The effect of subareolar isosulfan blue injection on pulse oximeter readings.

Besides several side effects including anaphylaxis, blue dyes are also known to cause false pulse oximeter readings. We aimed to examine the effects of subareolar isosulfan blue injection on pulse oximeter (SpO2) readings. The study group included 27 patients undergoing SLNB using both radiocolloid and isosulfan blue. Another group of 27 patients constituted the control group. Pulse oximeter readings were compared. SpO2 decline ≥4 % was defined as significant. All but one (96.2 %) of the patients in the study group showed SpO2 declines, compared to only one patient in the control group. Median ± Interqartile Range (IR) SpO2 decrease was 3.0 ± 4.0 % in the study and 0.0 ± 1.0 % in the control group (p < 0.001). There were significant (≥4 %) SpO2 decreases in 13 (48.1 %) patients in the study group. Statistically significant differences were noted between the two groups in all recordings between 15 and 180 min (p < 0.001). Initial time for SpO2 fall and the time to the lowest SpO2 recording were 10.0 ± 10.0 and 40.0 ± 30.0 min respectively. Using subareolar injection, the frequency of false readings is comparable with intraparenchymal injections, and is higher than intradermal injections. Time to peak SpO2 fall, and the recovery period, are delayed in the subareolar technique.

Sentinel lymph node biopsy in breast cancer: review on various methodological approaches.

AIMS AND BACKGROUND: Sentinel lymph node biopsy has been accepted as a standard procedure for early stage breast cancer. In this retrospective analysis, the results obtained with different methodological approaches using radiocolloid with or without blue dye were examined. METHODS: A total of 158 sentinel lymph node biopsies were performed in 152 patients. Group A (85 patients) underwent lymphatic mapping using a combination of periareolar intradermal radiocolloid and subareolar blue dye injections. Group B (73 patients) underwent only periareolar intradermal radiocolloid injection. One large tin colloid and two small radiocolloids (nanocolloid of serum albumin -NC- and colloidal rhenium sulphide -CS-) were used. RESULTS: Successful lymphatic mapping was attained in 157 of 158 procedures (99.4%). Radiocolloids localized sentinel lymph nodes in 99.4% and blue dye in 75.3% of the cases. The number of sentinel lymph nodes removed was greater in nanocolloid and colloidal rhenium sulphide groups (P ≤0.05). Among 60 metastatic sentinel lymph nodes, frozen section analysis using hematoxylin and eosin staining failed to detect 1 macro- and 10 micrometastasis. Radiocolloid uptake was higher in sentinel lymph nodes accumulating blue dye (1643 ± 3216 counts/10 sec vs 526 ± 1284 counts/10 sec, P <0.001). Higher count rates were obtained by using larger sized colloids (median and interquartile range: tin colloid, 2050 and 4548; nanocolloid, 835 and 1799; colloidal rhenium sulphide, 996 and 2079; P = 0.01). Only 2 extra-axillary sentinel lymph nodes were visualized using periareolar intradermal injection modality. CONCLUSIONS: Radiocolloids were more successful than blue dye in sentinel lymph node detection. More sentinel lymph nodes were harvested with small colloids, but different sized radiocolloids were similarly successful. Sentinel lymph nodes having higher radiocolloid uptake tended to accumulate blue dye more frequently. Sentinel lymph nodes manifested higher count rates when a larger colloid was used. Frozen section was very successful in detecting macrometastatic disease in sentinel lymph nodes, but the technique failed in most of the micrometastates.

Superior mesenteric artery syndrome: a rare cause of intestinal obstruction. Diagnosis and surgical management.

Superior mesenteric artery syndrome is a rare but well-known clinical entity characterized by compression of the third or transverse portion of the duodenum against the aorta by the superior mesenteric artery, resulting in chronic, intermittent, or acute, complete or partial, duodenal obstruction. The treatment for this arteriomesenteric compression includes conservative measures and surgical intervention. The aim of the study was to evaluate our surgical management and outcomes of the patients with superior mesenteric artery syndrome. The cases with superior mesenteric artery syndrome admitted between January 2000 and January 2010 were retrospectively investigated from the patients' records. All six patients had a history of chronic abdominal pain, nausea, postprandial early satiety, vomiting, and weight loss. Diagnostic methods included barium esophagogastroduodenography, upper gastrointestinal endoscopy, and computed tomography. Medical management was the first step of treatment in all cases before surgery. Of those, four underwent Roux-en-Y duodenojejunostomy and two underwent gastroenterostomy. Postoperative periods were uneventful and mean duration of hospitalization after the operations was 7 days. Conservative initial treatment is usually followed by surgical intervention for the main problem that is the narrowing of the aortomesenteric angle in patients with superior mesenteric artery syndrome. This syndrome should be considered in the differential diagnosis in patients with chronic upper abdominal pain. Duodenojejunostomy is the most frequently used procedure with a high success rate.

Rectal Involvement of Recurrent Buschke-Lowenstein Tumor Causing Subileus: a Case Report.

