Timing of laparoscopic cholecystectomy in acute cholecystitis.

BACKGROUND: Timing of laparoscopic cholecystectomy (LC) in acute cholecystitis (AC) is still debated. AIMS: The aim of this study was to investigate the effect of timing on operative results; from the first appearance of symptoms to the operation. METHODS: The study included 57 sequential patients operated laparoscopically for AC. Patients operated within the first 3 days of admission (Group 1), those operated between 4th and 7th days (Group 2) and those operated after 7th day (Group 3) were evaluated and compared with respect to demographics, time from admission to operation, duration of operation, adhesion score, complications, conversion rates, duration of hospital stay, morbidity and mortality rates, bile culture results, and histopathological evaluation. RESULTS: A total of 63% of the patients were female and 21 (37%) were male. The mean age was 48 years (range, 21-74). There was no significant difference among the groups with respect to demographics (P > 0.05, for each). The duration of operation was significantly shorter in Group 1 than both Groups 2 and 3 (P < 0.05 and P < 0.001, respectively). Duration of operation was also significantly shorter in Group 2 than Group 3 (P < 0.001). Group 1 had significantly fewer adhesions compared to Group 2 and Group 3 (P < 0.05 and P < 0.001, respectively), and no significant difference was found between Group 2 and Group 3 (P > 0.05). Duration of hospital stay was significantly shorter in Group 1 compared to Group 2 and Group 3 (P < 0.001) and also was significantly shorter in Group 2 than Group 3 (P < 0.05). Group 1 had significantly lower rate of culture proliferation than Group 3 (P < 0.001), whereas no significant differences were evident in other inter-group analyses (P > 0.05, for each). CONCLUSION: LC can safely be performed within 7 days of admission in cases of AC.

A rare solitary fibrous tumour of the ascending mesocolon: a case report.

Solitary fibrous tumours are rare mesenchymal tumours which mostly arise from pleura. Such tumours occurring in the mesocolon are exceptionally rare. A 35-year-old man was referred to the general surgery department with a painless and nonpalpable mass in the right quadrant of the abdomen, which was detected incidentally on magnetic resonance imaging. The patient had no symptoms and the physical examination revealed no findings. The patient underwent surgical resection and excisional biopsy results revealed an intra-abdominal solitary fibrous tumour originating from the ascending mesocolon. He was discharged two days after surgery and remained disease-free at the end of the two-month follow-up period.

DIAGNOSTIC VALUE OF DUPLEX DOPPLER ULTRASOUND PARAMETERS IN PAPILLARY THYROID CARCINOMA.

CONTEXT: Papillary thyroid carcinoma (PTC) is the most common type of thyroid cancer due to its high fibrotic content; it can affect the blood flow resistance. OBJECTIVE: To introduce duplex Doppler ultrasonography (DDUS) parameters of papillary thyroid carcinoma (PTC) and their correlation with size. DESIGN: The study was designed as a prospective study. SUBJECTS AND METHODS: Thyroid nodules of the patients who were already scheduled for thyroid surgery either for malignant thyroid nodules or multinodular goiter were evaluated for DDUS parameters. Size, systolic to diastolic flow velocity (S/D) ratio, pulsatility index (PI), and resistive index (RI) of each nodule were recorded. Nodules were diagnosed as PTC or benign nodules based on histopathology. DDUS parameters were compared between PTCs versus benign nodules and micro PTCs (≤ 10 mm) versus large PTCs (> 10 mm). A correlation analysis was performed between the size and DDUS parameters. RESULTS: 140 thyroid nodules (30 PTCs, 110 benign nodules) were obtained. The mean S/D ratio, PI, and RI values were significantly higher in PTC than in benign nodules (p values were 0.0001, 0.0003, and 0.0001 respectively). The optimal cut-off values of S/D (0.732), PI (0.732), and RI (0.738) had accuracy rates of 71%, 69%, and 69%, respectively. There was no statistically significant difference between micro PTC and large PTC with regards to DDUS parameters. The size and DDUS parameters of PTC showed no significant correlation. CONCLUSIONS: PTC has a high resistive flow pattern regardless of its size; however the clinical utility of DDUS to differentiate a PTC from benign nodule is limited.

Factors affecting sentinel lymph node metastasis in Turkish breast cancer patients: Predictive value of Ki-67 and the size of lymph node.

