Surgical management of Stapfer Type 2 ERCP perforations.

BACKGROUND: While numerous studies have proposed algorithms for the management of Stapfer Type 2 ERCP perforations, there is limited research on surgical treatment options specifically for this patient group. Our aim is not to propose a new algorithm for these patients but to describe our surgical approach and contribute to the literature with our surgical procedure applied in Stapfer Type 2 ERCP perforation cases. METHODS: Between 2016 and 2023, a total of 12 patients with Stapfer Type 2 ERCP perforations underwent surgery at our hospital. Duodenal diverticulization is a commonly used method in complex duodenal perforation cases. We performed a procedure that involves the removal of the external biliary pathway, hepaticojejunostomy, and a wide Braun anastomosis in addition to the duodenal diverticulization procedure, which we have termed "modified duodenal diverticulization." RESULTS: Eleven out of the 12 patients were discharged successfully without any complications. One patient, who had a late diagnosis, underwent surgery 5 days after ERCP. This patient had ongoing sepsis before the operation, which continued postoperatively and eventually led to multiple organ failure and death. CONCLUSION: There are limited alternatives for the surgical treatment of Type 2 ERCP perforations, and the widely preferred triple ostomy method may not address the underlying pathology necessitating ERCP. The modified duodenal diverticulization method, offering a definitive treatment, can be considered a surgical option for Type 2 ERCP perforations.

The use of Bakri balloon to reduce the anastomosis tension in hepaticojejunostomy.

One of the factors that impair anastomosis healing in patients undergoing hepaticojejunostomy is tension of the anastomosis. There may be tension, especially in cases with a short mesojejunum. In cases where the jejunum cannot be brought higher, positioning the liver a little lower may be a solution. We placed a Bakri balloon between the liver and diaphragm to position the liver to a lower level. Here we present a successful hepaticojejunostomy case in which we placed a Bakri balloon to decrease the anastomosis tension.

Is carpal tunnel release safe in electrical burn decompressive therapy: Six-years experience.

Objectives: Upper extremity electrical burn can create severe sequela and debilitation if not treated properly. Immediate decompression with fasci- otomy and carpal tunnel release seem to be the most promising choice of treatment. Neurologic functional loss can be avoided if median nerve is liberated. Material and Methods: During 6-year time interval, 50 out of 1158 burn patients underwent upper extremity decompressive fasciotomy with carpal tunnel release. Their hand motor function based on nerve innervation and daily usage questionnaire were followed in 12-month intervals. Results: Average score rose markedly after 18th month and reached nearly normal at the end of 66th month. Median, ulnar and radial nerve function tests were all positive, and no irreversible nerve function loss observed. Conclusion: All compartments of the forearm should be explored and carpal tunnel release should be added into upper extremity decompressive fasciotomy after electrical burns.

A rare cause of duodenal obstruction: Bouveret syndrome.

Gallstone ileus is a relatively rare pathology, most commonly obstructing the terminal ileum. Bouveret syndrome, leading to gastric outlet obstruction and seen with an incidence of less than 1%, is a syndrome met particularly in elderly patients and develops as the result of cholecysto-enteric fistula. In this report, it was aimed to present a 95-year-old case diagnosed with Bouveret syndrome.

Should percutaneous cholecystostomy be used in all cases difficult to manage?

