Does focal heterogeneity affect survival in postoperative ipsilateral multifocal and multicentric breast cancers?

OBJECTIVE: In multicentric/multifocal breast tumors, there may be immunological and histological differences between foci that may affect survival and treatment choice. We aimed to evaluate the effect of focal heterogeneity seen in multicentric/multifocal breast tumors on survival. METHODS: We retrospectively collected and analyzed the clinicopathological data of 89 female patients with multifocal/multicentric breast cancer, whose surgical and medical treatment was completed and who were followed up for 5 years. RESULTS: Of all patients, 29.2% (26/89) were heterogeneous. Heterogeneity of these foci was as follows: histologic heterogeneity of index foci (mix type): 15.7% (14/89), histologic heterogeneity of inter-foci: 7.9% (7/89), and immunohistochemical heterogeneity of inter-foci: 10.1% (9/89). When additional foci were evaluated, oncological therapy was changed for 3 (3.3%) of 89 patients. Heterogeneity does not have a significant (p>0.05) effect on recurrence and survival in multicentric/multifocal breast cancers. Pathological N stage is an independent risk factor for disease-free survival (hazard ratio=2.29, 95% confidence interval=1.39-3.76, p=0.001). CONCLUSIONS: In multifocal/multicentric breast cancers, less than 4% of patients may experience heterogeneity requiring change in the therapeutic decision. However, heterogeneity does not have a significant effect on recurrence and survival in multifocal/multicentric breast cancers. The pathological N stage is an independent risk factor for disease-free survival.

Hemogram index parameters in the evaluation of male breast cancer and inflammatory response: a case-control study.

OBJECTIVE: Our aim was to investigate the hemogram index parameters and their clinical significance in the evaluation of the inflammatory response of patients with male breast cancer, who are rarely observed in the literature. METHODS: In total, 22 (n=22) healthy male and 28 (n=28) male breast cancer patients without synchronous/metachronous tumors were included in this study. They were grouped as the healthy male control group (Group 1) and the male breast cancer patient group (Group 2). The male breast cancer was divided into two subgroups, namely, early stage [(stage: 0/I/II) (Group 2A)] and late stage [(stage: III/IV) (Group 2B)], and their hemogram index parameters were compared. RESULTS: A significant (p>0.05) increase was observed in neutrophil/lymphocyte ratio (NLR) and·platelet/lymphocyte ratio (PLR) values in the late stage (Group 2B: stage III/IV) compared to the early stage (Group 2A: stage 0/I/II) and healthy control (Group 1) groups. CONCLUSIONS: In male breast cancer patients, neutrophil/lymphocyte ratio and platelet/lymphocyte ratio values were significantly higher as the stage of cancer increased. These readily available simple tests can be used to evaluate the host's inflammatory response in male breast cancer.

Gastrointestinal tract schwannomas and brief review of literature.

Schwannomas originating from Schwann cells arise from the peripheral nerve sheath and are slow-growing, benign tumors that originate mostly from the mesenchyme. It appears equally in both sexes. Schwannomas are often seen in the 3rd and 5th decades of life. Schwannomas can be seen everywhere where peripheral nerves are seen. Gastrointestinal schwannomas constitute 2-6% of all submucosal masses, and the stomach is the most common region (60-70%). Endoscopic Ultrasound (EUS)-guided sampling of gastrointestinal submucosal lesions has made it possible to achieve preop- erative differential diagnosis. Patients diagnosed with gastrointestinal schwannomas between January 2005 and December 2017 were included in this study. Three out of six patients were females. Median age was 52.5 (44-76) years. Schwannomas were found in two patients in the gastric region, one patient in the appendiceal region, two patients in the colon and one patient in the perianal region. Primary schwannomas are usually benign. Radical resection with free margin is necessary because of the risk of malignant degeneration; chemo and radiotherapy response is indeterminate, and local recurrence rates are high.

Mechanical Jaundice and Bile Duct Stricture Caused by the Migration of Endoclip and Silk Suture Material into the Common Bile Duct.

