Treatment of Granulomatous Mastitis With Steroids: Should the Decision to End the Treatment be Made Radiologically?

Objective: Idiopathic granulomatous mastitis (IGM) is a benign inflammatory breast disease of unknown etiology that affects women in their reproductive period. The most commonly preferred option as first-line treatment is steroids, but the lack of a standard treatment protocol and high recurrence rate after treatment constitutes a recurring challenge during its management. The aim of this study was to investigate whether the decision to end the treatment should be made radiologically or clinically. Materials and Methods: This retrospective cohort study included IGM patients who had complete clinical recovery with steroids and were followed for a minimum of 30 months. Patient demographics, disease severity and findings, treatment regimens and duration, and magnetic resonance imaging (MRI) findings at clinical recovery were assessed for their relation to recurrence. Results: Eighty-nine patients who were clinically completely healed after steroid treatment for IGM were included in the study. At the time of clinical healing, 51 (57.3%) patients had a complete radiological response and 38 (42.7%) had a partial radiological response (PRR) on MRI. Overall, recurrence developed in 22 (24.7%) patients after a median 38.6-month follow-up. Patients who experienced recurrence were significantly older and had PRR when their treatment was stopped upon clinical healing. Conclusion: During the process of clinical healing, the imaging findings revealed that the remaining disease seems to be a significant predictor for recurrence in IGM patients. In patients with PRR, extending the treatment with either prolonged steroid therapy or by surgical excision of the occult residual disease may prevent recurrences in IGM patients.

Idiopathic granulomatous mastitis with erythema nodosum: Is it a variant of clinical presentation indicating treatment resistance? A retrospective cohort study.

Idiopathic granulomatous mastitis (IGM) rarely occurs with erythema nodosum (EN) as a systemic finding. However, the impact of their coexistence on disease severity and response to steroids has not been investigated yet. Patients diagnosed with IGM between September 2014 and October 2018 were divided into two groups according to the presence or absence of EN during the first admission retrospectively. The IGM was more severe in patients with EN as it was presented more often as bilateral and diffuse involvement of the breast. Findings of mastitis did not resolve with steroids in 50% of this group. Repetitive excisions and mastectomy with reconstructions were required to control the disease. Coexistence of EN and IGM was found to be related to bilateral and aggressive involvement, which could be associated with insufficient response to steroids. Associated patients should be informed in terms of the aggressive course, and surgery can be highlighted as a first-line treatment.

Laparoscopic repair of lateral sided trocar site hernias.

OBJECTIVES: Repair of trocar site hernia (TSH) has been mentioned in a limited number of studies. Trocar site hernias are mostly located in the umbilical region with a small size. Laparoscopic repair could be a choice due to the appearance of large defects and requirement of mesh repair for lateral sided TSH. We aimed to share our experience with laparoscopic repair of lateral sided trocar site hernia (LRTSH) with a long term follow up. MATERIAL AND METHODS: Twenty-three patients who underwent LRTSH between March 2013 and July 2015 were included in our study. Four edges of the mesh were fixed with pre-tied 2/0 polypropylene suture for 9 patients initially (Group 1). Unexpected complication of chronic pain in 3 patients led us to revise our method and we avoided to position the mesh with transabdominal sutures for the rest of the patients (Group 2). RESULTS: Nineteen (82.6%) female and 4 (17.4%) male patients, with a mean age of 50.9 years underwent laparoscopic repair. Following the revision and avoiding transabdominal sutures to position the mesh, no complaint of chronic pain was observed, and the difference was statistically significant between the groups (p<0.05). CONCLUSION: Previous laparoscopic surgery indicates the lack of obstacle in laparoscopic repair of TSH, and LRTSH can be considered as first option in treatment. Shorter mean operative time in obese patients and lack of recurrence in our series support this view. Using transabdominal sutures should be avoided to prevent chronic pain in LRTSH.

Evaluation and management of pathological nipple discharges without using intraductal imaging methods.

