Anaplastic Carcinoma of the Pancreas: A Rare Clinical Entity.

Anaplastic carcinoma of the pancreas (ACP) is a very rare histologic subtype of pancreatic cancer and associated with more aggressive and poor prognosis than pancreatic ductal adenocarcinoma. We aimed to review this rare entity and discuss its clinical features, diagnosis and therapy. We presented a case of a 63-year-old male patient that diagnosed as ACP with cyst formation at a tertiary medical center with a detailed review of the current medical literature. We performed pancreaticoduodenectomy operation with lymph node dissection after diagnosis. Any complication after surgery was not observed. Anaplastic pancreas carcinomas are associated with poor survival when compared to invasive ductal adenocarcinomas. Clinical, radiological, laboratory and histological features may be helpful in making differential diagnosis and should be kept in mind in the diagnosis of this rare pancreatic malignancy.

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.

Progress in surgical and nonsurgical approaches for hepatocellular carcinoma treatment.

BACKGROUND: Hepatocellular carcinoma (HCC) is a complex and heterogeneous malignancy, frequently occurs in the setting of a chronically diseased organ, with multiple confounding factors making its management challenging. HCC represents one of the leading causes of cancer-related mortality globally with a rising trend of incidence in some of the developed countries, which indicates the need for better surgical and nonsurgical management strategies. DATA SOURCES: PubMed database was searched for relevant articles in English on the issue of HCC management. RESULTS: Surgical resection represents a potentially curative option for appropriate candidates with tumors detected at earlier stages and with well-preserved liver function. The long-term outcome of surgery is impaired by a high rate of recurrence. Surgical approaches are being challenged by local ablative therapies such as radiofrequency ablation and microwave ablation in selected patients. Liver transplantation offers potential cure for HCC and also correction of underlying liver disease, and minimizes the risk of recurrence, but is reserved for patients within a set of criteria proposed for a prudent allocation in the shortage of donor organs. Transcatheter locoregional therapies have become the palliative standard allowing local control for intermediate stage patients with noninvasive multinodular or large HCC who are beyond the potentially curative options. The significant survival benefit with the multikinase inhibitor sorafenib for advanced HCC has shifted the direction of research regarding systemic treatment toward molecular therapies targeting the disregulated pathways of hepatocarcinogenesis. Potential benefit is suggested from simultaneous or sequential multimodal therapies, and optimal combinations are being investigated. Despite the striking progress in preclinical studies of HCC immunotherapy and gene therapy, extensive clinical trials are required to achieve successful clinical applications of these innovative approaches. CONCLUSION: Treatment decisions have become increasingly complex for HCC with the availability of multiple surgical and nonsurgical therapeutic options and require a comprehensive, multidisciplinary approach.

Effects of carbon dioxide pneumoperitoneum on postoperative adhesion formation and oxidative stress in a rat cecal abrasion model.

INTRODUCTION: It is claimed that CO2 pneumoperitoneum (CP) is less adhesiogenic than laparotomy. Our aim in this study was to investigate the local oxidative stress responses and related adhesion formation resulting from exposure to CP. METHODS: Forty-five rats were randomised into six groups. Group 1 underwent laparotomy only; in group 2, 6 mmHg CP was performed for 60 min; in group 3, the same procedure was carried out using 12 mmHg CP; in group 4, laparotomy and cecal-peritoneal abrasion were performed; in group 5, 6 mmHg CP was performed for 60 min, followed by laparotomy and cecal-peritoneal abrasion; in group 6, the same procedure was carried out using 12 mmHg CP. Groups 1, 2 and 3 were sacrificed immediately and used only for biochemical examination. The other groups were sacrificed on the 14th postoperative day. RESULTS: The total adhesion scores, thickness, quantity, extent and type of adhesions decreased steadily in groups 4, 5 and 6 (p < 0.05). The median values for neutrophil and monocyte infiltration, and for capillary and fibroblast proliferation decreased steadily in groups 4, 5 and 6 (p < 0.05). CAT, SOD and GSHPx levels decreased significantly in line with increasing pressure in groups 1, 2 and 3. SOD and GSHPx levels were similar in groups 4, 5 and 6, while CAT levels decreased with increasing pressure in groups 4, 5 and 6. CONCLUSION: It was found that CP is associated with less adhesion formation than laparotomy in the presence of similar antioxidant levels. The reduced adhesion formation is probably caused by a decreased inflammatory response.