OBJECTIVES: We aimed to analyze the factors that affect the axillary lymph node involvement in Turkish breast cancer patients with clinically non-palpable axillary lymph node. BACKGROUND: Sentinel lymph node biopsy is the gold standard technique to evaluate the axillary lymph node status that directly influences the prognosis and the treatment options in breast cancer. METHODS: Breast cancer patients without axillary lymph node involvement in clinic examination were enrolled the study. Patients were categorized into the two groups according to existence of axillary lymph node metastasis or not. Demographic, histopathological and clinical data of patients were revealed retrospectively. RESULTS: One-hundred and eighty-seven patients were analyzed and 101 of patients fulfilled the criteria and were included the study. Metastatic lymph node was detected in 38 (37.6 %) patients (Group 1), and was negative in 63 (62.4 %) patients (Group 2). Sentinel lymph node metastasis were statistically significant higher in patients with Ki-67 ≥ 14 % than patients with Ki-67 < 14 % (51.9 % vs 22.4 %; p < 0.01). Likewise, the mean size of the sentinel lymph node was statistically significant higher in Group 1 compared to Group 2 (p < 0.01). CONCLUSION: Ki-67 proliferation index and sentinel lymph node size may provide a higher prediction about the sentinel lymph node involvement in patients with clinically negative axillary lymph nodes (Tab. 3, Fig. 1, Ref. 31).

Chylopericardium presenting as cardiac tamponade secondary to mediastinal lymphangioma.

Mediastinal lymphangioma is a rare entity and chylopericardium is a rare form of pericardial effusion. We report a case of acute chylous cardiac tamponade due to a cervicomediastinal lymphangioma in a one-year-old boy. A chest x-ray revealed marked cardiac enlargement and echocardiography showed massive pericardial effusion. Emergency surgery was performed whereby a pericardial window was created, followed by excision of the lymphangioma.

Incidental findings during routine pathological evaluation of gallbladder specimens: review of 1,747 elective laparoscopic cholecystectomy cases.

Introduction Cholecystectomy for benign gallbladder diseases can lead to previously undiagnosed gallbladder cancer during histopathological evaluation. Despite some controversy over its usefulness, histopathological evaluation of all gallbladder specimens is common in most hospitals. We evaluated the results of routine pathology of the gallbladder after cholecystectomy for benign gallbladder diseases with regard to unexpected primary gallbladder cancer (UPGC). Methods Patients undergoing cholecystectomy because of benign gallbladder diseases between 2009 and 2013 were enrolled in this study. All gallbladder specimens were sent to the pathology department, and histopathological reports were examined in detail. The impact of demographic features on pathological diagnoses and prevalence of UPGC assessed. Data on additional interventions and postoperative survival for patients with UPGC were collected. Results We enrolled 1,747 patients (mean age, 48.7±13.6 years). Chronic cholecystitis was the most common diagnosis (96.3%) and was associated significantly with being female (p=0.001). Four patients had UPGC (0.23%); one was stage T3 at the time of surgery, and the remaining three cases were stage T2. Conclusions Routine histopathological examination of the gallbladder is valuable for identification of cancer that requires further postoperative management.

Hyperbilirubinemia as a predictive factor in acute appendicitis.

PURPOSE: Our aim was to establish the role of hyperbilirubinemia as a predictive parameter for the prediction of either acute, or gangrenous/perforated appendicitis as well as to compare other parameters in a similar role. METHODS: Medical files of the patients who underwent appendectomies between September 2013 and September 2014 were evaluated. Age, gender, preoperative white blood cell count (WBC), neutrophil count (NEU), neutrophil percentage (NEU%), C-reactive protein (CRP), total/direct/indirect bilirubin levels, and the postoperative histopathological findings were recorded. The Fisher's exact, Pearson's χ (2), ANOVA, and Kruskal-Wallis tests while logistic regression for multivariate analysis was performed. p < 0.05 was accepted as statistically significant. RESULTS: The study group of 162 patients consisted of 97 (60 %) men and 65 (40 %) women with a median age of 36 (18-90). Histopathological examinations revealed normal appendix in 21 (13 %) patients, non-complicated acute appendicitis in 100 (62 %), and appendiceal gangrene/perforation in 41 (25 %) patients. WBC, NEU, NEU%, and CRP levels were significantly higher in cases of acute and gangrenous/perforated appendicitis (p < 0.01). Total and direct bilirubin levels were also significantly elevated in patients with acute and gangrenous/perforated appendicitis (p < 0.01). According to multivariate analysis, elevated CRP levels were associated with 14 times, elevated total bilirubin levels were associated with five times, and elevated direct bilirubin levels were associated with 36 times greater risk for appendiceal gangrene/perforation (p < 0.01, p < 0.05, p < 0.01, respectively). CONCLUSIONS: Hyperbilirubinemia, especially with elevated direct bilirubin levels, may be considered as an important marker for the prediction of appendiceal gangrene/perforation.