BACKGROUND: The most common cause of pathological nipple discharge (PND) is single papilloma, which is a benign intraductal lesion (BIL). However, underlying malign (MIL) or high-risk intraductal lesions (HIL) should be considered during examination. AIM: To reveal the value of conventional imaging methods (CIM), discharge characteristics, and cytology in lack of intraductal imaging methods to detect intraductal lesions (IL) and MIL that cause PND. METHODS: We compared the pathological findings with the characteristics of discharge, CIM, and cytology findings of the patients who admitted to our clinic with nipple discharge and underwent duct excision (n = 111). RESULTS: IL were detected in 69 (62.2%) patients as BIL (n = 31), HIL (n = 23), and MIL (n = 15). Most of the IL was observed with bloody, serosanguineous, and serous discharges (83.3%, 76.2%, and 69.2%, respectively). The sensitivities of ultrasonography, MRI, and cytology in detecting IL were found to be 50.7%, 42.6%, and 74.1%, while their specificities were found to be 73.8%, 88.2%, and 48.6%, respectively. None of the CIM was sufficient to detect MIL in 5 (33.3%) patients. The appearance of red blood cells detailed in cytology was significantly related to IL (p < 0.01), whereas the presence of inflammatory cells was related to ductal ectasia and periductal mastitis (p < 0.001). CONCLUSIONS: Although patients' physical examinations, CIM, and cytology findings were normal, duct excision procedures should be applied to exclude MIL or HIL, which can be a cause of discharge in case of suspicious color. The details in cytology reports have a role in increasing the value of cytology.

The influence of mesh removal during laparoscopic repair of recurrent ventral hernias on the long-term outcome.

INTRODUCTION: Recurrent hernias can be treated by laparoscopy without the need for mesh removal. However, shrinkage of the mesh following recurrence affects most of the patients, and leaving a partially floating and rigid foreign body could be discussed. AIM: To compare the outcomes of patients regarding the removal of previous mesh during laparoscopic repair of recurrent abdominal wall hernias. MATERIAL AND METHODS: Patients who underwent laparoscopic repair for recurrent ventral hernias between August 2012 and March 2015 were included in the study. The patients with complete removal of the mesh were included in the MR group and the patients with partial removal or without removal of the previous mesh were included in the non-MR group. Patient characteristics and demographics, previous hernia repair, defect size, mesh size, operative time, mean hospital stay, complications, recurrences, numeric pain rating scale (NRS), early termination of analgesics and prolonged use of analgesics were compared. RESULTS: A total of 112 patients with a mean age of 53.2 and mean body mass index of 31.1 kg/m2 underwent laparoscopic repair. There were 47 patients in the MR group and 54 patients in the non-MR group. Operative time was shorter in the non-MR group (p < 0.05), whereas symptomatic seroma and NRS scores on postoperative day 10 and at the 6th week were higher in comparison with the MR group (p < 0.05). CONCLUSIONS: Mesh removal during laparoscopic repair of recurrent ventral hernias has an association with the reduction of pain and symptomatic seroma. However, further prospective comparative studies are required to verify this view.

Effects of Hyalobarrier gel and Seprafilm in preventing peritendinous adhesions following crush-type injury in a rat model.

BACKGROUND: In the present study, the aim was to evaluate the effects of Hyalobarrier gel (Anika Therapeutics S.r.l., Abano Terme, Italy) and Seprafilm adhesion barrier (Genzyme Corporation, Cambridge, MA, USA) in the prevention of peritendinous adhesions following a crush-type injury. METHODS: Twenty five female Wistar Albino rats, weighing 230 to 270 g and 7 to 9 months of age were randomized into 5 groups. Group 1 was the control group, Group 2 comprised the Hyalobarrier gel group, Group 3 was made up of the Seprafilm-treated subjects, Group 4 was the tendon repair and Hyalobarrier gel group, and Group 5 was the tendon repair and Seprafilm group. Two gastrocnemius muscle tendons of each animal, a total of 50 tendons, were used. The animals were sacrificed with the administration of a high dose of anesthetic on postoperative day 40. Macroscopic evaluation of adhesions was classified by 2 blinded researchers according to Tang's adhesion grading system. The number of fibroblasts and the density and formation of collagen fibers were noted for histopathological examination. RESULTS: None of the subjects in Group 2 was determined to have a severe adhesion, and moderate or severe adhesions were detected in Groups 3, 4, and 5. There was no statistically significant difference between Group 2 and the control group (p=0.737). Groups 3, 4, and 5 demonstrated fewer adhesions than Groups 1 and 2 (p<0.05). Groups 4 and 5 had fewer adhesions than Groups 2 and 3 (p<0.05). There was no statistically significant difference between Groups 4 and 3 (p=0.342). The histopathological findings were consistent with the macroscopic findings. CONCLUSION: Seprafilm was found to be effective in the prevention of peritendinous adhesions following a crush-type injury with or without repair of the tendon fibers. In contrast, Hyalobarrier gel was found to be effective only following repair of the tendon fibers.

