A case with primary hyperaldosteronism associated with chronic kidney disease.

Primary hyperaldosteronism (PA) is one of the most common causes of secondary hypertension. PA may be associated with a decline in renal function. About 20% of cases with resistant HTN eventually cause PA, so all these patients should be evaluated for PA. Herein, we present a case with drug-resistant hypertension and chronic kidney disease (CKD), the cause of which was PA. Despite his low-salt diet modifications and treatment with several classes of antihypertensive medication, he had poorly controlled blood pressure (BP). Measurements of aldosterone and renin raised the concern of PA. Imaging confirmed bilateral adrenal hyperplasia. Due to the persistently high BP, despite the modification of the antihypertensive treatment, the patient underwent unilateral adrenalectomy, as the only feasible possibility of lowering aldosterone levels. After surgery, the patient had an improvement in both BP values and renal function. PA is difficult to diagnose in patients with CKD and Arterial Hypertension because hypertension is often associated with CKD, but PA accounts for a significant percentage of drug-resistant hypertension, so these patients should be screened for secondary arterial hypertension.

Anti-inflammatory and anti-apoptotic effect of nesfatin-1 on liver ischemia-reperfusion injury.

INTRODUCTION: Severe local and systemic tissue injury develop during reperfusion, which is a period during which arterial blood flow and tissue oxygenation are re-established. In this study, we aimed to investigate the anti-inflammatory, antioxidant and protective effects of nesfatin in IR damage developing in liver. MATERIAL AND METHODS: Twenty-four male Wistar-Albino rats were divided to three groups which contained eight rats in all groups. The rats were subjected to 30 minutes of hepatic pedicule occlusion followed by 2h of reperfusion to induce I/R damage. Nesfatin1 (10 µg/ kg) was administered, 30 min prior to ischemia and immediately before the reperfusion period. RESULTS: The findings showed that while the blood levels of AST, ALT and LDH were markedly elevated in the I/R group, they returned to normal levels upon treatment in the Nesfatin group. While IL-1 α, IL-1ß, IL-6, TNF-α and IFN- γ levels in blood and tissue were lower after therapy in the Nesfatin group compared to the I/R group, statistically significant decreases were only noted in IL-1ß, IL-6, TNF-α and IFN- γ levels. TAS levels increased in the treatment group, while upon nesfatin treatment statistically significant decreases were noted in TOS and OSI levels. Histopathological investigations also showed statistically significant decreases in Bax and Caspase-3 staining intensity and the number of stained cells in the Nesfatin group. CONCLUSION: The nesfatin has antioxidant activity and anti-inflammatory effect on improvement of liver functions and histopathological findings in liver ischemia and reperfusion injury. KEY WORDS: Anti-inflammatory, Anti apoptotic Liver ischemia-reperfusion injury, Nesfatin-1.

A rare case of ectopic ACTH syndrome originating from malignant renal paraganglioma.

Ectopic adrenocorticotropic hormone (ACTH) syndrome is characterized by hypercortisolism due to the hypersecretion of a non-pituitary ACTH-secreting tumor leading to Cushing's syndrome. Only a few cases have been reported previously as causing ectopic ACTH related to paraganglioma. Herein, we present a case of Cushing's syndrome, in who was proved to be attributable to an ACTH-secreting renal malignant paraganglioma. A 40-year-old woman presented with a five-month history of newly diagnosed hypertension and diabetes, weakness, hyperpigmentation, oligomenorrhea, hirsutism, and acneiform lesions. She showed cushingoid features, including moon face, facial hirsutism, facial and truncal acne, hyperpigmentation, and severe muscle weakness of the limbs. She did not have other findings such as striae, supraclavicular fat accumulation, and buffalo hump. Laboratory examination showed the presence of hypopotasemia, hyperglycemia, hyperthyroidism, and leukocytosis. The serum levels of ACTH, cortisol, and urine-free cortisol were markedly elevated. Results of an overnight 2-mg dexamethasone suppression test included a basal serum cortisol of 61.1 mcg/dL (normal range: 4.6-22.8 mcg/dL) and a cortisol value of 46.1 mcg/dL after dexamethasone administration. There was no suppression found after 2-day 8-mg dexamethasone administration. Magnetic resonance imaging (MRI) of the pituitary gland indicated two microadenomas. An abdominal MRI scan revealed horseshoe kidney, bilateral adrenal hyperplasia, and masses with dimensions of 35 x 31 mm in the left kidney. Inferior petrosal sinus sampling showed no evidence of a central-to-peripheral gradient of ACTH. A positron emission tomography/computed tomography scan showed intense increased activity in the lower pole of the left kidney. Left adrenalectomy and left partial nephrectomy were performed. The resected tumor was diagnosed as the ACTH-secreting paraganglioma in the pathological examination, which was confirmed by immunohistochemical studies with chromogranin A, synaptophysin, and ACTH. Only a few cases of paragangliomas as a cause of ectopic ACTH syndrome have been reported. To our knowledge, this is the first case of renal paraganglioma resulting in Cushing's syndrome due to ectopic ACTH hypersecretion.