The Effect of Thyroid-Stimulating Hormone on Tumor Size in Differentiated Thyroid Carcinoma.

We evaluated the correlation between serum thyroid-stimulating hormone (TSH) levels and tumor size and other invasiveness parameters of tumor in patients with differentiated thyroid carcinoma (DTC). Several clinical studies have reported that TSH may also have a role as a regulator of the development and function of the thyroid gland. It is currently not clear whether TSH is involved in the existence of thyroid cancer or progression of thyroid cancer or both. Patients with DTC who underwent thyroid surgery between 2003 and 2008 were included this study. Preoperative serum T3, T4, and TSH levels were compared with the size and invasiveness of cancer, retrospectively. DTC was observed in 110 patients over the 5-year period. Seventy-seven (70 %) of them were euthyroid and classified as the "normal-TSH group" (NTG), and 33 (30 %) have an overt or subclinical hyperthyroidism, classified as the "low-TSH group" (LTG). The mean tumor diameter in the LTG was found to be 8.91 ± 8.03 mm; however, it was found to be 18.19 ± 16.24 mm in the NTG. There were significantly differences among the groups related to the diameter of tumor (p = 0.001). Microcarcinoma was determined in 36 patients (46.8 %) in the NTG and 23 patients (69.7 %) in the LTG (p = 0.027). Although there were no significant differences, tumor capsule invasion (33.8 vs. 18.2 %, p = 0.099) and lymphovascular invasion (16.9 vs. 6.1 %, p = 0.130) rates were higher in the NTG. These findings suggest that TSH has effects on growing and proliferation of not only normal thyroid cells but also cancer cells in DTC. This study revealed that serum TSH level can be explored as an important factor that affects the size and invasiveness of tumor in DTC.

Ex vivo intra-arterial methylene blue injection in the operation theater may improve the detection of lymph node metastases in colorectal cancer.

INTRODUCTION: Lymph node (LN) assessment after colorectal cancer resection is fundamentally important for therapeutic and prognostic reasons. LN positivity is an indication for adjuvant treatment. This study aimed to investigate whether immediate postoperative intra-arterial methylene blue (MB) injection (MBI) into colorectal cancer specimens by a surgeon in the operating room could improve the rate of total LN and metastatic LN recovery for pathological examination. MATERIALS AND METHODS: Seventy-three consecutive patients prospectively enrolled between January 2011 and December 2013 were assigned to the methylene blue (MB)-stained group and compared with 107 controls in the unstained group. RESULTS: The median number and range values of metastatic LNs, the number of LNs <0.5 cm, the total number of LNs harvested, and the number of cases with LN metastasis were significantly different between the MB-stained and MB-unstained groups (p = 0.016, p = 0.010, p = 0.025, and p = 0.006 respectively). CONCLUSIONS: Immediate MBI (fresh, unfixed samples) by a surgeon in the operating room may result in a significant increase in the number of metastatic LNs diagnosed and the number of cases with positive LNs. Shifting of the injection from the pathology laboratory to the operation theater would be a good alternative whenever the operation theater is not the area located as the pathology department.

Robot-assisted laparoscopic colorectal surgery.

Colorectal cancer is one of the most common malignancies seen in developed countries. Its current treatment is based on a multidisciplinary approach entailing surgery, chemotherapy and radiotherapy. Surgery can be performed with open and minimal invasive methods. Single incision laparoscopic surgery (SILS), natural orifice transluminal endoscopic surgery (NOTES) and robot assisted laparoscopic surgery (RALS) are the final points to be reached in minimally invasive surgery. The first robotic colorectal surgical intervention was performed in 2001 after getting the FDA approval for the da Vinci surgical system in intraabdominal surgery, and since then, its use in this field gradually increased. Compared to open surgery, the advantage and superiority of robotic surgery, especially in narrow areas such as the pelvis, has been shown in many studies. It is a safe and feasible method. Although there are many existing studies about minimally invasive surgery, more randomized studies with larger case numbers should be carried out in order to establish the favorable oncological and functional outcomes of robotic surgery in addition to its obviously observed advantages.

"Diagnostic value of MRCP in biliary pancreatitis: result of long-term follow-up".

