The Necessity of Upper Extremity Neurologic Examination while Evaluating Breast Pain.

INTRODUCTION: Breast pain is one of the most frequent complaints and occurs in 45-69% of all women. Cervical disc herniation is a common cause of cervical radiculopathy with an incidence rate of 18.6 per 100,000, and it should be considered as a cause of breast pain. OBJECTIVE: To identify the extent to which upper extremity neurologic findings and cervical root disorders accompany breast pain. METHODS: We prospectively collected clinical features of patients with breast pain. An upper extremity neurologic examination was performed in patients and controls. Patients who had neurologic findings underwent cervical spine magnetic resonance imaging (MRI) to identify cervical root disorders. RESULTS: Out of the 554 participants, 233 had breast pain, and 321 were controls. Women with breast pain had more numbness (116 [49.8%] vs. 104 [32.4%], p < 0.001) and more dysesthesia (36 [15.5%] vs. 17 [5.3%], p < 0.001) than the controls, but they had similar upper extremity weakness (10 [4.3%] vs. 14 [4.4%], p > 0.05). The number of women with one neurologic finding was significantly greater in the group with breast pain (119 [51.1%] vs. 111 [34.6%], p < 0.001). Ninety (16.2%) patients underwent a cervical vertebra MRI, which showed that 86 (95.6%) patients had cervical root disorders including 21 (23.3%) cases of bulging, 9 (10%) of annular tear, and 56 (62.2%) of central disc protrusion; 4 (4.4%) patients had normal findings. The multivariate logistic regression analysis revealed that age was the only significant predictor of neurologic findings in patients with breast pain (p < 0.05, OR: 1.02, CI: 1.002-1.053). CONCLUSIONS: Cervical root disorders should be considered as a cause of extramammary breast pain.

Both a biopsy method and a therapeutic procedure in BI-RADS 4A and 4B lesions: Ultrasound-guided vacuum-assisted breast biopsy.

OBJECTIVES: This study aimed to evaluate outcomes, complications, and follow-up results of ultrasound-guided vacuum-assisted breast biopsy (UG-VABB) in BI-RADS 4 A and B lesions. MATERIAL AND METHODS: Between Agust 2014 to January 2018, fifty BI-RADS 4A and BI-RADS 4B lesions of 41 patients biopsied with 10G vacuum needle by a single radiologist were retrospectively evaluated. RESULTS: All patients were females and mean age of the 41 patients was 50.12 ± 8.63. Of all lesions, 84% was benign, 6% was ADH, 4% was in-situ cancer, and 6% was diagnosed as malign. Follow-up duration after VABB was 0-51 months and mean was 20.92 months. Complications were as vasovagal-induced seizure in 3 patients (7.3%) and intramammary hematoma in 16 patients (39%). Hematoma was diagnosed in 3 patients (7.3%) at the 6th month follow-up and it was resolved in all patients at the 12th month follow-up. Higher breast density resulted in higher hematoma rates. There was no relationship between lesion BI-RADS subgroups, lesion size or sample number and hematoma development. During the follow-up, residue lesion in 1 (2.4%) patient and scar tissue in 2 (4.9%) patients was detected. CONCLUSION: US-guided VABB, with low complication rates and low scar development, is also a therapeutic excision method without remaining residue, which should be primarily preferred in smaller than 2 cm BI-RADS 4A and 4B lesions whose malignancy rates are relatively low. Hematoma, which is the most frequent complication, resorbed entirely in the 12th month in all patients.

Antimicrobial and antibiofilm activity of polyurethane/Hypericum perforatum extract (PHPE) composite.

Microbial accumulation in materials used in sectors such as medical, textile and food can lead to serious diseases, infections and uncontrollable problems. Many of the materials used in the above-mentioned industries have highly sensitive surfaces for microorganisms and cause colonization and biofilm formation. Colonization and biofilm formation threaten human health and they cause many diseases that result in death every year. Antimicrobial materials have an important role in combating pathogens. This article is about a new material with antibiofilm and antimicrobial properties combining polyurethane and Hypericum perforatum extract (PHPE) together. Antimicrobial effect of H. perforatum extract was determined against three clinical pathogens; C. albicans, E. coli and S. aureus. The highest antimicrobial activity of H. perforatum extract was found against S. aureus strain. Antibiofilm analysis results revealed that H. perforatum was also inhibited by the biofilm formation of S. aureus by 56.85%. The combination of polyurethane material and H. perforatum extract (PHPE) resulted in 92.85% decrease in S. aureus biofilm compared to control group. The reduction of S. aureus after H. perforatum incorporation was revealed by Scanning Electron Microscopy (SEM) study. The results show that the polyurethane material combined with H. perforatum extract inhibits the formation of S. aureus biofilm.