The effect of enoxaparin on seroma and mesh-tissue adhesion in a hernia model.

The aim of this study was to investigate whether enoxaparin (ENX) administration would increase seroma risk and worsen mesh tissue recovery in an experimental rat hernia repair model. Fifty-six adult male Wistar-Albino rats were included in the study. Rats were equally and randomly separated into seven groups: Group 1, Control, only subcutaneous dissection was performed; group 2, Sham, Hernia defect was primary sutured; Group 3, Prolene mesh; Group 4, Dual mesh; Group 5, ENX + Sham; Group 6, ENX + Prolene mesh; Group 7, ENX + Dual mesh. ENX was subcutaneously injected at a dose of 180 U/kg per day for 7 days. Rats were killed after the amount of subcutaneous seroma was determined by ultrasound on day 7 following the surgical procedure. Mesh-tissue healing was evaluated using histopathological and immunohistochemical (CD31) staining methods. The mean seroma amount significantly increased in Groups 5-7 compared to Groups 2-4. CD31 immunostaining showed a reduction in neovascularization in Groups 6 and 7, compared to Groups 3 and 4. Neovascularization decreased and hemorrhage, necrosis and oedema findings remarkably increased in Groups 6 and 7, when compared to Groups 3 and 4. Fibroblastic activity and inflammation were more prominent in Groups 3 and 4. It should be kept in mind that ENX interferes with inflammation, which is desired in the early period of healing and leads to an increase in overall seroma amount with anti-coagulant effects, which in turn may disrupt wound healing and mesh-tissue adhesions, as was indicated in our study.

Extralevator abdominoperineal excision versus conventional surgery for low rectal cancer: a single surgeon experience.

OBJECTIVE: Extralevator abdominoperineal excision (ELAPE) reduces the risk of positive circumferential resection margin (CRM) and of intraoperative perforation (IOP), both of which are associated with high local recurrence rates and poor survival outcomes for rectal cancer. The aim of this study was to compare the results of ELAPE with conventional abdominoperineal excision (APE) for low rectal cancer. MATERIAL AND METHODS: A total of 25 consecutive patients underwent ELAPE for low rectal cancer between November 2008 and September 2011. Fifty-six patients treated by conventional APE prior to 2008 were selected from our rectal cancer database for comparison as a historical cohort. RESULTS: The mean follow-up was 44.7 months in the ELAPE group, and 70.6 months in the APE group. Patients undergoing ELAPE had a lower CRM positivity and IOP rate than APE (12% vs. 20%, p=0,531; 4% vs. 8,9%, p=0,826; respectively). The ELAPE group was associated with higher perineal wound complications than the APE group (16.0% vs. 1.8%, p=0.030). Local recurrence rates for patients in both groups did not differ significantly (4.0% vs. 3.6%, p=1.0). CONCLUSION: The results of this study suggest that ELAPE technique was associated with less CRM involvement and reduced rates of IOP but markedly higher rates of postoperative perineal complications occurred as compared to conventional surgery. ELAPE must be reserved for advanced low rectal cancers.

