Granulomatous mastitis: is it an autoimmune disease? Diagnostic and therapeutic dilemmas.

PURPOSE: Granulomatous mastitis (GM) is a rare benign inflammatory breast disease. The clinical presentation of granulomatous mastitis usually mimics malignancy or infection. The aim of this study was to review the clinical and diagnostic features of GM and discuss the medical and surgical treatment of our series of eight GM patients. METHODS: Between 2008 and 2010, eight patients were diagnosed with GM and underwent surgery. Patients were evaluated clinically and radiologically. The diagnosis of GM was confirmed in all cases by core needle or excisional biopsies. Serological tests were performed for rheumatoid factor (RF), antinuclear antibody (ANA), and anti-double-stranded DNA (anti-dsDNA). RESULTS: The mean patient age was 37 years. Common presenting symptoms were a hard mass, pain, inflamed hyperemic skin, and sinus formation. Serological tests for RF were positive in 6 patients, and ANA and anti-dsDNA antibodies were detected in 2 patients. All patients underwent antibiotic therapy before surgery, and were treated with wide surgical excision with negative margins. Methylprednisolone (16 mg/day for 3 months) therapy was used in 3 patients (all RF and 2 ANA/anti-dsDNA positive) following a wide excisional biopsy after a postoperative recurrence mimicking skin lesions was seen. These patients responded well to steroid therapy. CONCLUSIONS: The diagnosis of GM should be made carefully to avoid a misdiagnosis. Steroid therapy should be considered based on the idea that this is an autoimmune disease.

Elective and emergency surgery in chronic hemodialysis patients.

PURPOSE: Aim of this study was to report our experience in elective and emergency surgery on chronic hemodialysis (CH) patients for end-stage renal disease (ESRD). METHODS: All patients on CH for ESRD who underwent various surgical procedures in our unit within the past 9-year period (2001-2010) were included in this study. These patients were divided into two groups according to the type of surgery performed: elective or emergency. Demographic data, indications for surgery, primary causes of ESRD, surgical procedures, postoperative complications, and mortality rates were studied. RESULTS: Of 130 patients, 121 underwent elective surgery while 10 were addressed for emergency operation. In the elective surgery group, the most common diseases were secondary hyperparathyroidism, kidney diseases, cholelithiasis, and diabetic foot gangrene. Complications occurred in nine patients (morbidity rate, 7%) and only one patient died (mortality rate, 0.8%). In the emergency surgery group, the most common diseases were diabetic foot gangrene and obstructed sigmoid colon cancer. In this group, complications occurred in seven patients (total morbidity rate, 70%) and two patients died (mortality rate, 20%). CONCLUSIONS: Elective surgery in patients on CH for ESRD can be performed with acceptable surgical risks provided careful preoperative preparation, intraoperative, and postoperative precautions are taken.

Evaluation of intraoperative parathormone measurement for predicting successful surgery in patients undergoing subtotal/total parathyroidectomy due to secondary hyperparathyroidism.