What are the Endoscopic and Pathological Characteristics of Colorectal Polyps?

BACKGROUND: Colon polyps need to be excised upon detection during colonoscopy due to the risk of malignancy irrespective of their size. In our study, we retrospectively evaluated the clinicopathological characteristics of polyps detected during colonoscopy. MATERIALS AND METHODS: We assessed 379 patients with polyps detected during colonoscopy between January 2010 and May 2012. The demographics, complaints, colonoscopy findings (shape, place and size of the polyp) and histopathological findings were recorded. We carried out statistical analysis using PASW 18.0 for Windows. RESULTS: There were 227 males (59.9%) and 152 females (40.1%) in the trial. The mean age was 53.8 years (32-90). The most common complaint was rectal bleeding (36.1%), followed by abdominal pain (35.4%). Polyps were detected most commonly in the rectosigmoid region (43.8%), followed by the descending colon (17.4%). Some 239 patients had a single polyp (63.1%) while 140 were found to have multiple polyps (36.9%). While tubular adenoma was the most common pathological type, occurring in 181 patients (47.8%), tubulovillous adenoma (14.2%) and hyperplastic polyp (12.7%) followed, occurring in 54 and 48 patients respectively. While 313 patients (82.6%) did not feature dysplasia, 37 patients (9.7%) exhibited low- grade dysplasia, 28 (7.7%) had high-grade dysplasia and 4 had cancer (1.1%). The rates of villous components and dysplasia were detected to be high among pedunculated polyps and polyps larger than 1 cm (p<0.001). CONCLUSIONS: Due to the fact that large-diameter polyps with malignant potential are commonly located in the left colon and have a high prevalence among the middle-aged individuals, it would be appropriate to screen this population at regular intervals via rectosigmoidoscopy.

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.

Totally Curative Surgical Resection of Retrorectal Tumors.

BACKGROUND/AIMS: Retrorectal (also known as presacral) tumor (RT) is a rare disease of retrorectal space. There is no large numbered case series in the literature. Well documented small numbered case series will help to establish meta-analysis and surgical decision making. METHODOLOGY: Between 2000 and 2014 medical records of patients with diagnosis of RT at two institutions were reviewed. Clinical features, diagnostic studies, type of surgery, surgical findings, surgical technique, and histopathology of the tumor, morbidity and survival are examined based on data registry. RESULTS: During 14 years period of time, total of 12 patients operated with diagnosis of RT were retrieved to this study. There were five men and seven women. The median age at the time of diagnosis was 43 (27-56) years. The most frequent findings were pain and palpable mass. There were five anterior, four posterior and three anteroposterior approaches for surgery. There is no recurrence or disease related mortality observed after median of 7 years (1-14). CONCLUSION: The primary and only satisfactory treatment is surgery for RTs. Prognosis is directly related primary local control with complete excision, which is often difficult to achieve for malignant lesions.

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.

Gastric Remnant Cancer: Continuing Serious and Insidious Problem for Surgeons.