BACKGROUND: Cholecystectomy is the well-accepted management method for acute cholecystitis in patients suitable for surgery. Percutaneous cholecystostomy is planned and used in patients at high surgical risk due to acute symptomatic cholecystitis and/or acute or chronic comorbidity. Percutaneous cholecystostomy can provide permanent treatment, or it may act as a bridge for elective cholecystectomy. METHODS: We presented the outcomes of 50 patients who initially underwent ultrasound-guided transhepatic percutaneous cholecystostomy and 4-6 weeks later, an interval cholecystectomy. All patients had either impaired gallbladder wall integrity on contrast-enhanced abdominal computed tomography performed during admission or had grade II acute cholecystitis according to the Tokyo Guidelines 13 diagnostic criteria and severity grading of acute cholecystitis or exhibited clinical signs of acute cholecystitis on the fifth day of non-operative treatment. RESULTS: Our results suggest that although percutaneous cholecystostomy is a useful method for alleviation of the emergency clinical condition in acute cholecystitis, it makes the interval cholecystectomy more difficult to perform due to the dense fibrosis developing during the healing process, eventually complicating laparoscopic cholecystectomy. CONCLUSION: Cholecystostomy may cause fibrosis during the healing process, eventually complicating laparoscopic cholecystectomy. Thus, there is a need for better evaluation during the identification of indications for cholecystostomy.

Rare cause of duodenal obstruction: Bouveret syndrome.

Gallstone ileus is a relatively rare pathology, most commonly obstructing the terminal ileum. Bouveret syndrome is a syndrome found particularly in elderly patients, which develops as the result of a cholecystoenteric fistula. It leads to the gastric outlet obstruction and has an incidence of less than 1%. In this report, we presented a 95-year-old patient diagnosed with Bouveret syndrome.

Prognostic factors in acute mesenteric ischemia and evaluation with Mannheim Peritonitis Index and platelet-to-lymphocyte ratio.

BACKGROUND: Acute mesenteric ischemia (AMI) is a disease that has a very high mortality rate and for which the diagnosis is frequently delayed. The aim of the present study was to assess the predictive value of the Mannheim Peritonitis Index (MPI) and platelet-to-lymphocyte (P/L) ratio in the prognosis of AMI. METHODS: The files of 34 patients diagnosed with AMI between September 2014 and April 2016 were retrospectively examined. The patients were divided into 2 groups based on survival. The parameters of MPI and P/L ratio, demographic data, and duration of hospitalization were recorded and compared. RESULTS: In all, 19 (55.9%) patients were male, and 15 (44.1%) were female. Total of 19 patients (55.9%) were discharged with a complete recovery, while 15 (44.1%) died. MPI mean value was 21.13±7.55 and 16.00±5.24 in those who died and survived, respectively (p=0.026). P/L ratio was 288.48±233.01 and 373.82±389.62 in those who survived and died, respectively (p=0.045). CONCLUSION: MPI and P/L ratio are simple and reliable methods to predict the prognosis of AMI.

Recurrent pilonidal disease surgery: Is it second primary or reoperative surgery?

OBJECTIVE: Pilonidal sinus disease (PSD) effects mainly young men's social and work life with frequent recurrence rate. Reoperation for unimproved or recurrent disease is somehow troublesome. Surgeons may think that changing treatment strategy after recurrence may prevent further relapses of PSD. We analyzed patients with recurrent pilonidal sinus to determine their predisposing features for recurrence and the outcomes of the preferred surgical methods. MATERIAL AND METHODS: From 2007 to 2012, out of 95 recurrent pilonidal sinus disease (rPSD) patients, 62 operated cases were included and examined retrospectively. Their retrospective data were examined for demographics, 1(st) and 2(nd) operation types, patient satisfaction and pain scores. For cases with insufficient preoperative or postoperative data, phone call and interviews were done to obtain data. Some were kindly invited to the outpatient examination. Student's t test, Mann-Whitney U test, and Kaplan Meier test for disease free survival time were used where appropriate. P values less than 0.05 were accepted to be statistically significant. RESULTS: Total of 62 rPSD patients were examined. Male:female ratio was 2.9:1. The mean age after 1(st) and 2(nd) operations were 24.7 and 28.1 years, respectively. One and five-year recurrence rates were 33.9% and 66.1%, respectively. The mean interval between the 1(st) and 2(nd) operations was 45.6 months. Excision and midline closure was the most frequent type of operation followed by flap reconstructions and excision-lay open procedures. The 1(st) operation types of rPSD cases were different from that of 2(nd) operations. Pain perception and satisfaction scores were better in flap reconstruction groups. CONCLUSION: Reoperative surgery of rPSD is satisfactory with certain precautions. Relapses after flap reconstruction procedures with a well-being period should be referred as second primary disease. Changing surgical strategy is not always indicated as some patients with recurrence have relapsing or second primary disease that have distinct clinical course. Re-flap surgery after any kind of relapse is well appreciated.