In Vivo Healing Effects of Ankaferd Blood Stopper on the Residual Pancreatic Tissue in a Swine Model of Distal Pancreatectomy.

The aim of this study was to determine whether intraoperative Ankaferd blood stopper (ABS) application into the pancreatic channel and to the pancreatic remnant surface following distal pancreatectomy can or cannot prevent postoperative pancreatic fistula formation. Three pigs underwent distal pancreatectomy under general anesthesia. In two of the pigs, 0.5 ml of ABS was applied to the stump surface area after adding 0.5 ml of ABS into the pancreatic channel. The remaining one animal served as the control. The pigs were sacrificed on the seventh postoperative day for autopsy. The pancreatic remnants from the animals were then taken for histopathological analyses. It was observed that the oral intake had been broken and abdominal distention had developed in the control pig following on the third postoperative day. However, no significant clinical changes were observed in the ABS-applied pigs. In the autopsy, it was found that the control pig had generalized peritonitis with pancreatic necrosis. On the other hand, the ABS-applied pigs had either macroscopically and microscopically normal pancreatic tissue architecture with an occluded Wirsung duct at the pancreatic stump. It was concluded that application of ABS on the transected surface and into the pancreatic channel could prevent pancreatic fistula formation and improve wound healing in the residual pancreatic tissue following distal pancreatectomy.

A rare cause of acute abdomen: an isolated falciform ligament necrosis.

UNLABELLED: The falciform ligament is one of the anatomical structures which attach the liver to the diaphragm and anterior abdominal wall. Primary falciform ligament is very rare. In this article, we present a case of an isolated falciform ligament necrosis, a rare primary pathology of the falciform ligament, who was admitted with acute abdomen. CASE PRESENTATION: A 64-year-old female patient was admitted with the complaints of pain. Laboratory test results showed a leukocyte count of 17,000/mm(3). Imaging studies demonstrated intra-abdominal reactionary fluid along with a heterogeneous mass localized in the falciform ligament. Exploratory laparotomy revealed a necrotic mass of the falciform ligament. No other pathology responsible for falciform ligament necrosis was found. We believe that falciform ligament necrosis should be considered a preliminary diagnosis, if any ligament abnormality, tumor, intraligament air density, or the presence of reactionary fluid surrounding the ligament is detected through abdominal imaging studies.

Our results of lower gastrointestinal endoscopy: evaluation of 700 patients.

OBJECTIVE: Although radiological imaging modalities like barium enema and computed tomography provide some clues, endoscopic methods still maintain superiority in assessment and differential diagnosis of large intestinal symptoms and complaints that require biopsy. We aimed to present the results of colonoscopic procedures performed in our general surgery clinic in detail. MATERIAL AND METHODS: Seven hundred patients who presented to Afyon Kocatepe University, Faculty of Medicine, Department of General Surgery Endoscopy Unit between January 2011 and July 2012 with an indication for colonoscopy were retrospectively evaluated. RESULTS: Out of the 700 patients enrolled in the study 356 (50.8%) were male while 344 patients (49.2%) were female. The mean age of the patients was found to be 49 years. Within the group of 700 patients who underwent colonoscopic examinations, the terminal ileum and cecum have been reached on the first attempt in 432 patients (61.7%) and colonoscopic success has been achieved. Results of colonoscopies performed on 700 patients in our clinic revealed malignancy in 42 (6%) patients, and all of these patients were treated surgically in our clinic. Mortality was not observed in this series. Procedure-related bleeding and perforation developed in 6 patients. One patient developed respiratory arrest due to sedation and patient was responsive to resuscitation. The complication rate in our series was 1%. CONCLUSION: In the study where we revised our own clinical experience, we found that our success rate was lower than the literature, and our complication rate was higher. The main reasons are accepted as our colonoscopy unit's being young and the low patient volume.

A retained plastic protective cover mimicking malignancy: Case report.