Evaluation of the effects of absorbable and nonabsorbable tacks on laparoscopic suprapubic hernia repair: A retrospective cohort study.

BACKGROUND: The contradictory results of fixation methods concerning the pubic region are an obstacle to define a standardized procedure for laparoscopic repair of suprapubic hernia (LRSPH). This study aims to evaluate the effects of different tacks on LRSPH. MATERIALS AND METHODS: Seventy-three patients (70 females, three males) with suprapubic hernia were admitted and had LRSPH. Absorbable tacks were used in 42 (57.5%) patients (AG group), whereas nonabsorbable tacks were used in 31 (42.5%) patients (NAG group). Patient characteristics and demographics, previous operations, previous hernia repairs, size of the defect, size of the mesh, type of the mesh, type of the tacks, operative time, conversion rate, complications, recurrences, follow-up time, numeric pain rating scale (NRS), prolonged use of analgesics and early termination of analgesics were evaluated as variables. RESULTS: NRS results were significantly lower in the AG group regarding the postoperative day one (p < 0.001) and 10 (p:0.004), whereas there was no statistically significant difference on postoperative sixth week. Prolonged use of analgesics was significantly higher in NAG, whereas early termination of analgesics was significantly higher in AG (p < 0.001). There was no patient with complaints of pain that restricted daily activities on sixth month and the following annually visits. CONCLUSION: Absorbable tacks had satisfactory results with a reduction of pain and lower rates of using analgesics. However, considering the similar results of groups on long-term follow-up, it would be inaccurate to explain this situation with the property of absorption. Although the failure of attempts to bony structures during fixation with absorbable tacks could explain the lack of deep penetration, further studies are required to verify this view.

A rare cause of acute abdomen: Isolated necrosis of the cecum.

We would like to present the case of a 76-year-old female patient with cecal necrosis, which is a rare cause of acute abdomen in elderly women and a variant of ischemic colitis. The patient was admitted to our hospital with abdominal pain, anorexia, and nausea. Physical examination, laboratory parameters, and abdominal computed tomography revealed acute abdomen. We operated the patient with an infra-umbilical midline incision. Considering the pain localized to the right lower quadrant, our initial diagnosis was acute appendicitis; however, we kept in mind other differential diagnoses as well. After laparotomy Non-occlusive cecal necrosis was detected. Arterial pulse was palpated; however, no signs of trombus were detected. Patient also have a Meckel's diverticulum. Terminal ileum plus cecum resection and Meckel's diverticulum excision were performed. Isolated necrosis of the cecum may be caused due to multiple reasons. Especially in elderly female patients with predisposing factors like hypotension, sepsis, shock, drug use, vasculitis, and hypercoagulability, cecal necrosis should be kept in mind.

Evaluation of intradermal absorbable and mattress sutures to close pilonidal sinus wounds with Limberg flap: a prospective randomized comparative study.

PURPOSE: We aimed to compare skin closure techniques, standard (intermittent mattress) and continuous subcuticular sutures, following Limberg flap procedure. METHODS: From July 2013 to July 2015, 92 patients with sacrococcygeal pilonidal disease were prospectively randomized into 2 groups consisting of 46 patients for both. Patients underwent sinus excision and closure with Limberg flap; continuous subcuticular suture was used in subcuticular group (SG) and intermittent mattress sutures were used in mattress group (MG) for skin closure. Characteristics of patients, features of pilonidal disease, macerations, infections, wound dehiscence, flap necrosis, operation time, time of drain removal, wound complications, early recurrences, and time till return to work were compared between the 2 groups. RESULTS: There was no statistical difference between groups per sex, age, body mass index, smoking, number of sinuses, depth of intergluteal sulcus, distance of incision to anus, volume of extracted tissue, number of hair follicles per cm2, recurrence, operation, and mean follow-up time. Two patients showed signs of wound complications (4.4%) in SG, whereas 8 cases (17.4%) showed signs in MG (P < 0.05). One patient in SG had surgical site infection and required antibiotics (2.2%), where as there were 6 cases treated in MG (13.0%) (P < 0.05). Removal of drain tube, and time till return to work rates are lower for SG than MG (P < 0.05). CONCLUSION: In conclusion, surgical procedures which include Limberg flap method and subcuticular closure may reduce infection and maceration rates. Future studies are needed to achieve greater detailed evaluation.