It is quite rare the migration of metal clips and silk suture materials into the common bile duct (CBD) that were used for the closure of cystic duct in conventional or laparoscopic cholecystectomy. The most common cause of postoperative jaundice is unrecognised or overlooked stones in the bile ducts during operation. The authors present four patients who developed jaundice and in one case  biliary tract stricture,  caused by the migration of metal clip and silk suture material into CBD  following conventional and laparoscopic cholecystectomy. The migration of endoclip and suture material in to CBD is very rare and it should be kept in mind in post-cholecystectomy jaundice. Key Words: Cholecystectomy, Endoclip migration, Mechanical jaundice, Endoscopic retrograde cholangiopancreatography.

Infiltration of bupivacaine into the preperitoneal space and trocar incisions of patients undergoing laparoscopic totally extraperitoneal repair of unilateral inguinal hernia: a prospective randomized controlled observational study.

INTRODUCTION: Although laparoscopic repair of inguinal hernia is associated with reduced postoperative pain, it is not entirely painless. In addition to reducing the need for analgesic medication, postoperative complications, and hospitalization, postoperative pain control enables early return to normal activity. AIM: To evaluate the efficacy of bupivacaine instilled into the pre-peritoneal space and trocar incisions of patients undergoing laparoscopic totally extraperitoneal (TEP) repair of inguinal hernia. MATERIAL AND METHODS: Bupivacaine was instilled into the pre-peritoneal space and trocar incisions of the patients in group I (n = 23), whereas it was infiltrated only into the trocar incisions of the patients in group II (n = 21). No local anesthetic was administered to the patients in group III (n = 21). Postoperative pain was assessed using the Visual Analog Scale (VAS) at 4 and 24 h, and the dosage of analgesic medication was noted. RESULTS: No significant difference regarding age, gender, body mass index, ASA class, history of abdominal surgery, or smoking was noted between the three groups (p > 0.05). VAS score at 4 h was significantly higher in group III than in groups I and II (p < 0.05). The dosage of analgesic medication was significantly higher in group III than in groups I and II (p < 0.05), with no significant difference between groups I and II (p > 0.05). CONCLUSIONS: Infiltration of long-acting local anesthetic into the pre-peritoneal space and trocar incisions of patients undergoing laparoscopic TEP repair of inguinal hernia reduces the need for analgesic medication by reducing early postoperative pain.

Endoscopic treatment of postoperative biliary fistulas.

BACKGROUND: Biliary fistula is one of the most common complications of liver and biliary tract surgeries. Endoscopic retrograde cholangiopancreatography (ERCP) is used for the diagnosis and treatment of biliary fistulas. In this study, we aimed to analyze the contribution of ERCP in this regard. METHODS: Patients who underwent ERCP for biliary fistulas following liver and biliary tract surgery between January 2012 and December 2017 were included in this study. The demographic characteristics of the patient, surgical procedure, localization of the biliary fistula, classification of biliary duct injury, and success of ERCP were retrospectively evaluated. RESULTS: In total, 90 patients (37 male and 53 female) with a diagnosis of biliary fistula underwent ERCP. Common biliary duct (CBD) cannulation was achieved in 87 patients using ERCP. In five patients, the proximal part of the biliary tract was not visualized, and complete injury of CBD was considered. In ERCP, contrast extravasation was detected in the cystic duct in 44 patients: CBD, eight patients; liver bed, four patients; hepatic duct bifurcation, two patients; the right hepatic canal, seven patients; and the left hepatic canal, two patients. CONCLUSION: ERCP is an effective method for the diagnosis and treatment of biliary diseases. The diagnosis and treatment of postoperative biliary fistulas with ERCP reduces surgery cost, morbidity, and mortality.

Abdominal cocoon syndrome: A rare cause of acute abdomen syndrome.