OBJECTIVES/BACKGROUND: The aim of this study is to investigate the predictive value of intraoperative parathormone measurement addressing successful surgical resection in patients with secondary hyperparathyroidism. METHODS: The study included 42 consecutive patients operated on between May 2006 and July 2008. Patients were grouped according to successful surgery (Group 1, n = 36) and persistent postoperative hyperparathyroidism (Group 2, n = 6). Serum phosphorus (P), total calcium (tCa), ionized calcium (iCa), intact parathormone (iPTH), and alkaline phosphatase (ALP) were drawn preoperatively and intraoperatively upon 15 minutes after completion of resection (iPTH(15)). The rate of decrease of pith detected by iPTH(15) compared to preoperative values was calculated (iPTH(%)). RESULTS: Preoperative P, tCa, iCa, iPTH, and ALP were comparable. Subtotal parathyroidectomy (sPx) (n = 27) and total parathyroidectomy with autotransplantation (tPx) (n = 15) were performed. Mean iPTH(15) value, iPTH(%) rates were 145.9 +/- 12.3 pg/mL, % 91.6 +/- 0.7, and 522.5 +/- 85.4 pg/mL, % 75.1 +/- 2.0 (P = ,001) in Groups 1 and 2, respectively. Mean serum tCa and iCa at POD#1 in Group 1 were 7.6 +/- 0.1 mg/dL, 0.910 +/- 0.4 mmol/L, and Group 2 were 8.3 +/- 0.3 mg/dL, 1.050 +/- 0.4 mmol/L (P < .05), respectively. ALP levels were similar. CONCLUSION: iPTH(15) value and iPTH(%) rate accurately predicts the completeness of resection in secondary hyperparathyroidism. The rate of decrease in serum iPTH detected intraoperatively compared to preoperative baseline levels exceeding 90% in sPx, 95% in tPx, accurately predicts the success of surgery. Postoperative normocalcemia without calcium replacement would raise a suspicion about completeness of surgical resection.

Use of smooth muscle plasty after intersphincteric rectal resection to replace a partially resected internal anal sphincter: long-term follow-up.

PURPOSE: Patients with very low rectal cancer were treated by intersphincteric rectal resection employing partial internal anal sphincter resection. They then underwent smooth muscle plasty to restore internal anal sphincter function. We assessed the functional and oncological outcomes. PATIENTS AND METHODS: Patients were selected if their biopsies revealed well-differentiated or moderately well-differentiated very low rectal tumors with distal tumor margins that permitted preservation of part of the internal anal sphincter. Functional results after closing the loop ileostomy were assessed by use of a standardized questionnaire. Continence was evaluated by use of the Kirwan score. RESULTS: Forty-seven patients with T2 to T3 very low rectal carcinomas underwent intersphincteric rectal resection and smooth muscle plasty that extended into the anal canal. All received neoadjuvant treatment. Postoperative morbidity was 38.3%. There were 46 R0 resections based on frozen section analysis; one patient achieved an R0 resection after reexcision of a positive distal margin on the frozen section. The median follow-up period was 67.2 months. One patient had local recurrence. The five-year overall and disease-free survival rates were 85% and 82%, respectively. Six months, one year, and two years after intersphincteric rectal resection, 80%, 87%, and 89%, respectively, had good continence (Kirwan I and II). Evacuation difficulty was detected in two patients with colonic S-pouches. CONCLUSION: Providing neodjuvant treatment and preserving at least half of the functional internal anal sphincter mass produces acceptable oncological and functional outcomes in patients undergoing intersphincteric rectal resection for very low rectal cancer. However, whether smooth muscle plasty further improves postoperative continence should be tested by further studies.

Evaluation of gadolinium pre-treatment with or without splenectomy in the setting of renal ischemia reperfusion injury in rats.

INTRODUCTION: This study aims to investigate gadolinium chloride (Gd) pre-treatment with/without splenectomy (Splx) in the setting of renal ischemia/reperfusion (IR) injury in rats. MATERIALS AND METHODS: Under anesthesia, male Wistar albino rats with or without splenectomized (Splx) were right nephrectomized and subjected to 45 min of renal pedicle occlusion followed by 3 h of reperfusion. Gadolinium chloride (10 mg kg(-1)) or saline was administered 24 hours prior to ischemia via penile vein. Right nephrectomy and intravenous saline administration was performed in the control group. At the end of the reperfusion period, following decapitation, kidney samples were taken for histological examination or determination of renal malondialdehyde (MDA) and glutathione (GSH) levels and myeloperoxidase (MPO) and Na(+)-K(+) ATPase activities. Creatinine, blood urea nitrogen (BUN), lactate dehydrogenase (LDH), TNF-alpha, and IL-1 beta were assayed in the serum samples. RESULTS: Ischemia/reperfusion caused significant increases in the serum TNF-alpha, IL-1 beta, BUN, creatinine, AST, ALT, LDH, and tissue MDA levels and MPO activity, while either Gd pre-treatment or Splx decreased these parameters significantly. On the other hand, IR induced a decrease in the tissue GSH, and Na(+)-K(+) ATPase activity was restored by both gadolinium and Splx. Furthermore, histopathological alterations induced by IR were also reversed. CONCLUSION: The extent of renal IR injury depends on the pro-inflammatory cytokine response. Gd pre-treatment decreases macrophage-derived cytokine secretion and thereby effectively limits the extent of renal IR injury in rats similar to Splx. Further studies needed to define an optimal way of decreasing macrophage-derived cytokine release due to the clinical limitations of Gd.