Retroperitoneal paraganglioma presenting with pancytopenia: A rare case with rare manifestation.

INTRODUCTION: Paragangliomas are tumors that arise from extraadrenal chromaffin cells and most of them are asymptomatic presenting with painless mass. Retroperitoneal paragangliomas are mostly benign with good prognosis; however, they can present with abdominal pain, palpable mass, or hypertensive episodes. Surgical resection is still the main treatment and necessary for histological assessment. CASE REPORT: A 41 year old female patient presented with 6 months of loss of appetite, weight loss, weakness and breathlessness on exertion.. The patient's initial blood examination showed marked anemia, reduced leukocyte count with neutropenia and lymphopenia and a marked reduction in the platelet count. The patient was admitted for evaluation of her pancytopenia. Magnetic resonance imaging revealed a 8×7×8cm sized mass closed to the pancreatic tail invading splenic hilum. A large mass was identified retroperitoneally, closed to the tail of pancreas with a splenic hilum invasion. Total mass resection and splenectomy was performed. DISCUSSION: Complete surgical excision is the treatment of choice for extra-adrenal paragangliomas as well as for recurrent or metastatic neoplasms. Reactive thrombocytosis is a common cause of thrombocytosis. Splenectomy was found to be one of the main causes of extreme reactive thrombocytosis. Reactive thrombocytosis is a predictable finding after splenectomy and management of the thrombocytosis and prevention of complications should be initiated.

Treatment of hypertriglyceridemia-induced acute pancreatitis with insulin.

INTRODUCTION: Hypertriglyceridaemia (HT)-induced pancreatitis rarely occurs unless triglyceride levels exceed 1000 mg/dl. Hypertriglyceridaemia over 1,000 mg/dl can provoke acute pancreatitis (AP) and its persistence can worsen the clinical outcome. In contrast, a rapid decrease in triglyceride level is beneficial. Insulin-stimulated lipoprotein lipase is known to decrease serum triglyceride levels. However, their efficacy in HT-induced AP is not well documented. AIM: To present 12 cases of AP successfully treated by insulin administration. MATERIAL AND METHODS: Three hundred and forty-three cases of AP were diagnosed at our clinic between 2005 and 2012. Twelve (3.5%) of these cases were HT-induced AP. Twelve patients who suffered HT-induced AP are reported. Initial blood triglyceride levels were above 1000 mg/dl. Besides the usual treatment of AP, insulin was administered intravenously in continuous infusion. The patients' medical records were retrospectively evaluated in this study. RESULTS: Serum triglyceride levels decreased to < 500 mg/dl within 2-3 days. No complications of treatment were seen and good clinical outcome was observed. CONCLUSIONS: Our results are compatible with the literature. Insulin may be used safely and effectively in HT-induced AP therapy. Administration of insulin is efficient when used to reduce triglyceride levels in patients with HT-induced AP.

Characteristics of Emergency Gastrointestinal Stromal Tumor (GIST).

BACKGROUND/AIMS: Gastrointestinal Stromal Tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract (GIT). Importance of GISTs is increasing while surgeons are facing with more frequent either in emergency setting of elective cases. Delineating the presentation and management of emergency GIST is important. METHODOLOGY: From 2005 to 2014, emergency cases with final diagnosis of GIST were examined retrospectively. Total of 13 operated cases were evaluated by patients characteristics, clinical presentation, operational findings and postoperative prognosis. RESULTS: There were 9 male and 4 female with the mean age of 48.15 years. The most frequent presentations are ileus and GIT hemorrhage both covering the 84% of patients. Small bowel was the dominating site with ileus. Stomach was the second frequent site of the disease with the finding of hemorrhage. CONCLUSION: Emergency patients are more likely to come with small bowel GIST and obstruction symptoms. Hemorrhage is the most frequent symptom for emergency GIST of stomach and duodenum.