BACKGROUND: A rare cause of acute abdomen or intestinal obstruction, the abdominal cocoon syndrome is also described in the literature as sclerosing peritonitis or sclerosing encapsulating peritonitis. Abdominal cocoon is characterized by the total or partial wrapping of the abdominal organs by a fibrous membrane. Although it is usually observed in young women, the etiology is unknown. The diagnosis is usually made during laparotomy. In this case series, we aimed to present seven patients diagnosed with abdominal cocoon syndrome during operation. METHODS: The records of patients who underwent laparotomy for abdominal pain and/or intestinal obstruction in our hospital and diagnosed as abdominal cocoon during operation between January 2012 and November 2018 were retrospectively reviewed. The demographic characteristics of the patients, etiologic factors, surgical procedures, operative findings and follow-up of the patients were recorded. RESULTS: Four out of seven patients who were operated for abdominal cocoon were male and 3 of them were female. The median age of patients was 61 (57-63) years in male and 39.6 (28-49) years in female. Six of the patients were operated in emergency conditions with the diagnosis of an acute abdomen or ileus. One of the patients was operated with the diagnosis of an intra-abdominal mass in elective conditions. In five out of seven patients, all of the small intestines were wrapped with a fibrous collagen capsule, while two of the patient intestines were partially wrapped with a fibrous collagen capsule. Four of the patients had no underlying disease, while one of the patients had Familial Mediterranean Fever (FMF), one had Endometriosis and one had beta-blocker medication. One patient who had small bowel necrosis and septic peritonitis were observed during the operation and died post operative 6th days. Postoperative complications were not observed in the follow-up of other patients and reoperation was not required due to recurrence. CONCLUSION: Abdominal cocoon is a condition that is usually diagnosed during operation in patients that were operated for reasons, such as the acute abdomen or intestinal obstruction. When the diagnose delayed, death can be seen due to small bowel necrosis and septic complications. High clinical suspicion and radiological imaging are important in the preoperative diagnosis. Treatment is required adhesiolysis and excision of the fibrous membranes.

Clinical characteristics of appendiceal diverticular disease.

BACKGROUND: Appendiceal diverticular disease (ADD) is a rare pathology which is associated with an increased mortality risk due to rapid perforation and high rates of neoplasm. In our study, we aimed to evaluate the clinical and histopathological characteristics of ADD with differences from acute appendicitis (AA) diagnosis and to determine the association with neoformative processes. METHODS: The 4279 patients who underwent appendectomy were evaluated retrospectively. ADD patients histopathologically classified into four groups. Patients' demographic characteristics, imaging and preoperative laboratory findings, additionally postoperative histopathology results were compared between groups. RESULTS: The prevalence of ADD was 2.29% (n = 98). In addition, the male/female ratio was 2.37 in ADD patients who were found to be significantly older than those with AA patients. Type III was the most frequently (62.2%) identified sub-group of ADD. The incidence of neoplasms, plastrone, and Littre's hernia was found statistically higher in ADD group than AA group. Mucinous adenomas (10.2%) was the most common neoplasm while the carcinoid tumor (1%) and precancerous serrated adenomas (4.1%) were also reported. CONCLUSIONS: As a result, high neoplasm in ADD patients can be shown with incidence of perforation and plastron, and in order to avoid possible neoplasm or major complications, it is necessary to carry out new studies for the right diagnosis of ADD whether the diagnosis is done preoperatively or intraoperatively. We recommend surgical resection of the ADD, which may even be incidentally detected during any surgical procedure, due to its high risk of neoplasm and rapid perforation.

Evaluation of the predictive power of laboratory markers in the diagnosis of acute appendicitis in the elderly.