AIM: Magnetic resonance cholangiopancreatography (MRCP) has increasingly been used to evaluate the common bile duct. This study was to determine the role of MRCP instead of endoscopic retrograde cholangiopancreatography (ERCP) in the management of patients with acute biliary pancreatitis. METHODS: A total of 81 patients with mild or moderate biliary pancreatitis who underwent MRCP and were treated in our department with selective ERCP between May 2001 and July 2007 were entered into a prospective database. RESULTS: MRCP was considered abnormal in 13 patients. Ten patients underwent ERCP. Three patients did not undergo ERCP due to protocol violations. In nine patients, stone extraction was performed. The remaining patient who had dilatation of the CBD underwent ES. The false positive rate of MRCP was 10%. The median follow-up of overall patients was 36 months (range 23-99 months). The patients with normal MRCP had a median follow-up of 39.5 months (range 23-99 months). During the follow-up period in the normal MRCP group, five patients were diagnosed with recurrent biliary pancreatitis, of which three underwent ERCP (7.4%). There was no disease-related mortality during this period. CONCLUSION: In conclusion, the use of MRCP in acute biliary pancreatitis is safe and may be recommended as a tool to aid in the selective use of ERCP.

Robot-assisted laparoscopic abdominoperineal resection for low rectal cancer.

BACKGROUND: This article reports on patients with low rectal cancer treated with robot-assisted laparoscopic abdominoperineal resection. METHODS: Robot-assisted laparoscopic abdominoperineal resection was performed on seven patients in the General Surgery Clinic of Umraniye Training and Research Hospital between 2010 and 2011 by performing abdominal and perineal skin incisions using the same technique. Gender, age of the patients, intraoperative and postoperative complications, morbidity and mortality were evaluated. RESULTS: Five of the patients were male and two of them were female. Mean age was 59.2 years. All of the procedures were completed robotically. No intraoperative complication occurred, whereas urinary bladder dysfunction (n = 1) and chylous ascites (n = 1), treated conservatively, developed in the postoperative period. On histopathological examination, surgical and circumferential margins were found to be negative in all specimens. Early recurrence was not found on postoperative follow-up. CONCLUSION: Robot-assisted laparoscopic surgery can be performed safely in narrow and deep anatomical areas, such as the pelvis.

Evolution-based algorithm for the management of penetrating abdominal stab injury.

PURPOSE: As an increasing amount of penetrating abdominal stab injuries has been observed in the last few decades, it is important to evaluate the adequacy of the medical systems and surgical education and training to handle this type of injury. The aim of this study was to analyze the outcome of patients with penetrating abdominal stab injuries admitted to the Emergency Unit and to evaluate the effects of using a new treatment algorithm. METHODS: From January 2009 to April 2009, a standardized education and training system for the surgical team was implemented in order to improve the emergency medical care system. From April 2009 to April 2011, 106 patients with the diagnosis of a penetrating abdominal stab injury were prospectively included in the study. RESULTS: The cohort included 98 males and the mean age was 29.40 ± 10.9 years. Eighty-two percent of the patients were managed conservatively, whereas 18 % underwent surgery. Based on the surgical outcomes of the patients, the rate of negative, non-therapeutic, and therapeutic laparotomies was 5, 11, and 84 %, respectively. No statistically significant difference between patients who did and did not receive surgery was observed with regards to blood pressure, temperature, hematocrit, hemoglobin, and C-reactive protein (CRP) values. However, a statistically significant difference was observed in the pulse rate, leukocyte, and neutrophil counts. The mortality and morbidity rates were 0.94 and 3.77 %, respectively. CONCLUSIONS: Selective non-operative management, which has been standardized in trauma centers, may be carefully utilized in order to treat penetrating abdominal stab wounds with caution in well-equipped medical centers with well-trained staff.

Dieulafoy lesion in the stomach.

Dieulafoy disease is an uncommon cause of gastrointestinal system bleeding. Although the exact cause is not known, it is characterized by bleeding from abnormal submucosal vessels. There are many methods for diagnosis and treatment. In this case, a patient with a long-time undiagnosed stomach Dieulafoy lesion had a surgical resection. During the postoperative period the patient was discharged without any complication.

Femoral hernia: a review of 83 cases.