INTRODUCTION: Cases of retained foreign bodies during surgery are more frequently seen in developing countries. Following surgical procedures, unintentionally retained foreign bodies can cause serious complications, in addition to medico-legal issues. PRESENTATION OF CASE: A 60-year-old man presented with abdominal cramps. He had previously undergone a laparoscopic radical right nephrectomy due to renal cell carcinoma. Abdominal tomography revealed a mass surrounding the main vascular structures with malignant features in the location of previously performed nephrectomy. Further evaluation of the mass was undertaken by PET/CT. Increased FDG uptake on the PET/CT scan suggested disease recurrence. Retroperitoneal lymph node dissection was performed. The dissection specimen was opened to determine the nature of the mass. Retained plastic foreign bodies were found. There were no malignant cells in the histopathological examination of the surgical specimen. DISCUSSION: A granulomatous reaction which is mainly responsible for morbidity occurs around the foreign bodies due to the inflammatory response. These granulomas may cause confusion during patient follow-up, especially in those who have undergone major abdominal surgery due to cancer. CONCLUSION: Following surgical resection for malignancy, unintentionally retained foreign bodies can produce a moderate increase in FDG uptake mimicking disease recurrence.

Severe gastrointestinal burn with hydrochloric acid.

Inadvertantly or purposely, an oral intake of corrosive substances may cause life-threatening problems. Early admission to the hospital, clinical and endoscopic evaluation, and early surgery when required, may reduce morbidity and mortality. We report the case of a 49-year-old male patient, who had attempted suicide, by drinking about 800 mL of 25% hydrochloric acid, and who had severe intra-abdominal damage. The aim of this report is to state the fact that a good outcome is possible in severe burns caused by oral intake of corrosive substances, when fast, multidisciplinary, and appropriate management is provided on time.

Comparing the efficacy of preemptive intravenous paracetamol on the reducing effect of opioid usage in cholecystectomy.

BACKGROUND: The purpose of the present study was to determine the post-operative analgesic effects of preemptive intravenous (iv) paracetamol and the amount of reduction in tramadol (Contramal(®)) consumption. MATERIALS AND METHODS: Following local research ethics committee approval, ASAI-II, 300 patients were assigned in a randomized manner into three groups: Group I (preemptive) received iv paracetamol 1 g/100 mL 10 min before skin inscision and 100 mL of saline solution at the end of the operation, Group II (post-operative) received 100 mL of saline solution 10 min before skin inscision and iv paracetamol 1 g/100 mL at the end of the operation and Group III (placebo) received 100 mL of saline solution 10 min before skin insicision and 100 mL of saline solution at the end of the operation as well. The time to first analgesic requirement use and 24 h total analgesic consumption were recorded. Visual analog scale (VAS) pain scores were obtained from all patients at 15, 30, min 1, 2, 4, 6, 8, 12 and 24 h after the end of the operation. RESULTS: Time to first analgesic requirement was significantly longer in Group I and Group II, compared to Group III (P < 0.05). Time to first analgesic requirement was significantly longer in Group I compared to Group II (P < 0.05). Total analgesic consumption and postoperative VAS pain scores recorded were significantly lower in Group I and II, compared to Group III. Total analgesic consumption and postoperative VAS pain scores recorded were significantly lower in Group I compared to Group II (P < 0.05). CONCLUSION: In conclusion, preemptive iv paracetamol provided effective and reliable pain control after cholecystectomy surgeries and reduced post-operative pain scores, the need for and use of supplementary opioids and the time to first request of analgesics.

Does topical rifampicin reduce the risk of surgical field infection in hernia repair?

OBJECTIVE: Inguinal hernia operations are common procedures in general surgery. There have been many approaches in the historical development of hernia repair; tension free repair with mesh being the most commonly used technique today. Although it is a clean wound, antibiotic use is still controversial due to concerns about infection related to synthetic mesh. We aimed to determine the probable role of topical rifampicin in patients with tension-free hernia repair and mesh support. MATERIAL AND METHODS: The charts of patients who underwent tension-free inguinal hernia repair were retrospectively analyzed. Information and operative notes on patients, in whom synthetic materials were used, were identified. The patients were divided into two groups, placebo group (G1) and patients with application of topical rifampicin on the mesh (G2). Infection rates between the groups in the early postoperative period were compared. RESULTS: The mean age of the 278 patients who were included in the study was 49.6±15.39 and the female/male ratio was 10/268. There were recurrent hernias in four patients and superficial wound infections in 22 patients in the early period. One patient had testicle torsion and underwent an orchiectomy. There were no significant differences between the groups in terms of age and gender. The types of hernia and body mass index were homogenous between the two groups. In the early postoperative period the infection rates were 16/144 (11.1%) and 6/134 (4.48%) in the groups, respectively, with the difference being statistically significant (p=0.041). CONCLUSION: We suggest that applying rifampicin locally can decrease surgical site infection in hernia operations where meshes are used.