Separate and synergistic effects of taurolidine and icodextrin in intra-abdominal adhesion prevention.

BACKGROUND: In our present study, we aimed to evaluate the effects of taurolidine, a blocking agent of fibrin deposition, and icodextrin, a colloid osmotic material that also inhibits fibrin accumulation, and the effect of their application separately and concomittantly in intra-abdominal adhesion prevention. METHODS: Forty BALB/c male mice, weighing 30-35 g and 11-12 weeks old were divided into four groups as follows: group 1: control group, group 2: taurolidine group, group 3: icodextrin group, and group 4: taurolidine and icodextrin group. Animals were sacrificed by cervical dislocation after 14 days. The adhesions were classified and scored by two blinded researchers according to Nair's macroscopic adhesion staging system and microscopically evaluated using Zuhlke classification system. RESULTS: In group 2 there was no mice with score 4. In group 3, scores 3 and 4 were absent. Scores 2, 3, and 4 were not detected in group 4. The mean value of adhesion scores decreased from groups 1 to 4. There was a significant statistical difference between all the groups and group 1. There was no change between the study groups on macroscopic examination, whereas histopathological examination revealed statistically significance between group 4 and other groups. CONCLUSION: Taurolidine and icodextrin, when used alone or together, decrease postoperative intra-abdominal adhesion formation. Macroscopic appearence was not supportive of statistical difference between group 4 and other groups. Microscopic evaluation paves the road for future studies for determining significance when taurolidine and icodextrin are applied concomittantly. Additional experimental studies are required for dose adjustment.

Laparoscopic repair of large suprapubic hernias.

INTRODUCTION: Suprapubic hernia is the term to describe ventral hernias located less than 4 cm above the pubic arch in the midline. Hernias with an upper margin above the arcuate line encounter technical difficulties, and the differences in repair methods forced us to define them as large suprapubic hernias. AIM: To present our experience with laparoscopic repair of large suprapubic hernias that allows adequate mesh overlap. MATERIAL AND METHODS: Nineteen patients with suprapubic incisional hernias who underwent laparoscopic repair between May 2013 and January 2015 were included in the study. Patients with laparoscopic extraperitoneal repair who had a suprapubic hernia with an upper margin below the arcuate line were excluded. RESULTS: Two men and 17 women, with a mean age of 58.2, underwent laparoscopic repair. Most of the incisions were midline vertical (13/68.4%). Twelve (63.1%) of the patients had previous incisional hernia repair (PIHR group); the mean number of previous incisional hernia repair was 1.4. Mean defect size of the PIHR group was higher than in patients without previous repair - 107.3 cm2 vs. 50.9 cm2 (p < 0.05). Mean operating time of the PIHR group was higher than in patients without repair - 126 min vs. 77.9 min (p < 0.05). Although all complications occurred in the PIHR group, there was no statistically significant difference. CONCLUSIONS: Laparoscopic repair of large suprapubic hernias can be considered as the first option in treatment. The low recurrence rates reported in the literature and the lack of recurrence, as observed in our study, support this view.

An unusual appearance of complicated hydatid cyst: necrotizing pancreatitis.

Hydatid acute pancreatitis is a rare condition and always presents as consequence of acute edematous pancreatitis. Intrabiliary rupture of hepatic hydatid cysts and obstruction of papillary orifice with hydatid membrane is possible mechanism. A 49-year-old man was admitted with epigastric and right upper quadrant pain, nausea, and vomiting. Computed tomography scan showed 5 x 5 cm cyst in left hepatic lobe, which had ruptured into the biliary tract and caused necrotizing pancreatitis. Endoscopic retrograde cholangiopancreatography trial failed. Surgical choice was drainage of cyst, insertion of T-Tube, exploration of common bile duct and omentoplasty. No additional necessary surgical intervention was necessary for necrotizing pancreatitis. Clinical and laboratory findings resolved rapidly and there was no recurrent pancreatitis episode during 1 year of follow-up. Hydatid edematous and necrotizing pancreatitis have similar progress. Recovery is quick and uneventful after elimination of mechanical obstruction of papillary orifice.