Effect of early preoperative 5-fluorouracil on the integrity of colonic anastomoses in rats.

AIM: To determine the effect of chemotherapy on wound healing by giving early preoperative 5-fluorouracil (5-FU) to rats with colonic anastomoses. METHODS: Sixty Albino-Wistar male rats (median weight, 235 g) were used in this study. The rats were fed with standard laboratory food and given tap water ad libitum. The animals were divided into three groups: Group 1: Control group (chemotherapy was not administered), Group 2: Intraperitoneally (i.p.) administered 5-FU group (chemotherapy was administered i.p. to animals at a dose of 20 mg/kg daily during the 5 d preceding surgery), Group 3: Intravenously (i.v.) administered 5-FU group. Chemotherapy was administered via the penil vein, using the same dosing scheme and duration as the second group. After a 3-d rest to minimize the side effects of chemotherapy, both groups underwent surgery. One centimeter of colon was resected 2 cm proximally from the peritoneal reflection, then sutured intermittently and subsequently end-to-end anastomosed. In each group, half the animals were given anaesthesia on the 3rd postoperative (PO) day and the other half on the 7th PO day, for in vivo analytic procedures. The abdominal incisions in the rats were dissected, all the new and old anastomotic segments were clearly seen and bursting pressures of each anastomotic segment, tissue hydroxyproline levels and DNA content were determined to assess the histologic tissue repair process. RESULTS: When the i.v. group was compared with the i.p. group, bursting pressures of the anastomotic segments on the 3rd and 7th PO days, were found to be significantly decreased, hydroxyproline levels at the anastomotic segment on the 7th PO day were significantly decreased (P < 0.01). CONCLUSION: In this study, we conclude that early preoperative 5-FU, administered i.v., negatively affects wound healing. However, i.p. administered 5-FU does not negatively affect wound healing.

Predictors of hypocalcemia occurring after a total/near total thyroidectomy.

PURPOSE: The aim of this study was to identify the predictors of early postoperative hypocalcemia after a total/near total thyroidectomy in order to select patients for prompt treatment to prevent symptomatic hypocalcemia. METHODS: Patients with hypocalcemia within 24 h of surgery were identified as Group I and normocalcemic patients as Group II. The perioperative serum total calcium (tCa, ionized calcium (iCa) and intact parathormone (iPTH) were measured perioperatively. Skin closure (SC) was accepted as the reference time point. Data are expressed as the mean +/- SEM. RESULTS: The study included 73 patients. Hypocalcemia (Group I) was detected in 40 patients (54%) within the first 24 h postoperatively. Symptomatic hypocalcemia was detected in 40% of the patients in Group I. Intact parathormone values at 10 min of SC were significantly lower in Group I (P = 0.001). IPTH measurement at 10 min of SC showing a >/=30% decrease had a 92.3% sensitivity and 92.6% specificity in predicting hypocalcemia after a total/near total thyroidectomy. The postoperative day 15 mean tCa, iCa, and iPTH values were similar in both groups of patients. The mean iPTH level was 16.79 +/- 2.5 pg/dl at 10 min after SC in patients who developed symptomatic hypocalcemia. CONCLUSIONS: Intact parathormone measurement 10 min after SC is helpful to predict early postoperative hypocalcemia. An IPTH decrease >/=30% at this time point estimates the risk of postoperative hypocalcemia.