Impact of high dose chemoimmunotherapy after surgery on the overall and disease-free survivals in advanced stage malignant melanoma.

BACKGROUND: To investigate the impact of high dose chemoimmunotherapy in addition to surgery on the cumulative survival and disease-free survey of malignant melanoma patients. METHODS: A total of 86 malignant melanoma patients [35 females (40.7%), 51 males (59.3%), mean age: 55.5] were treated according to their stages between Februrary 1997 and June 2007. After surgery, adjuvant immunotherapy was applied to patients in Stage 2, while adjuvant chemotherapy and adjuvan immunotherapy were administered to those at Stages 3 and 4. RESULTS: Overall rate of mortality was 31.4% (27/86). The most frequent postoperative complications were wound infection (n=8, 9.3%) in the early period and lymphedema in lower extremities (n=4, 4.6%) in the late period. Temporary and tolerable complications ensourcing from chemoimmunotherapy were encountered in 9 (10.4%) patients. The survival rates and disease-free periods of combined treatment protocol were found to be similar to those in ECOG 1684 and ECOG 1690 studies. CONCLUSION: Adjuvant immunotherapy and chemoimmunotherapy seem to improve overall survival and disease-free survey in malignant melanoma. Further clinical studies are necessary to demonstrate the actual effectivity of this promising protocol in the management of malignant melanoma.

The predictive value of mean platelet volume in differential diagnosis of non-functional pancreatic neuroendocrine tumors from pancreatic adenocarcinomas.

OBJECTIVE: The aim of the present study is to evaluate in a retrospective manner the diagnostic value of mean platelet volume (MPV) in pancreatic adenocarcinomas and pancreatic neuroendocrine tumors (PNETs). PATIENTS AND METHODS: A total of 92 patients, who were admitted for pancreatic adenocarcinoma (n=76) and PNET (n=16) between March 2007 and December 2009, were analyzed retrospectively for demographics and clinical information. RESULTS: Thirty-nine patients (51.3%) had a resectable, whereas 37 patients (48.7%) had an unresectable pancreatic adenocarcinoma. Nine patients (56.3%) had a non-functional PNET, 6 patients (37.5%) had an insulinoma, and the remaining one patient had a gastrinoma. The mean age was 59.3±10.5 for pancreatic adenocarcinomas and 45.1±10.6 for PNETs. The mean age at diagnosis was significantly higher in patients with pancreatic adenocarcinomas than the patients with PNET (p<0.001). Preoperative mean hemoglobin levels were significantly lower in patients with pancreatic adenocarcinoma than those with PNET (12.4±1.8g/dl vs 13.7±2.2g/dl), (p<0.013). The preoperative median MPV levels were significantly lower in patients with PNET 7.8fL (7.2-9.4) than in patients with pancreatic adenocarcinomas 8.6fL (6.6-13.5), (p<0.014). In subgroup analysis, a significant difference in MPV levels was mainly caused by the difference between pancreatic adenocarcinomas and non-functional PNETs (p=0.017). The cut-off value of MPV level for detection of PNETs was calculated as≤7.8fL using ROC analysis [Sensitivity: 66.7%, specificity: 75.9%, AUC: 0.734 (0.587-0.880) p=0.022]. In logistic regression analysis, independent predictive factors for determining PNETs in the differential diagnosis of pancreatic adenocarcinomas were calculated as age (OR=0.068, 95% CI: 0.012-0.398), Ca 19-9 (OR=0.039, 95% CI: 0.006-0.263), MPV (OR=0.595, 95% CI: 0.243-1.458), and hemoglobin (OR=1.317, 95% CI: 0.831-2.086). CONCLUSION: Age, Ca 19-9, MPV, and hemoglobin levels have diagnostic value for distinguishing PNETs from pancreatic adenocarcinomas.