Splenectomy proportions are still high in low-grade traumatic splenic injury.

OBJECTIVE: The spleen is the most vulnerable organ in blunt abdominal trauma. Spleen-preserving treatments are non-operative management with or without splenic angioembolization, partial splenectomy, and splenorrhaphy. The aim of the present study was to determine the rate of SPTs and to evaluate the usefulness of Injury Severity Score after traumatic splenic injury. MATERIAL AND METHODS: We searched our institution's database between May 2012 and December 2015. Patients' clinicopathological features, surgeon's title, type of treatment, admission and discharge dates, duration of surgery, intensive care unit requirement, and Glasgow Coma Scale were recorded. RESULTS: The mean age of patients was 33.36±11.58 years. Of the 33 patients, 26 (78.8%) were males, and 7 (21.2%) were females. Thirty (90.9%) had total splenectomy (TS), and 3 (9.1%) had spleen preserving treatment (2 Nonoperative management and 1 partial splenectomy). No fatal hemorrhage developed after nonoperative management. Exitus rates were 5/30 (15.1%) and 0/3 in the total splenectomy and spleen preserving treatment groups, respectively. Of the 18 hemodynamically stable patients, only 2 (11.1%) had spleen preserving treatment. Of the 19 patients with grade I-III splenic injury, only 3 (15.8%) had spleen preserving treatment. For academic and non-academic surgeons, spleen preserving treatment rates were 3/11 (27.3%) and 0/22 (0%), respectively (p<0.05). Injury severity score and mean arterial pressure, number of transfusions, control hematocrit, and GCS had statistically significant relationships. CONCLUSIONS: Spleen preserving treatment proportions were low after traumatic splenic injury. Following trauma, guidelines will not only improve spleen preservation rates but also improve the overall health status of the patients and it will also prevent complications of splenectomy.

Adherence to vaccination recommendations after traumatic splenic injury.

BACKGROUND: The occurrence of a serious infection called overwhelming post-splenectomy infection (OPSI) increases more than 50 times in patients who have hyposplenia. The aim of this study was to investigate the adherence to vaccination recommendations after traumatic splenic injury. METHODS: We identified patients who underwent total splenectomy due to abdominal trauma between May 2012 and March 2016. We recorded the clinical, laboratory, and pathological features of the patients. We calculated the vaccination proportions before discharge, after discharge, and final. RESULTS: Twenty-seven patients underwent total splenectomy. For the vaccination status before discharge, after discharge, and final, the number of patients who received all the three vaccinations were 0 (0%), 0 (0%), and 8 (18.5%) and those who received none were 13 (48.2%), 11 (40.8%), and 9 (33.4%), respectively. The data of 17 patients were available for developing OPSI. The median follow-up time was 17.8 (4.4-41.2) months, and no OPSI cases were observed. CONCLUSION: Adherence to vaccination recommendations remains still low. Establishing a vaccination tracking system and following vaccination recommendations will be helpful to prevent serious infections, such as OPSI, after traumatic splenectomy.

Obturator hernia should be considered in the differential diagnosis of hip and knee pain.

Obturator hernia is a rare disease usually occurring in debilitated elderly women. Pain radiating down the medial thigh and knee (Howship-Romberg sign) is a specific sign of the disease. Presently described is a case of obturator hernia in a 73-year-old female patient who presented with severe left hip pain radiating down the medial thigh and knee, nausea, and loss of appetite. Initially, vertebral disc herniation was thought to be cause, but abdomino-pelvic computed tomography scan revealed left strangulated obturator hernia. Diagnosis of obturator hernia can be challenging. Physicians should consider obturator hernia in the differential diagnosis of knee and hip pain, and investigate for Howship-Romberg sign. Early diagnosis of the disease not only decreases morbidity and mortality, but also presents opportunity to treat with minimally invasive methods.