We present a 48-year-old caucasian woman presenting with anal pain, discharge and difficulty in defecation due to recurrent Buschke-Lowenstein tumor with rectal involvement discuss it in the light of literature. A 48-year old caucasian woman was referred to our institute with anal mass causing pain, discharge and difficulty in defecation. She initially had simple excision and electrocoterisation 3 and 15 years before at different centers. At physical examination, multiple vegetative mass lesions presented as a cauliflower-like tumor were seen at perianal region. Colonoscopy showed an inflamated, vegetative mass covering all mucosa annularly and starting from 2 cm away from anal verge and reaching until 20 cm was seen. Due to the large extent of tumor invasion in this case, curative surgery would have been achieved only by wide local surgical excision and abdominoperineal resection due to rectal involvement. This severe mutilation was refused by the patient. Thus, patient was referred to medical oncology for radiochemotherapy. Wide radical excision of Buschke-Lowenstein tumor (BLT) is the preferred treatment for achieving local control, but excision alone often is ineffective treatment. Abdominoperineal resection is necessary in cases with infiltration involving the sphincter muscles or rectum, especialy for recurrent cases.

A rare cause of acute abdomen: small bowel obstruction due to phytobezoar.

BACKGROUND: Phytobezoars are a rare cause of acute small bowel obstruction. The aim of this work was to identify the diagnostic difficulties and treatment of this rare entity. METHODS: Data of 14 patients operated between January 1999-January 2009 with small bowel phytobezoar were retrospectively studied. The patients (n=432) were treated in our clinic for small bowel obstructions. Of these, 14 (3.2%) phytobezoar-induced small bowel obstructions were included in this series. Median patient age was 57.25 years; nine (64%) of the patients were male, and five (36%) were female. RESULTS: The predisposing factor was previous gastric surgery in 12 (87.5%) patients and previous abdominal surgery and total absence of the teeth in two (14.3%) patients. A completely obstructing terminal ileal phytobezoar was found in nine (64%) patients and jejunal phytobezoar in five (36%) patients during exploration. There was no mortality. CONCLUSION: Phytobezoar-induced small bowel obstruction remains an uncommon diagnosis that poses a diagnostic and management challenge. It should be suspected in patients with an increased risk of bezoar formation, such as in the presence of previous gastric surgery, poor dentition or a history suggestive of increased fiber intake.

Gallstone ileus as an unexpected complication of cholelithiasis: diagnostic difficulties and treatment.

BACKGROUND: Gallstone ileus is a rare complication of cholelithiasis, mostly in the elderly. The aim of this study was to evaluate our experience with 12 gallstone ileus cases and discuss current opinion as reported in the literature. METHODS: Data of 12 patients operated between January 1998 and January 2008 with gallstone ileus were retrospectively studied. RESULTS: There were 12 cases (9 F, 75%; 3 M, 25%) with a mean age of 63.6 (50-80) years. Median duration of symptoms before admission to the hospital was 4.1 (1-15) days. Preoperative diagnosis was made in only five cases (41.6%). Enterolithotomy was done in nine cases (75%). Enterolithotomy and resection of the small intestine--required for decubital necrosis from the gallstone--was performed in one case (8.3%). In one case (8.3%), enterolithotomy was completed in one stage with cholecystectomy and closure of the fistula during acute surgery, and in another case (8.3%), enterolithotomy + primary suturing of the jejunal perforation was performed. There were two (16.6%) perioperative mortalities. CONCLUSION: Gallstone ileus remains a diagnostic challenge despite advances in imaging techniques, and pre-operative diagnosis is often delayed. Gallstone ileus should be suspected in all cases admitted to the emergency service with acute intestinal obstruction with a history of cholelithiasis, especially in the elderly and females.

Intussusception in adults: clinical characteristics, diagnosis and operative strategies.

AIM: To evaluate 20 adults with intussusception and to clarify the cause, clinical features, diagnosis, and management of this uncommon entity. METHODS: A retrospective review of patients aged > 18 years with a diagnosis of intestinal intussusception between 2000 and 2008. Patients with rectal prolapse, prolapse of or around an ostomy and gastroenterostomy intussusception were excluded. RESULTS: There were 20 cases of adult intussusception. Mean age was 47.7 years. Abdominal pain, nausea, and vomiting were the most common symptoms. The majority of intussusceptions were in the small intestine (85%). There were three (15%) cases of colonic intussusception. Enteric intussusception consisted of five jejunojejunal cases, nine ileoileal, and four cases of ileocecal invagination. Among enteric intussusceptions, 14 were secondary to a benign process, and in one of these, the malignant cause was secondary to metastatic lung adenocarcinoma. All colonic lesions were malignant. All cases were treated surgically. CONCLUSION: Adult intussusception is an unusual and challenging condition and is a preoperative diagnostic problem. Treatment usually requires resection of the involved bowel segment. Reduction can be attempted in small-bowel intussusception if the segment involved is viable or malignancy is not suspected; however, a more careful approach is recommended in colonic intussusception because of a significantly higher coexistence of malignancy.