OBJECTIVE: The aim of this study was to analyze the predictive value of preoperative laboratory findings in acute appendicitis in geriatric patients aged >65 years. METHODS: We enrolled a total of 4121 patients. A retrospective evaluation of the demographic features was made using preoperative laboratory values such as the white blood cell (WBC), neutrophil, and lymphocyte counts; platelet counts; the mean platelet volume and bilirubin values; and postoperative pathological data of the patients from the electronic file system. The neutrophil-to-WBC and neutrophil-to-lymphocyte ratios were calculated. Patients were divided into two groups, as geriatric (≥65 years old, n=140) and non-geriatric (<65 years old, n=3981). RESULTS: The white blood cell and lymphocyte counts, and the neutrophil-to-WBC ratio, were significantly higher in the non-geriatric group (p<0.001, p=0.013, and p=0.021, respectively). The neutrophil and platelet counts were higher in the non-geriatric group, but this difference was not statistically significant (p=0.073 and p=0.072, respectively). A higher neutrophil-to-lymphocyte ratio was determined in the geriatric group, but the difference was not significant (p=0.176). According to the optimumal cutoff value of 12.11×103/µL for WBC, specificity and sensitivity values of 65.4% and 57.9% were calculated, respectively; the AUC value was 0.632±0.024 (p<0.001). A receiver operating characteristic (ROC) analysis was used to calculate the optimum cutoff values of neutrophil-to-WBC ratio, lymphocyte, and the mean platelet volume, but the diagnostic accuracy of these tests was inadequate with an AUC of <0.6. CONCLUSION: WBC values >12.11×103/µL were predictive of acute appendicitis in geriatric patients. The other parameters were not predictive, and further studies are required.

Resection of Mucosal and Submucosal Gastrointestinal Lesions and a Double Endoscope Experience.

AIM: The patients who underwent endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) for mucosal and submucosal lesions of the esophagus, stomach, and duodenum and the advantages of the double endoscope method we used for traction during ESD were evaluated. MATERIAL AND METHODS: The patients who underwent ESD and EMR due to upper gastrointestinal lesions were evaluated retrospectively between January 2014 and April 2018 in our endoscopy unit. RESULT: The mean age of 10 patients with esophageal lesions was 53 years. ESD was performed for 7 lesions and EMR for 3 lesions. The most common lesion was leiomyoma and the median size of the lesions was 1.4 cm (range, 0.6-2.5 cm).The median age of 26 patients with gastric lesions was 61 years. EMR were performed for 11 lesions and ESD for 15 lesions. Double endoscope was used in 6 patients. One patient had intramucosal carcinoma, while the other lesions were benign and dysplasia was the most common lesion. The median size of lesions was 1.8 cm (range, 1-3 cm).All lesions were evaluated with endoscopic ultrasonography. Bleeding was seen in 4 patients and perforation in 1 patient during ESD and defect was closed with endoscopic clips. CONCLUSION: The advantages of endoscopic resections; short hospitalization, low complication rates, patient comfort, and doesn't require the general anesthesia. For endoscopic resection, we think that the second endoscope shortens the duration of the procedure, reduces the complication rate, and increases the comfort of the endoscopist.

Stent experiences in emergency conditions in acute mechanical intestinal obstruction caused by colorectal cancer.

INTRODUCTION: Stent treatment can be applied to avoid surgery in surgically risky patients or to turn a high-risk emergency operation into a lower-risk elective operation and save time. AIM: In this study, the techniques, clinical efficacy, safety and complications of endoscopic stents applied in emergency conditions were evaluated in patients with acute mechanical intestinal obstruction (AMIO) due to colorectal cancer. MATERIAL AND METHODS: Between 2013 and 2015, 23 patients with an average age of 69.5 ±13.5 years who presented with AMIO and anastomosis stenosis secondarily to cancer to the emergency department were subjected to stent treatment under emergency conditions. RESULTS: Thirteen (56.5%) patients were diagnosed with colon cancer, 5 (21.7%) with rectal cancer, and 5 (21.7%) with stenosis in the previous anastomosis line. Fourteen (60.9%) patients were diagnosed with stage 4 cancer, 7 (30.4%) with stage 3 cancer and 2 (8.7%) with stage 2 cancer. The stents were applied to the sigmoid colon in 10 (43.5%) patients, to the recto-sigmoid area in 9 (39.1%) patients and to the rectum area in 4 (17.4%) patients. While 14 (60.9%) patients had local or locally advanced disease, 9 (39.1%) patients had metastases in different parts of their bodies, particularly in their livers. CONCLUSIONS: The study demonstrates that stents offer a favorable therapeutic alternative to emergency surgery and are associated with promising short-term outcomes as well as an acceptable safety profile for AMIO.