BACKGROUND/AIMS: Gastric remnant cancers (GRC) are usually detected at a later stage resulting in low rates of curative resection and a consequently poor prognosis. The incidence and etiology of GRC have been changing recently because of early detection and improved outcomes in patients with gastric cancers. This study was performed to evaluate the clinicopathological characteristics and prognosis of patients with GRC. METHODOLOGY: From January 2004 and July 2014, 27 patients with GRC who underwent surgery were analyzed retrospectively. The clinicopathological and follow-up data of 27 patients were evaluated including age, gende types of reconstruction, tumor location, histological types, TNM stages, surgical treatment and prognosis. RESULTS: Total 221 patients underwent gastrectomy for gastric cancer and ulcer disease and 27 (12.7%) consecutive GRC patients were included in this study. The median survival for all 27 patients was 20.0 ± 2.4 months. Previous malign disease, advanced TNM stage and non-curative resection were the negative prognostic factors for survival in patients with remnant stomach cancer (p < 0.05). CONCLUSIONS: Regular follow-up is one of the important factors affecting the early diagnosis and median survive time of patients with GRC. Curative resection is recommended operative treatment procedure to improve the survival when GRC patient diagnosed.

Heterotopic gastric mucosa of upper oesophagus: evaluation of 12 cases during gastroscopic examination.

INTRODUCTION: Oesophageal heterotopic gastric mucosa mostly presents in the upper part of the oesophagus. It is commonly under-diagnosed because of its localisation. AIM: To expose the association between heterotopic gastric mucosa and endoscopic features of the upper gastrointestinal tract. MATERIAL AND METHODS: A total of 1860 upper endoscopic examinations performed between January 2012 and July 2013 were analysed retrospectively. Endoscopic features and histological examinations of 12 heterotopic gastric mucosa (HGM) of the upper oesophagus were documented and evaluated retrospectively. RESULTS: There were 7 (58%) male and 5 (42%) female patients aged between 22 and 80 years with a mean age of 43.2 years. Heterotopic gastric mucosa was present in 12 (0.6%) of all patients. We were able to perform biopsy for histopathological observation on 8 (66%) of the 12 patients in which HGM was seen during endoscopy. Five (42%) patients with heterotopic gastric mucosa had oesophagitis. Los Angeles Grade A oesophagitis was found in all patients, and histologically proven Barrett's oesophagus was detected in only one patient. CONCLUSIONS: When a patient has ongoing dyspeptic complaints and reflux symptoms despite the treatment, one should be careful about possible HGM during upper gastrointestinal endoscopy. The point to be taken into consideration for patients who have metaplasia or dysplasia within HGM may need to be considered for surveillance.

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.

Evaluation of affecting factors for conversion to open cholecystectomy in acute cholecystitis.

INTRODUCTION: Laparoscopic cholecystectomy has become the gold standard for the surgical treatment of gallbladder disease. Severe inflammation makes laparoscopic dissection technically more demanding in acute cholecystitis. Conversion to open cholecystectomy due to adverse conditions is still required in some patients. AIM: To evaluate predictive risk factors associated with conversion to open cholecystectomy in acute cholecystitis. MATERIAL AND METHODS: A retrospective analysis was performed on 165 patients who underwent a laparoscopic cholecystectomy for acute cholecystitis in our clinic. Patients who completed laparoscopic cholecystectomy and required conversion to open cholecystectomy were compared in terms of age, sex, fever, laboratory and USG findings, operation timing, complications, and duration of hospital stay. RESULTS: There were 53 (32%) male and 112 (68%) female patients; the mean age was 52.4 ±12.5 years. Forty-six (27.9%) of the 165 patients were converted to open cholecystectomy. Male sex of the patients who underwent conversion (47.1%) was found to be statistically significant (p < 0.001). Preoperative white blood count, blood glucose and amylase values, morbidity rate, and hospital stay were raised in patients who underwent conversion, and all were found to be statistically significant (p < 0.05). CONCLUSIONS: Male sex, blood leucocyte, glucose, and raised amylase emerged as the effective factors for conversion cholecystectomy in our study. These factors should help the clinical decision-making process when planning laparoscopic cholecystectomy in acute cholecystitis. By predicting these risk factors for conversion, preoperative patient counselling can be improved.

Evaluation of factors affecting mortality in Fournier's Gangrene: Retrospective clinical study of sixteen cases.