Effect of epidural anesthesia on anastomotic leakage in colonic surgery: experimental study.

BACKGROUND: The association between the infusion of continuous epidural anesthesia and the anastomotic strength of colonic anastomosis was examined in an animal model. METHODS: Fourteen white male New Zealand rabbits were included in the study and randomly assigned to two groups. Group 1 (n=7) had continuous epidural 0.9% NaCl infusion (0.4 ml kg-1 bolus and 0.2 ml kg-1 h-1 infusion) and Group 2 (n=7) had continuous epidural 1% lidocaine infusion (0.4 ml kg-1 bolus and 0.2 ml kg-1 h-1 infusion). Infusions started at the beginning of the operation and were continued for six hours postoperatively. All experimental animals underwent right colon resection and colo-colonic anastomosis under general anesthesia. On the fourth postoperative day, relaparotomy was applied and the bursting pressures of the anastomosis (BPA) were measured in situ. Segments 1-cm long consisting of the complete suture lines were excised, and the levels of hydroxyproline and collagen were measured. RESULTS: BPAs were statistically higher in the epidural lidocaine group (median: 248 mmHg; min 117 - max 300) than in the saline group (median: 109 mmHg; min 47 - max 176) (p=0.006). There was no difference between the groups in terms of hydroxyproline and collagen levels in the sample tissues (p>0.05). CONCLUSION: We concluded that the strength of colonic anastomosis may be increased by epidural lidocaine infusion.

Gallbladder perforation: clinical presentation, predisposing factors, and surgical outcomes of 46 patients.

BACKGROUND/AIMS: We aimed to investigate the clinical features and the relation between patient characteristics and the different types of gallbladder perforation and to determine the predisposing factors. MATERIAL AND METHODS: The medical records of 478 patients who received urgent surgical treatment with the diagnosis of acute cholecystitis and underwent urgent surgery in our clinics between January 1997 and November 2008 were reviewed retrospectively. The demographic data of patients, time elapsed from the onset of the symptoms to the time of surgery, comorbidity status, American Society of Anesthesiologists classification, laboratory data, imaging results, surgical procedures, postoperative complications, and postoperative length of stay of the patients were analyzed. RESULTS: There were 46 (9.6%) patients with the diagnosis of gallbladder perforation. Morbidity and mortality occurred in 15 (32.6%) and 7 (15.2%) patients, respectively. Advanced age, male gender, fever >38°C, high white blood cell count, and presence of cardiovascular comorbidity were found to be significant risk factors for gallbladder perforation. CONCLUSIONS: While early diagnosis and early surgical intervention are the keys to managing gallbladder perforation, we suggest that patients having the above-mentioned clinical features should be carefully investigated.

The relationship between vasopressor dose and anastomotic leak in colon surgery: an experimental trial.

BACKGROUND: The effect of vasopressors on the healing of gastrointestinal anastomoses is still controversial. The purpose of our study was to research the relationship between dose of dopamine, which is used generally as a vasopressor in shock status, and anastomotic leak in colonic surgery. METHODS: Forty-two male New Zealand rabbits were included in the study. Under general anesthesia, the right colon was identified, incised, and divided 5 cm distal to the ileocecal valve. Colonic integrity was then established with end-to-end anastomosis in all animals. The animals were randomized into 6 groups. While group 1 was not given any vasopressors, groups 2, 3, 4, 5, and 6 were administered 5, 10, 15, 20, and 25 microgkg(-1)h(-1) dopamine infusions, respectively, for 2h. On the 4th postoperative day, relaparotomy was performed under general anesthesia. The bursting pressures of anastomoses (BPA) were measured in situ, and then the lines of anastomoses were excised. The levels of hydroxyproline and collagen were measured in this tissue. RESULTS: When compared with the control group (140+/-39 mmHg), BPA were found to be statistically increased only in group 5 (238+/-91 mmHg) (p=0.03) and group 6 (277+/-64 mmHg) (p=0.002). There were no differences between groups in terms of the hydroxyproline and collagen levels in the tissue (p>0.05). CONCLUSIONS: Although vasopressors appeared to increase the risk of anastomotic leakage as a result of splanchnic vasoconstriction, deterioration of microcirculation, and local hypoxia, we found that BPA were increased with high doses of vasopressor. We speculated that the use of vasopressors without shock might increase blood supply to the anastomotic line by increasing cardiac output.

