing process of gastrointestinal anastomosis. In this study, the effects of amelogenin treatment on ischemic colon anastomosis were evaluated. METHODS: Adult male Wistar Albino rats weighing 200-250 g were divided into three weight-matched groups as normal colon anastomosis group (n=8), ischemic colon anastomosis group (n=8), and amelogenin-treated ischemic colon anastomosis group (n=8). Sufficient equal volume of amelogenin to cover the anastomosis area entirely was applied topically. All animals were sacrificed on postoperative day four. Bursting pressure levels were measured. Peri-anastomotic colon tissue hydroxyproline levels were also assessed. RESULTS: Bursting pressure level of the ischemic colon anastomosis group was significantly lower than the normal colon anastomosis and the amelogenin-treated ischemic colon anastomosis groups, respectively (p=0.006, p=0.008). CONCLUSION: Amelogenin treatment supports the physical strength of ischemic colon anastomosis.

Spontaneous rectus sheath hematoma: an analysis of 15 cases.

BACKGROUND: Spontaneous rectus sheath hematoma (RSH) is an uncommon and frequently misdiagnosed cause of acute abdominal pain. The purpose of this study is to present our experiences in the diagnosis and treatment of spontaneous RSH. METHODS: This is a retrospective study of the medical histories of 15 patients admitted to our emergency surgery unit between January 2000 and July 2009 and diagnosed with spontaneous RSH (12 females, 3 males; mean age, 64.5 years; range, 20-79 years). RESULTS: All cases presented with acute abdominal pain or abdominal wall mass, or both. Eleven of the cases (73%) had been receiving some form of anticoagulation therapy. The leading indications for anticoagulation and/or anti-platelet therapy were atrial fibrillation in 5 patients (33%) and mitral valve replacement in 3 patients (20%). Diagnosis was made by abdominal ultrasonography and/or computerized tomography in 14 patients (93%). Twelve (80%) of the 15 patients were discharged uneventfully after conservative management following a mean hospital stay of 8.8 days (range, 3-24 days). The mortality rate was 20%. CONCLUSION: Spontaneous RSH must be suspected in patients with advanced age who are using anticoagulation medications and present with acute abdominal pain. Early diagnosis permits conservative management and avoids unnecessary surgical interventions.

Transumbilical totally laparoscopic single-port Nissen fundoplication: a new method of liver retraction: the Istanbul technique.

INTRODUCTION: Mustafa Kemal Atatürk, founder of the Turkish Republic, had guarded many German scientists of a Jewish descent before the Second World War. Dr. Rudolf Nissen was one of the outstanding surgeons who had served in the Turkish university hospitals. He had created an antireflux procedure which is named after his own name while he was working in our clinic, the Cerrahpasa Hospital. From a laparoscopic approach, the Nissen fundoplication was the gold standard intervention for the surgical treatment of gastroesophageal reflux disease (GERD). Currently, video laparoscopic surgery is evolving quickly with the guidance of new technology. Single-port (SP) laparoscopic transumbilical surgery is one of the newest branches of advanced laparoscopy. DISCUSSION: Simple or complex manipulations may be performed with SP laparoscopic transumbilical surgery. The advantages, which are gained from conventional laparoscopy, can be invigorated by an SP laparoscopic approach. The retraction technique of the liver and the optical system were the most important factors, which made the Nissen fundoplication possible via single port. Here, we report that totally laparoscopic transumbilical SP Nissen fundoplication procedure was performed in three patients for sliding hiatal hernia with GERD. CONCLUSION: Totally laparoscopic transumbilical SP Nissen fundoplication is a safe and feasible technique for the surgical treatment of GERD.

Evaluation of intravenous paracetamol administration on postoperative pain and recovery characteristics in patients undergoing laparoscopic cholecystectomy.

PURPOSE: In this study, the effects of intravenous paracetamol treatment on early postoperative period analgesia and recovery characteristics after laparoscopic cholecystectomy have been evaluated. METHODS: Forty patients whose American Society of Anesthesiologists physical status I or II underwent laparoscopic cholecystectomy and randomly divided into 2 equal groups. In the first group, 1 g paracetamol was given to the patients intravenously after intubation before start of the surgery in 15 minutes. The 100 mL 0.9% NaCl was infused intravenously for the control group in 15 minutes. Postoperative pain was evaluated and recovery characteristics were evaluated. RESULTS: Verbal and visual pain scores of the paracetamol group were significantly lower than control group (P<0.05). First morphine requirement and total administered morphine dose and duration of staying in recovery room were significantly decreased in the paracetamol group (P<0.05). CONCLUSIONS: Beside its effective analgesic properties, paracetamol administration during per operative period supports effective and faster recovery.

Comparison of the electrothermal vessel-sealing system versus endoclip in laparoscopic appendectomy.

BACKGROUND: Various techniques have been used for the division of mesoappendix, such as endoloops, endoscopic linear cutting staplers, an electrothermal vessel-sealing system (LigaSure), the Harmonic Scalpel, clips, and bipolar coagulation. In the present study, LigaSure and an endoclip were compared in laparoscopic appendectomy (LA). MATERIALS AND METHODS: This study included patients who underwent LA for acute appendicitis at Istanbul University, Cerrahpasa Medical Faculty, Emergency Unit (Istanbul, Turkey) between May 2003 and April 2007. The patients were assigned to two groups according to the mesoappendix dissection device: LigaSure and endoclip groups. The main outcome measures (e.g., operating time, conversion rate, hospital stay, postoperative complications, etc.) were then compared. RESULTS: LA was performed in 280 patients with acute appendicitis. LigaSure and endoclips were used in 127 and 153 patients, respectively. The mean operative times were 41 and 54 minutes in the LigaSure and endoclip groups, respectively. Conversions to open rates were found to be 9.4% (12 patients) in the LigaSure and 11.1% (17 patients) in endoclip groups. No statistically significant differences regarding hospital stay or complications were found, whereas significant differences were observed in surgical time and conversion rate. CONCLUSION: The use of LigaSure facilitates the dissection of mesoappendix and shortens the operation time in LA. We believe that LigaSure is a safe, useful tool for mesoappendix dissection.