OBJECTIVE: Fournier's gangrene is a progressive, necrotizing fasciitis due to synergistic infection of the perineum and external genitalia that is associated with high mortality and morbidity. The purpose of this study is to review the diagnostic and treatment methods that effect mortality in Fournier's gangrene. MATERIAL AND METHODS: Sixteen patients who were diagnosed and treated at our clinic between 2011 and 2013 due to Fournier's gangrene were retrospectively analyzed. The surviving and non-surviving patient groups were compared in terms of age, sex, onset time of symptoms, isolated microorganisms, concomitant diseases, Fournier's gangrene severity index (FGSI), and length of hospital stay. RESULTS: Ten of our cases (62.5%) were male and six (37.5%) were female, with a mean age of 61.2±12.3 (42-73) years. The mortality rate was 18.8% (3 cases). The mean duration of symptoms before admission was 4.31±1.81 (2-8) days. This period was 6.67±1.52 days in patients who succumbed to death, and 3.77±1.42 days in patients who survived (p=0.007). Ten cases (62.5%) had concomitant diabetes mellitus. The most common organism isolated in wound cultures was Escherichia coli (68.7%), and Acinetobacter baumannii, Proteus mirabilis, methicillin-resistant Staphylococcus aureus and Enterococcus spp. in the remaining patients. The mean FGSI of surviving patients was 3.84±1.77, and 7.66±0.57 in fatal cases (p=0.003). The mean length of hospital stay was 25.5 days (2-57) and duration of hospitalization was significantly longer in survivors (p<0.05). CONCLUSION: The delay in diagnosis and higher FGSI may be responsible for worsening of prognosis and mortality in Fournier's gangrene. Early diagnosis and determination of the severity of the disease, aggressive surgical debridement and appropriate antimicrobial therapy may improve prognosis.

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.

Carbondioxide pneumoperitoneum prevents postoperative adhesion formation in a rat cecal abrasion model.

PURPOSE: We aimed to investigate the role of the carbon-dioxide (CO(2)) pneumoperitoneum on the prevention of postoperative adhesion formation. METHODS: Thirty adult male Sprague-Dawley rats (250-350 g) were used for this study. The rats were randomly divided into three groups; in the sham group (n = 10) only, laparotomy was made, in group 2 (n = 10), a pneumoperitoneum was applied for a half-hour duration, followed by laparatomy, and in group 3 (n = 10), pneumoperitoenum time was 2 hours and after a pneumoperitoneum laparotomy was made. A cecal abrasion model was studied for making an adhesion formation. On day 14, all rats were sacrificed and adhesions were scored. Tissue samples from adhesions and peritonea and the cecum wall were examined, both pathologically and biochemically, for tissue hydroxyproline content. RESULTS: There was a statistically significant difference between the control and pneumoperitoneum groups, regarding adhesion numbers and grades (P < 0.001). Cecal tissue hydroxypyroline content level was lower in group 1, and statistically significant differences were observed between groups 1, 2, and 3 regarding hydroxyproline content (P < 0.001). There was a statistically significant difference between the control and pneumoperitoneum groups regarding inflammation (P = 0.002). CONCLUSIONS: Pretreatment with the CO(2) pneumoperitoneum had a prophylactic effect on postoperative adhesion formation in this study.

Restorative proctocolectomy for familial adenomatous polyposis coexisting with colorectal cancer.

The aim of this study was to assess whether restorative proctocolectomy was suitable as an initial procedure for selected familial adenomatous polyposis patients with coexisting colorectal cancer. Six malignancy patients who underwent restorative proctocolectomy for familial adenomatous polyposis were reviewed. At the time of restorative proctocolectomy, cancer was not suspected in four patients. The two remaining familial adenomatous polyposis patients had a known associated colorectal cancer. Operative procedures, pathological findings, complications and long-term follow-up were evaluated. All patients were Stage I-II cancers. There was no mortality or pouch failure. No evidence of tumor recurrence was found and all the patients are still alive and disease-free in follow-up (mean 28 months). As an initial procedure, restorative proctocolectomy for patients with familial adenomatous polyposis with coexisting Stage I-II colorectal cancer seems to be a dependable procedure.