Spontaneous healing of gallbladder perforation: report of a case.

Gallbladder perforation is a serious complication of acute cholecystitis. Spontaneous healing is very rare, and only three cases have been reported in the English literature. In this study, we present a 73-year-old female patient who underwent a laparoscopic cholecystectomy years after a gallbladder perforation and spontaneous healing.

Prosthetic repair of incarcerated inguinal hernias: is it a reliable method?

BACKGROUND AND AIM: It is generally accepted that most inguinal hernias should be operated on electively using synthetic grafts. However, limited information is available on the usage of these materials in patient with incarcerated and strangulated hernias. The objective of this study is to compare the outcomes of incarcerated inguinal hernia repair with or without graft. MATERIALS AND METHODS: One hundred-thirteen patients with incarcerated inguinal hernia that underwent surgery were included in this study. Patients who underwent Lichtenstein repair were assigned to group I; those who underwent primary repair were assigned to group II. Demographics and characteristics of patients in each group were compared. Chi-square and Student's t-tests were used. RESULTS: No statistical difference was found between patients who did and did not receive anastomosis in both groups in terms of surgery duration, length of hospital stay, postoperative morbidity, and mortality. Recurrence was found in 4.0% and 20.8% patients in group I and group II, respectively (P = 0.036). CONCLUSIONS: Mesh repair can be preferred in incarcerated inguinal hernia patients because recurrence rate was significantly lower in patients who underwent Lichtenstein repair in this study.

Prognostic Factors of Patients With Transmural Advanced Gastric Carcinoma.

BACKGROUND: The purpose of this study is to evaluate perioperative morbidity, mortality and the prognostic factors that influence survival of the patients with transmural advanced gastric carcinoma after curative surgical therapy. METHODS: Fifty patients with transmural advanced gastric adenocarcinoma underwent curative resection in our clinic. The records of the patients were reviewed and the prognostic factors such as age, gender, location and size of the tumor, type of surgery, blood transfusion, depth of tumor invasion, lymph node metastases, stage of the disease, grading, vascular invasion, lymph vessel invasion, characteristics of the tumor according to Lauren's classification, and lymph node ratio were evaluated by using statistical methods. RESULTS: In a total of 12 patients (24%) major morbidities developed, and five patients (10%) died. The overall survival rate was 48% at 1 year, 31% at 3 years, and 19% at 5 years. Lymph node metastases (P = 0.03), lymph vessel invasion (P = 0.001), blood transfusion (P = 0.021), and lymph node ratio (P = 0.006) were the prognostic features identified by univariate analysis. Among the multiple significant prognostic factors in the univariate analysis only one factor, lymph node ratio, proved to be independently significant in the multivariate analysis (RR: 4.47). CONCLUSIONS: Our data showed that we can expect a good survival for patients with a lymph node ratio less than 0.2.

Band ligation of the perforated gall bladder during laparoscopic cholecystectomy.

Perforation of the gall bladder is a frequent complication during laparoscopic cholecystectomy. Grasping the perforated part of the gall bladder, clip application, or endoscopic loop application are possible solutions to prevent spillage. We propose laparoscopic rubber band application to close the perforated part of the gall bladder as an easy and safe method. We performed rubber band application after iatrogenic perforation of the gall bladder during laparoscopic cholecystectomy in 5 patients. Two-millimeter-wide multiple rubber rings, cut from a 14-Fr Foley catheter, are loaded on a grasper. When a perforation occurred during the dissection of the gall bladder, the hole is grasped with this instrument and 1 of the rings is placed on the gall bladder by the aid of a dissector. Thus, the grasper remained available for traction of the Hartmann's pouch during further dissection of the gall bladder. The rubber bands were placed successfully in all cases. Two perforations occurred in 1 case, and 2 bands were placed with ease. Bile leakage or gall stone spillage did not occur. Operation time was not prolonged. Rubber band ligation of perforation of the gall bladder is a simple, safe, inexpensive, and effective method to prevent spillage of the bile or gallstones in laparoscopic surgery.

Surgical treatment of hepatic injury: morbidity and mortality analysis of 109 cases.