A 4-year single-center experience in the management of esophageal perforation.

BACKGROUND: Esophageal perforation (EP) is a lethal surgical emergency that needs to be diagnosed and treated immediately. Diagnosis and treatment options for EP are limited due to its lower incidence. There are scoring systems proposed for this purpose; however, they cannot be applied to every patient. The recent trend in the treatment of EP is toward the non-operative approach over the surgical treatment methods. The purpose of the present study was to evaluate our treatment methods and outcomes in patients with EP. METHODS: Thirteen patients with EP treated in our clinic between 2013 and 2017 were retrospectively reviewed. The Pittsburgh Perforation Severity Score (PSS), systemic condition status, and Clavien-Dindo Classification (CDC) score were assessed, and treatment methods were reviewed. Their effects on morbidity and mortality were examined using Fisher's exact test and biserial correlation test. RESULTS: A total of 13 patients (six males and seven females; median age 64 years) were included in the study. Ten patients were managed non-operative, and three were treated surgically. Of the 10 patients, two had additional surgery after non-operative management. The PSS, systemic condition status, CDC score, duration of stay in the hospital, time to diagnosis, presence of hypotension, and being in shock were strongly correlated with mortality (p<0.05). The PSS, CDC score, and stay in the intensive care unit were strongly correlated with morbidity (p<0.05). The comparison between the non-operative and operative groups did not yield a statistically significant difference in mortality and morbidity. CONCLUSION: Even if the scoring systems help to understand the severity of the condition, they are inadequate to determine the treatment option. Early diagnosis and treatment are the most important steps in management. Operative and non-operative treatment options are not superior to each other, but their complementary use will be more beneficial for the patients.

Evaluation of endoscopic mucosal resection and endoscopic submucosal dissection in submucosal lesions of the colon and rectum.

INTRODUCTION: Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are commonly used for the minimally invasive treatment of submucosal lesions of the gastrointestinal tract. AIM: To evaluate the safety, efficacy, outcome and recurrence rate of EMR and ESD for mucosal and submucosal lesions in the colon and rectum. MATERIAL AND METHODS: Records of 26 patients who underwent ESD and EMR for mucosal and submucosal lesions in the colon and rectum between January 2013 and March 2018 in our endoscopy unit were retrospectively reviewed. RESULTS: A total of 26 patients (6 female and 20 male) were evaluated. The mean age of the patients was 58.03 ±15.19 (21-80). Fifteen patients underwent ESD and EMR for rectal lesions. Tubular adenomas were found in 3 of these patients, tubulo-villous adenomas in 2, inflammatory polyps in 1, neuroendocrine tumors in 2 and carcinomas in 7 (intramucosal, in-situ and invasive). Eleven patients underwent ESD and EMR for colonic lesions. Villous adenomas were found in 2 of these patients, tubular adenoma showing dysplasia in 2, tubulo-villous adenomas showing dysplasia in 1 and carcinoma (in-situ, invasive and intramucosal) in 6. Two lesions were resected with secondary transanal local excision to obtain free margins. The follow-up period was 3 to 48 months and no recurrence was observed. CONCLUSIONS: The EMR and ESD are reliable minimally invasive techniques with a low rate of complications and short hospital stay in the treatment of colon and rectal lesions, including early stage carcinomas of different size and morphology.

Clinical Outcomes of Upper Gastrointestinal Stents and Review of Current Literature.