We evaluate the factors that affect morbidity and mortality in patients who underwent surgery due to femoral hernia. The medical records of 83 patients who underwent femoral hernia repair between January 1996 and June 2004 were retrospectively analyzed. The femoral hernias were repaired either with McVay or mesh plug hernioplasty. Sex, age, surgical repair technique, presence of incarceration/strangulation, incarcerated/strangulated organs, postoperative complications, duration of hospitalization, recurrence rate, and factors that affect mortality and morbidity were studied. There were 83 patients with femoral hernia in our study. Patients' age ranged from 10 to 75 years (mean age was 46.84) with a predominance of female (71%). Thirty-six patients (40%) underwent emergency surgery with the diagnosis of strangulation or incarceration of femoral hernia. Seventeen patients had strangulation and underwent resection; eleven of these patients had omentum in the hernial sac, whereas six patients had intestines. Four of these patients underwent laparotomy. The remaining 19 patients had incarceration and underwent simple reduction of hernial sac content without resection. Forty-seven (60%) patients underwent elective surgery. McVay technique was used for 79 patients, while the other four patients were treated with mesh-plug. Twelve patients (15%) developed a variety of complications (nine patients (25%) in emergency, three patients (6%) in elective group). There was one mortality. Recurrences occurred in two patients. Femoral hernia is an important surgical pathology with high rates of incarceration/strangulation and intestinal resection. Emergency surgery can increase morbidity and mortality especially in the elderly. Early elective surgery may reduce complication.

Unnecessary laparotomy by using physical examination and different diagnostic modalities for penetrating abdominal stab wounds.

BACKGROUND: The modern management of penetrating abdominal trauma has decreased the incidence of unnecessary laparotomy by using selective non-operative management protocols. However, the real benefits of physical examination and different diagnostic methods are still unclear. METHODS: From January 2000 to April 2003, we prospectively collected data on 117 patients with penetrating stab wounds to the thoracoabdominal, anterior abdominal, and back regions who had non-operative management. Clinical examination was the primary tool to differentiate those patients requiring operation. Findings of physical examination, ultrasound, computed tomography, endoscopy, echocardiography, diagnostic peritoneal lavage, and diagnostic laparoscopy were reviewed. The number of therapeutic, non-therapeutic, and negative laparotomies were recorded. RESULTS: Non-operative management was successful in 79% of patients. There were 11 early (within 8 hours of admission) and 14 delayed (more than 8 hours after admission) laparotomies performed, depending on the results of various diagnostic procedures. Non-operative management failed in 21% of patients, and the rate of non-therapeutic laparotomy in early and delayed laparatomy groups was 9% and 14% respectively. There was no negative laparatomy. CONCLUSIONS: The use of physical examination alone and/or together with different diagnostic methods allows reduction of non-therapeutic laparotomies and elimination of negative laparatomies.

Inflammatory pseudotumour of the liver presenting with obstructive jaundice.

Inflammatory pseudotumours are rare benign tumours characterized by an inflammatory process and can occur in any system. We present a case of inflammatory pseudotumours of the liver presenting with obstructive jaundice due to a mass forming lesion in the left lobe of the liver which was treated by left hepatic lobectomy. Inflammatory pseudotumour of the liver is a benign lesion and diagnosis with an image examination is difficult. Surgical management depends on the location of the lesion. Peripheral hepatic pseudotumours may be treated with simple observation or conservative therapy. In contrast to this, those involving the porta hepatis require treatment for obstructive jaundice.

Torsion of a wandering spleen presenting with acute abdomen: a case report.

Wandering spleen is a rare condition characterized by increased splenic mobility due to the absence or laxity of its suspensory ligaments that may present as acute abdomen when it is twisted on its pedicle. Herein we report a case of torsion of a wandering spleen in a 17-year-old male patient with communicating hidrocephalus and ventriculoperitoneal shunt. The patient presented with suspicious clinical findings of acute abdomen, a laparotomy was performed and the infarcted spleen was removed. Although wandering spleen is a rare clinical entity, the possibility of torsion should be kept in mind in the differential diagnosis of acute abdomen.

Delayed traumatic diaphragmatic hernias presenting with strangulation.

Traumatic diaphragmatic injuries commonly occur following blunt and penetrating trauma, and that may be missed during a first evaluation, resulting in chronic diaphragmatic hernia and/or strangulation. In this study, we present three cases of delayed traumatic diaphragmatic hernias presenting with strangulation. The type of trauma was blunt in two and penetrating in one patient. In all three cases, the diagnoses of diaphragmatic injuries were missed in acute and chronic settings. While two patients had transverse colonic strangulation, the other one had strangulated stomach and spleen. Transverse colon resection was performed in one patient. Two patients had postoperative complications, and no postoperative mortality was detected. Patients complaining of upper abdominal pain and dyspnea with past history of thoracoabdominal trauma should be evaluated for a missed diaphragmatic injury. A high index of suspicion, physical examination of the chest, and x-ray film are helpful for diagnosis of delayed traumatic diaphragmatic hernias presenting with strangulation.