The association between thyroid malignancy and chronic lymphocytic thyroiditis: should it alter the surgical approach?

BACKGROUND: The relation between thyroid neoplasms and chronic lymphocytic thyroiditis (CLT) is controversial. While it is accepted that focal lymphocytic thyroiditis develops secondarily to malignancy, it is not clear whether diffuse lymphocytic thyroiditis has a tendency to develop into thyroid cancer. The aim of this study was to investigate the relation between CLT and malignant tumours of the thyroid and evaluate the surgical approach to CLT cases. MATERIAL AND METHODS: In this study, 917 patients operated on for thyroid diseases were investigated retrospectively. Seventy-seven (8.4%) patients histopathologically diagnosed as having CLT (either non-specific or Hashimoto's thyroiditis) were investigated for any concurrent malignant neoplasm. Fifteen patients in whom CLT and thyroid malignancy were coexisting were included in the study. RESULTS: In the pathological evaluation of 917 cases, malignancy in the thyroid was found in 97 (10.6%) cases. Seventy-seven cases were categorised as CLT. Of these 77, 16 (20.8%) were Hashimoto's thyroiditis (specific CLT) and the other 61 (79.2%) were non-specific CLT. In 15 cases, thyroid malignancy was found to be concurrent with CLT. Of the malignities, nine (60%) were papillary carcinoma, three (20%) medullar carcinoma, one (6.6%) follicular carcinoma, one (6.6%) Hurthle cell carcinoma, and one (6.6%) lymphoma. In our series, the rate of the development of malignancy against the background of CLT was 19.48%, while the rate in the groups without CLT was 9.76%, with a statistically significant difference between the groups (p = 0.008). CONCLUSIONS: CLT cases should be evaluated more carefully in terms of malignancy. If a nodule is detected on thyroiditis, the minimal surgical intervention should be lobectomy. Total thyroidectomy should be considered as preferable to subtotal thyroidectomy because of its many advantages such as controlling thyroiditis, removing the probability of reoperation, and hormonal stability.

[Comparison of the analgesic effects of intravenous paracetamol and lornoxicam in postoperative pain following thyroidectomies]. / Tiroidektomi sonrasi postoperatif agrida intravenöz parasetamolün analjezik etkinliginin lornoksikamla karsilastirilmasi

OBJECTIVES: The purpose of the present study was to determine the efficacy of intravenous (iv) paracetamol and iv lornoxicam on postoperative analgesia and the reduction in tramadol consumption. METHODS: Sixty patients (ASA class 1-2, age: 18-72 years) undergoing thyroidectomy were enrolled in the study, and were randomized into three groups: Group L received 8 mg of iv lornoxicam, Group P received 1 g iv paracetamol and Group C received 100 cc of iv saline solution. All patients received standard general anesthesia. The postoperative salvage analgesic consumption was recorded at 0-6, 6-12 and 12-24 hour (h) intervals. Pain scores were evaluated with a visual analogue scale at 15 min, and 1, 2, 4, 6, 8, 12, 18, and 24 h postoperatively. RESULTS: The time to first analgesic requirement was approximately 127.5 min in Group L, 162.3 in Group P and 35.5 min in Group C, and the time was found to be significantly prolonged in Group L and Group P. Pain scores were significantly lower in Group P and Group L at 15 min, and 1, 8, 12, and 18 h. Twenty-four hour analgesic consumption was significantly lower in Group P and Group L compared to Group C. Supplemental analgesics requirement was as follows: 100% in Group C, 50% in Group L and 55% in Group P. The degree of satisfaction with postoperative pain management was excellent in 90% in Groups L and P, versus in only 30% in Group C. CONCLUSION: Administration of iv lornoxicam and iv paracetamol following thyroid surgery decreased the postoperative pain scores and opioid requirement, as well as the incidence of nausea and vomiting, while also prolonging the time to the first analgesic supplement.