BACKGROUND/AIMS: We aimed to determine the factors that affect morbidity and mortality in patients that underwent surgery for hepatic injury. METHODOLOGY: Records of 109 blunt or penetrating hepatic trauma patients that underwent surgery in the Third Surgical Clinic of Izmir Atattürk Training and Research Hospital between 1994 and 2004 were reviewed retrospectively. Evaluated parameters were: age, gender, cause of injury, diagnostic procedures, preoperative blood pressure (BP), hemoglobin (Hb) level, amount of intraabdominal blood, associated injuries, the number of involved hepatic segments and anatomic distribution, severity of injury, abdominal trauma index (ATI), amount of blood transfusions, type of surgery, hospital stay, and rates of morbidity and mortality. RESULTS: Median age of the patients was 29 years. The injury was penetrating in 53.2% of the patients and blunt in 46.8%. Abdominal blood was 500cc or less in 70 (64.2%) patients. Isolated hepatic injury was encountered in 29 (26.6%) cases. 22.9% of the patients had major injuries. Hemostasis was achieved by electrocautery, sponge-gel, primary suturing, hepatic resection or perihepatic packing. Morbidity and mortality rates were 40.4% and 14.6% respectively. CONCLUSIONS: Age, type of the injury, BP and Hb levels, amount of intraabdominal blood, degree of injury, ATI, and accompanying organ injuries significantly affect morbidity and/or mortality.

Lower recurrence rate for Limberg vs. V-Y flap for pilonidal sinus.

PURPOSE: Pilonidal sinus is a disease that does not have a standardized surgical treatment method. This study was designed to compare the outcomes of Limberg fasciocutaneous transposition and V-Y fasciocutaneous advancement flaps in the treatment of patients with pilonidal sinus. METHODS: A total of 111 patients (98 males; 88.3 percent; mean age, 27.1 years) who received reconstruction after pilonidal sinus excision in our clinics with Limberg flap (Group 1, n = 66, 59.5 percent) or V-Y flaps (Group 2, n = 45, 40.5 percent) between 1997 and 2004 were investigated retrospectively. RESULTS: No significant difference was detected between Groups 1 and 2 in terms of gender, history of infection or abscess, mean duration of operation, requirement for analgesics, wound-related complications, such as necrosis, seroma, and infection, and average time off work. Mean follow-up periods were 45.4 vs. 48.8 months in Group 1 and Group 2, respectively (P = 0.337). On the other hand, rate of recurrence was significantly lower in Group 1 (n = 1, 1.5 percent) compared with Group 2 (n = 5, 11.1 percent; P = 0.039). CONCLUSIONS: We conclude that, if the defect is to be reconstructed with a flap in pilonidal sinus cases, reconstruction with Limberg flap should be preferred over reconstruction with V-Y flap because of its lower rate of recurrence.

Survival analysis after surgical treatment of gastric cancer: review of 121 cases.

BACKGROUND/AIMS: This study was performed to evaluate major morbidity, early mortality and to analyze survival in our patients that underwent surgical treatment for gastric cancer. METHODOLOGY: Records of 121 patients with gastric adenocarcinoma that underwent surgery between 1997 and 2004 were reviewed retrospectively. Age, gender, tumor site, presence of local invasion, depth of tumor invasion, lymph node metastases, stage of the disease, distant metastases, histological differentiation, type of surgery, and blood transfusions were evaluated in relation to survival. Survival curves were estimated using the Kaplan-Meier method and the differences in survival were compared by the log-rank test. RESULTS: Forty-two cases (34.7%) underwent total gastrectomy, 34 (28.1%) had subtotal gastrectomy, and 45 (37.2%) received palliative surgery. The majority of the patients (61.2%) had stage IV gastric cancer. Total morbidity and mortality were 26.4% and 17.3%, respectively. The factors that influence survival were type of surgery, adjacent organ invasion, existence of metastases, lymph node status, blood transfusions, and stage of the disease in this study. Among the significant prognostic factors in the univariate analysis, only one factor, R0 resection proved to be independently significant in the multivariate analysis. CONCLUSIONS: R0 resection was found to have a significant favorable effect on survival in our study.

Palliative surgery for advanced stage (stage IV) gastric adenocarcinoma.