Management of pilonidal sinus disease with oblique excision and bilateral gluteus maximus fascia advancing flap: result of 278 patients.

PURPOSE: Excision followed by natal cleft depth reduction should be performed, with no leftover midline scar tissue, to prevent recurrence of pilonidal sinus, which is the main problem in the treatment of this disease. We investigated the potential advantages of this advancing flap technique, which we developed. METHOD: An S-type incision together with a bilateral gluteus maximus fascia advancing flap was applied on 278 (89 percent) patients, who did not have extensive gluteal involvement, of the 312 patients who had pilonidal sinus disease, between January 1997 and January 2007. No drainage was performed on any patient. RESULTS: All patients were discharged within 24 hours. Total complication rate was 7.2 percent and recurrence rate was 0.7 percent. The mean time off from work was 12 +/- 2 days (range, 10 to 22). The mean follow-up period was 66 +/- 32 months (range, 12 to 120). CONCLUSION: We suggest that this surgical procedure may successfully be applied to a large majority of the patients. It does not lead to unnecessary excision of healthy tissue because of its significantly simpler nature compared with the full-layer flap technique and its S-type incision, it does not create a midline scar tissue, and it is able to flatten the gluteal sulcus.

Early vs. delayed closure of temporary covering ileostomy: a prospective study.

BACKGROUND/AIMS: Temporary loop ileostomies constructed to protect distal anastomoses are generally closed at 8 to 12 weeks, a period long enough to encounter stoma-related complications, which reduces the quality of life. Early closure may be considered to overcome these adverse effects. This prospective study was designed to investigate the reliability of early closure of loop ileostomies. METHODOLOGY: Fifty consecutive patients were sequentially distributed either to group A (delayed closure) or group B (early closure). Anastomotic integrity was examined before closure in all patients. RESULTS: There were 25 patients in each group who were comparable in terms of age, sex, comorbid conditions, primary pathology, and tumor stage. Early closure was achieved in 88% (n=22) of the patients in group B. Stoma-related complications were significantly greater in group A patients (44% vs. 16%) (p<0.05) while the complications following closure were similar in both groups (16% vs. 8%) (p>0.05). CONCLUSIONS: Early closure during the same hospital admission produces less stoma-related complications with similar accomplishment as the late closure. Early closure of temporary ileostomy is recommended in suitable patients without anastomotic complications.

Plasma leptin levels in rats with pancreatitis.

Diagnosis of pancreatitis is based on the determination of serum amylase and lipase levels. However, recent identification of specific leptin receptors in the pancreas suggests that this peptide may also play some roles in the modulation of pancreatic function. The objective of the present study was to investigate the relationship between serum leptin levels and pancreatitis. Thirty male Wistar rats were divided into 3 groups: the control group, acute pancreatitis group and chronic pancreatitis group. Pancreatitis was induced by injection of ethyl alcohol into the common biliary duct. A sham laparotomy was performed in the control group. Control and acute pancreatitis groups were sacrificed 24 hours later, and chronic pancreatitis group was sacrificed on postoperative day 7. Blood was taken by cardiac puncture for the determination of plasma leptin levels, and the pancreatic tissue was excised for histopathologic confirmation of pancreatitis. Plasma leptin rose significantly from the median of 0.78 +/- 0.12 ng/ml in the control group to 1.92 +/- 0.10 ng/ml and 1.86 +/- 0.13 ng/ml in acute and chronic pancreatitis groups, respectively (p < 0.001, for both). There was no significant difference in the plasma leptin levels between the acute pancreatitis group and the chronic pancreatitis group (p > 0.05). These findings confirm that leptin has a role in pancreas inflammation, and the inflamed tissue can be the source of local production of leptin.