Determination of optimal operation time for the management of acute cholecystitis: a clinical trial.

INTRODUCTION: Although all studies have reported that laparoscopic cholecystectomy (LC) is a safe and effective treatment for acute cholecystitis, the optimal timing for the procedure is still the subject of some debate. AIM: This retrospective analysis of a prospective database was aimed at comparing early with delayed LC for acute cholecystitis. MATERIAL AND METHODS: The LC was performed in 165 patients, of whom 83 were operated within 72 h of admission (group 1) and 82 patients after 72 h (group 2) with acute cholecystitis between January 2012 and August 2013. All data were collected prospectively and both groups compared in terms of age, sex, fever, white blood count count, ultrasound findings, operation time, conversion to open surgery, complications and mean hospital stay. RESULTS: The study included 165 patients, 53 men and 112 women, who had median age 54 (20-85) years. The overall conversion rate was 27.9%. There was no significant difference in conversion rates (21% vs. 34%) between groups (p = 0.08). The operation time (116 min vs. 102 min, p = 0.02) was significantly increased in group 1. The complication rates (9% vs. 18%, p = 0.03) and total hospital stay (3.8 days vs. 7.9 days, p = 0.001) were significantly reduced in group 1. CONCLUSIONS: Early LC within 72 h of admission reduces complications and hospital stay and is the preferred approach for acute cholecystitis.

Pancreatic carcinosarcoma: case report of a rare type of pancreatic neoplasia.

CONTEXT: Carcinosarcoma of the pancreas is a rare entity comprising a small subset of all pancreatic neoplasms. Diagnosis is usually established by immunohistochemical examination of the resected specimen. Prognosis is limited to several months after resection. CASE REPORT: We review the current literature on this rare type of neoplasia, considering histopathological and clinical features. The pathologic findings revealed areas of both adenocarcinoma and sarcoma of the pancreas. The adenocarcinomatous areas localized to the tumor within the head of the pancreas whereas the sarcomatous areas localized to regions of the intraductal component. DISCUSSION: Carcinosarcoma of the pancreas is a rare disease having a dismal prognosis. To our knowledge, this carcinosarcoma is the very rare reported case of a primary pancreatic neoplasm with mixed carcinomatous and sarcomatous components.

A new and simple predictive formula for non-sentinel lymph node metastasis in breast cancer patients with positive sentinel lymph nodes, and validation of 3 different nomograms in Turkish breast cancer patients.

BACKGROUND: Nomogram accuracies for predicting non-sentinel lymph node (SLN) involvement vary between different patient populations. Our aim is to put these nomograms to test on our patient population and determine our individual predictive parameters affecting SLN and non-SLN involvement. PATIENTS AND METHODS: Data from 932 patients was analyzed. Nomogram values were calculated for each patient utilizing MSKCC, Tenon, and MHDF models. Moreover, using our own patient- and tumor-depended parameters, we established a unique predictivity formula for SLN and non-SLN involvement. RESULTS: The calculated area under the curve (AUC) values for MSKCC, Tenon, and MHDF models were 0.727 (95% confidence interval (CI) 0.64-0.8), 0.665 (95% CI 0.59-0.73), and 0.696 (95% CI 0.59-0.79), respectively. Cerb-2 positivity (p = 0.004) and size of the metastasis in the lymph node (p = 0.006) were found to correlate with non-SLN involvement in our study group. The AUC value of the predictivity formula established using these parameters was 0.722 (95% CI 0.63-0.81). CONCLUSION: The most accurate nomogram for our patient group was the MSKCC nomogram. Our unique predictivity formula proved to be as equally effective and competent as the MSKCC nomogram. However, similar to other nomograms, our predictivity formula requires future validation studies.