BACKGROUND/AIMS: The factors that effect resectability, major morbidity, early mortality, and survival in advanced stage gastric adenocarcinoma patients are evaluated. METHODOLOGY: Records of 74 patients that underwent surgery for stage IV gastric adenocarcinoma in the Third Surgical Clinic of Izmir Atatürk Training Hospital between January 1997 and January 2004 were reviewed retrospectively. Two groups (the patients with resectable disease and those with unresectable disease) were compared with regard to age, gender, primary complaint, symptoms, site of the tumor, involvement of adjacent organs, lymph node involvement, distant metastases, differentiation of tumor, surgical procedure, perioperative blood transfusions, and postoperative hospital stay. RESULTS: Mean age of the 74 patients was 58.4 years. Forty-five cases (60.8%) were considered as unresectable and 29 (39.2%) patients underwent a palliative resection. There was a significant relation between resectability and site of the tumor, and severity of invasion. As the number of perioperative blood transfusions increased, morbidity and mortality increased significantly. Although early mortality was high in the palliative resection group, survival (mean 10.4 months, longest 25 months) was better compared to that of the unresectable gastric cancer group (mean 3.5 months, longest eight months). CONCLUSIONS: A palliative gastric surgery may be applied to improve prognosis of advanced gastric cancer patients, even at the presence of peritoneal dissemination, hepatic metastases, N3 lymph node involvement, adjacent organ invasion, or poor differentiation of the tumor.

Special anoscope for easy purse-string suture application in stapled hemorrhoidopexy.

BACKGROUND: Internal hemorrhoids and loose rectal mucosa may block exposure during the purse-string suturing in stapled hemorrhoidopexy, and this may lead to complications. MATERIALS AND METHODS: To retract the prolapsing rectal mucosa, we modified the purse-string anoscope of the PPH01 kit (Ethicon-Endosurgery, Cincinnati, OH, USA) and produced a special anoscope. The open part of the purse-string suture anoscope is covered by transparent acrylic (Orthoacryl, Dentaurum, Pforzheim, Germany). The covering had completely cylindrical outer and inner surfaces and was thin enough to let the anoscope easily rotate in the anal dilator and to let the 26 mm curved, round-bodied needle of the 2/0 polypropylene suture move in the anoscope. A window, 3 cm long and 3-4 mm wide, was opened at the angled part of the anoscope 2 cm to the tip. This special anoscope was used for the purse-string suture during the stapled hemorrhoidopexy procedure in five patients. RESULTS AND CONCLUSIONS: No postoperative complications, early or late, were encountered, and we propose that stapled hemorrhoidopexy procedure can be applied more easily by using this special anoscope.

Acute intraperitoneal rupture of hydatid cysts.

BACKGROUND: Rupture into the abdominal cavity is a rare but serious complication of hydatid disease. The cysts may be ruptured after a trauma, or spontaneously as a result of increased intracystic pressure. Rupture of the hydatid cyst requires emergency surgical intervention. METHODS: Seventeen patients received surgical treatment for intraperitoneal rupture of the cysts over a period of 18 years. Age, gender, time to surgery from the onset of the symptoms, laboratory findings, diagnostic procedures, surgical treatment modalities, in-hospital stay, morbidity, mortality and recurrence were evaluated retrospectively. RESULTS: Five cases (29.4%) had a history of blunt abdominal trauma. Ultrasonography scans revealed intra-abdominal fluid in all cases. Intraperitoneal multiple cysts with heterogeneous cavity or cystic structures in the liver were shown in 14 cases. Computed tomography and magnetic resonance imaging showed multiple cystic lesions in the liver and peritoneum with intra-abdominal free fluid. Procedures to fill the cystic cavities were applied after removal of the intraperitoneal fluid. Four patients (23.5%) died in the early postoperative period. A total of nine morbidities developed in six patients (35.3%). Median hospital stay was 18 days and median follow-up was 78 months. Intra-abdominal recurrence occurred in one case (7.7%). CONCLUSIONS: Rupture of hydatid cysts into the peritoneal cavity, although rare, presents a challenge for surgeons. This pathology should be included in the differential diagnosis of acute abdomen in endemic areas. Computed tomography scan, in addition to clinical presentation, is essential for diagnosis. Emergency surgery is the main treatment for acute ruptured hydatid cysts. The morbidity and mortality rates of surgical interventions for ruptured hydatid cysts are higher than the rates for elective uncomplicated cases.