BACKGROUND AND OBJECTIVES: The self-expandable metal stent (SEMS) is an alternative for several possible surgical and palliative treatments of upper gastrointestinal obstructions that occur in several disease states. The present study was performed to describe a single-center experience with upper gastrointestinal stents. METHODS: All patients at a single center who had an SEMS placed for the treatment of obstruction over a 3-year period were retrospectively evaluated. Pre- and postoperative dysphagia scoring was calculated and used to evaluate postprocedure improvement in quality of life. Procedural success and early and late complication rates were investigated. RESULTS: A total of 171 endoscopic procedures were performed in 73 patients. Procedural success was 95.8% (n = 69) and dilatation was performed in 80 patients. The rate of perioperative complication was 26% (n = 19). After 1 month, stents were patent in all patients (n = 73). Stent obstruction was noted in 6 patients: 2 each at 2, 7, and 10 months. CONCLUSION: SEMS usage for palliative and curative purposes in benign or malignant upper gastrointestinal system obstructions is an efficient and reliable treatment method with advantages, such as shortening hospital stay, decreased pain, cost-effectiveness, and low mortality-morbidity rates when compared to surgical procedures, and a high rate of clinical success.

Multiple plastic biliary stent placement in the management of large and multiple choledochal stones: single center experience and review of the literature.

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy is the first step treatment modality of choledocholithiasis. In spite of an extended sphincterotomy, 10-15% of complex choledochal stones (larger than 15 mm and/or more than 3 stones) cannot be removed and recurrent ERCP procedures may be needed. AIM: To evaluate the role and efficiency of multiple biliary stent application in the treatment of large and multiple choledochal stones. MATERIAL AND METHODS: Patients with complex choledochal stones and patients with inadequate choledochal clearance during ERCP were included in the study. The study group was divided into 2 groups as the placement of single (n = 27 patients) or multiple stents (n = 58 patients). After a mean time interval of 21 days (10-28), the ERCP procedure was tried for the second time and a stent was placed in case of recurrence. RESULTS: Successful biliary drainage was provided in both groups. The decrease in the longitudinal or transverse size of the stones after stent placement was found to be statistically significant in both groups (p = 0.001). Cholestatic enzymes (alkaline phosphatase (ALP), γ-glutamyltransferase (GGT)) and bilirubin levels decreased significantly in both groups following stenting (p = 0.001). Additionally, multiple stents functioned as a bridge starting from the first ERCP to full clearance in patients with large and multiple stones which could not be removed at once and saved them from the possible morbidities of an invasive operation. CONCLUSIONS: Endoscopic multiple biliary stent placement should be preferred in the treatment of patients with complex choledochal stones and high rates of co-morbidity, as a safe alternative to surgery.

Colonoscopic perforations: Single center experience and review of the literature.

OBJECTIVE: Iatrogenic colonic perforation is a well-known complication that can increase mortality and morbidity in patients undergoing colonoscopy. Closer follow-up and a well-planned treatment strategy are required when perforation arises as a complication. The aims of this study are to (1) report our experience with a large colonoscopy series; (2) evaluate the underlying mechanisms of iatrogenic colonic perforation; (3) discuss the ideal period between onset and treatment; and (4) review the current literature regarding the management of iatrogenic colonic perforations. MATERIAL AND METHODS: Patients who underwent colonoscopy between January 2005 and May 2015 at a single center were reviewed retrospectively. Procedures during which colonic perforations occurred were documented and analyzed. RESULTS: Between January 2005 and May 2015, 31,655 patients underwent colonoscopy and 5,214 patients underwent recto-sigmoidoscopy at our center. Thirteen of these procedures were associated with perforation. The perforation rate was found to be 0.041%. The most frequent locations of perforation were (a) the rectosigmoid junction, (b) the proximal rectum, and (c) the sigmoid colon. Management included surgical treatment in 11 patients and conservative management in 2 patients. Twelve patients (92.31%) were discharged uneventfully, and death occurred in one (7.69%) patient. CONCLUSION: Although they are rarely encountered, colonic perforations are serious complications of colonoscopy. A high index of clinical suspicion is required for early diagnosis and appropriate treatment. Age, co-morbidities, the location and size of the perforation, and the time interval between onset and diagnosis should be evaluated, and the treatment approach should be planned accordingly.