Current approach to liver traumas.

INTRODUCTION: Liver injuries remain major obstacle for successful treatment, due to size and location of the liver. Requirement for surgery should be determined by clinical factors, most notably hemodynamical state. In this present study we tried to declare our approach to liver traumas. We also tried to emphasize the importance of conservative treatment, since surgeries for liver traumas carry high mortality rates. PRESENTATION OF CASE: Patients admitted to the Department of Emergency Surgery at Kartal Research and Education Hospital, due to liver trauma were retrospectively analyzed between 2003 and 2013. Patient demographics, hepatic panel, APTT (activated partial thromboplastin time), PT (prothrombin time), INR (international normalized ratio), fibrinogen, biochemistry panel were recorded. Hemodynamic instability was the most prominent factor for surgery decision, in the lead of current Advanced Trauma Life Support (ATLS) protocols. Operation records and imaging modalities revealed liver injuries according to the Organ Injury Scale of the American Association for the Surgery of Trauma. 300 patients admitted to emergency department were included in our study (187 males and 113 females). Mean age was 47 years (range, 12-87). The overall mortality rate was 13% (40 out of 300). Major factor responsible for mortality rates and outcome was stability of cases on admission. 188 (% 63) patients were counted as stable, whereas 112 (% 37) cases were found unstable (blood pressure ≤ 90, after massive resuscitation). 192 patients were observed conservatively, whereas 108 cases received abdominal surgery. High levels of AST, ALT, LDH, INR, creatinine and low levels of fibrinogen and low platelet counts on admission were found to be associated with mortality and these cases also had Grade 4 and 5 injuries. Hemodynamic instability on admission and the type and grade of injury played major role in mortality rates). Packing was performed in 35 patients, with Grade 4 and 5 injuries. Mortality rate was %13 (40 out of 300). CONCLUSION: A multidisciplinary approach to the management of hepatic injuries has evolved over the last few decades, but the basic principles of trauma continue to be observed. Diagnostic and therapeutic endeavors are chosen based mainly on the stability of the patient. Stable patients with reliable examinations and available resources can be managed nonoperatively. Unstable patients require surgery. Our current approach to liver traumas is non operative technique, if possible.

Retroperitoneal mucinous cystadenoma of the appendix mimicking hydatid cyst: A case report.

Appendiceal mucocele is a cystic dilatation of the appendix due to abnormal appendiceal mucinous secretion. Cystadenoma of the appendix is one of the most common causes and is encountered in 0.6% of all appendectomy specimens. The diagnosis may be difficult due to the asymptomatic nature of the disease; pain in the right lower quadrant may be the only symptom. Complex ovarian cyst, urolithiasis or cystic hydatid disease of the liver have been reported as mimicking appendiceal mucocele in the literature. In this study, we present a case of mucinous cystadenoma of the appendix mimicking retroperitoneal hydatid cyst in a 59-year-old woman. The patient was treated with laparoscopic appendectomy with partial resection of the caecum following laparoscopic exploration.

Acute mechanical intestinal obstructions.

BACKGROUND: In this study, we evaluated our treatment modality and timing of surgery in acute mechanical intestinal obstruction (AMIO) patients who were admitted to the emergency room. METHODS: Only patients with the diagnosis of AMIO were included in this study. Surgery was performed in patients with hemodynamic instability despite fluid resuscitation and peritoneal signs upon physical examination. Patients were divided into two groups. Adhesion cases were assigned to Group 1, while non-adhesion cases were assigned to Group 2. The decision to provide surgical or medical therapy was assessed 24 hours (h) after admission. RESULTS: Twenty-two patients in Group 1 and 53 patients in Group 2 underwent surgical procedures. The difference between the groups was statistically different (p < 0.05). The mean monitoring time after admission to the hospital was 128.3 +/- 24.85 h and 43.1 +/- 15.51 h in Groups 1 and 2, respectively (p = 0.0001). In Group 2, 76.6% of the patients who were monitored for over 24 hours required surgery. In contrast, this rate was only 36% in Group 1 (p < 0.05). CONCLUSION: Our clinical experience shows that medical therapy and monitoring over 24 hours is not a good substitute for surgical treatment of AMIO when the obstruction is not due to an adhesion.