The effect of halofuginone, a specific inhibitor of collagen type 1 synthesis, in the prevention of pancreatic fibrosis in an experimental model of severe hyperstimulation and obstruction pancreatitis.

BACKGROUND: The aim of this paper is to assess the effects of halofuginone, a specific inhibitor of synthesis of collagen Type 1, on fibrogenetic process in an experimental model of early pancreatic fibrosis. METHODS: Thirty rats were divided into three equal groups: group 1, sham laparotomy; group 2, severe hyperstimulation and obstruction pancreatitis (SHOP) with no treatment; group 3, SHOP with halofuginone treatment group. SHOP model was induced by complete pancreatic duct obstruction and daily cerulein hyperstimulation (50 microg/kg, intraperitoneally). Halofuginone was administered daily from the operative day (5 mg/kg, intraperitoneally). All of the animals were sacrificed, and blood and pancreatic tissue samples were obtained for biochemical and histopathological examination on the 5th postoperative day. RESULTS: No mortality was observed in any group. Serum amylase, lipase, hyaluronic acid, and nitric oxide levels were significantly higher in groups 2 and 3 compared with group 1 (P < 0.05), but were significantly lower in group 3 compared with group 2 (P < 0.05). No significant differences were observed regarding serum malondialdehyde and glutathione levels between groups 1 and 3. Tissue hydroxyproline levels were found to be significantly higher in groups 2 and 3 compared with group 1 (P < 0.001), but were significantly lower in group 3 compared with group 2 (P < 0.001). Although tissue hydroxyproline levels were significantly higher in the halofuginone treatment group compared with the control group, histopathological evaluation did not reveal a significant difference between these groups regarding collagen deposition. When group 3 was compared with group 2, halofuginone significantly reduced inflammation and acinar atrophy in the pancreas as well (P < 0.05). CONCLUSION: Halofuginone was found to be effective in reducing SHOP-related inflammation, acinar atrophy, and fibrosis in the pancreas.

Serum YKL-40 as a marker of disease activity and stricture formation in patients with Crohn's disease.

BACKGROUND AND AIM: YKL-40 is secreted by macrophages and neutrophils and is a growth factor for vascular endothelial cells and fibroblasts. Elevated serum levels of YKL-40 have been reported in patients with various inflammatory conditions and ongoing fibrosis. The aim of this study was to investigate the relationship between serum concentrations of YKL-40 and disease activity, acute phase reactants, and the presence of strictures in patients with Crohn's disease (CD). METHODS: We studied the serum concentrations of YKL-40 in 41 patients with CD, in which 12 had an endoscopically- or radiologically-proven stricture formation. Forty-six age- and sex-matched healthy volunteers served as controls and a multivariate regression analysis was performed to find out the independent predictors of intestinal strictures and clinical activity. RESULTS: The serum YKL-40 concentrations in the patients were significantly higher than that in the healthy controls (105.69 +/- 88.08 ng/mL [range 20.23-333.57]vs 44.92 +/- 24.89 ng/mL [range 18.31-113.43], P = 0.000) and patients with a stricture formation had significantly higher YKL-40 levels than those without strictures (167.50 +/- 119.30 ng/mL [range 23.62-333.57]vs 80.12 +/- 56.38 ng/mL [range 20.23-259.19], P = 0.003). Significant correlations were noted between YKL-40 levels and clinical activity (r = 0.681; P = 0.000) and the presence of intestinal strictures (r = 0.457; P = 0.003). The multivariate regression analysis found the serum YKL-40 levels to be an independent predictor of intestinal strictures (P = 0.001) and clinical activity (P = 0.001). CONCLUSION: Patients with CD, particularly those with a stricture formation, have significantly higher levels of YKL-40. YKL-40 seems to be a useful marker of disease activity as well as stricture formation in patients with CD.

Laparoscopy offers diagnosis and treatment in abdominal stab injuries.

PURPOSE: To assess the role of laparoscopy in the diagnosis and treatment of abdominal stab injuries (ASI). METHODS: Patients who underwent laparoscopic procedures due to ASI were included in the study. Hemodynamic instability, injuries to the posterior trunk, concomitant severe cranial injuries, and prior abdominal operations were considered as contraindication for laparoscopy. RESULTS: From January 1997 to March 2006, 88 patients underwent laparoscopic management of ASI. In 45 patients (51.1%), there was no intra-abdominal pathology requiring surgical intervention (nontherapeutic laparoscopy) and 5 patients in this group had no peritoneal penetration (negative laparoscopy). In another 25 patients (28.4%), laparoscopic treatment was performed (therapeutic laparoscopy), including bleeding control in liver, colonic, gastric, and diaphragmatic repairs and intra-abdominal bleeding control. Laparotomy was avoided in a total of 70 (79.5%) patients. In 18 patients (20.5%), laparoscopy was converted to laparotomy. There was no mortality, and except one missed small bowel injury nor perioperative morbidity in patients undergoing laparoscopy. In the laparotomy group, major complications were seen in 7 patients. CONCLUSIONS: Laparoscopy is safe and efficient in the management of ASI and should be more frequently considered as a therapeutic tool.