First Video Case Report of Chronic Retrograde Jejunojejunal Intussusception after Subtotal Gastrectomy with Braun's Anastomosis.

Intussusception, which is seen rarely in adults, is defined as the pulling or invagination of a part of the intestine into another segment of the intestine. In this case report we present chronic retrograde jejunojejunal intussusception following gastric surgery with Braun's anastomosis in adult with video presentation. A 66-year-old woman, who had undergone gastric surgery 39 years ago and cholecystectomy 20 years ago, was admitted to our clinic with the complaints about weight loss, abdominal pain, nausea, and vomiting. Upper gastrointestinal endoscopy (UGISE) was applied, and patient was treated with surgery. This case report indicates that intussusception should be considered in the presence of clinical complaints following gastric surgery, as well as importance of endoscopy in diagnosis.

Giant choledochal calculosis: surgical treatment.

CONTEXT: Gallstone disease is one of the most common surgical pathologies. Choledocholithiasis may occur in some of these cases and require surgical intervention. Although there are relatively non-invasive procedures such as endoscopic retrograde cholangiopancreatography (ERCP), this technique is usually unsuccessful in patients with stones larger than 10 mm. In our case, we aimed to report a giant choledochal stone (15 cm × 4.5 cm), which is rare in surgical practice and our treatment with open surgery. CASE REPORT: The patient was a 59-year-old woman. Magnetic resonance cholangiopancreatography (MRCP) had showed a hydropic gallbladder with an excessively dilated CBD and a 110 mm × 41 mm stone. In the operation, an excessively dilated CBD was seen and after choledochotomy and a very large calculus that filled CBD completely. Choledochotomy incision was carried forward and a T-tube choledochostomy with choledochoduodenostomy (CD) was performed. The patient was discharged without any complications on postoperative 8(th) day. CONCLUSION: Benign gallstone disease is a multifactorial process, with risk factors such as obesity, hemolytic diseases, diabetes mellitus, and pregnancy. Risk factors for choledocholithiasis are similar to those for gallstone disease. MRCP is a non-invasive technique in detecting choledocholithiasis. The gold standard intervention for CBD stones is ERCP. Stones in CBD may reach very considerable dimensions without causing serious symptoms. The most common symptom is jaundice. During preoperative radiological examination, giant stones may be interfered with malignancies. Surgeons should obey conventional algorithms in diagnosis and open surgery must be kept in mind in earlier stages without being too insistent on endoscopic interventions.

Disseminated peritoneal leiomyomatosis with chronic constipation: a case report.

INTRODUCTION: Disseminated peritoneal leiomyomatosis is a rare disease. Almost all disseminated peritoneal leiomyomatosis cases described in the literature are associated with a gynecological disorder or a mass in the abdominal cavity. Disseminated peritoneal leiomyomatosis with only chronic constipation has not been reported in the English literature. We present a case of a patient with disseminated peritoneal leiomyomatosis who manifested solely with chronic constipation. CASE PRESENTATION: A 49-year-old premenopausal nulliparous Caucasian woman was admitted with complaints of abdominal distention and chronic constipation. Open subtotal colectomy with ileorectal anastomosis was performed. There were diffuse nodular and polypoid tumor formations in her colonic mesoderm. Based on morphological and pathological evaluation of the resection material, she was diagnosed with disseminated peritoneal leiomyomatosis. CONCLUSIONS: In general, disseminated peritoneal leiomyomatosis is seen in women who are of childbearing age with estrogen hypersecretion. Preoperative diagnosis of disseminated peritoneal leiomyomatosis is almost impossible and it can be confused with disseminated intra-abdominal malignancies. There are no specific methods to diagnose disseminated peritoneal leiomyomatosis in a preoperative period.