Detailed dissection of hepato-caval junction and suprarenal inferior vena cava.

BACKGROUND/AIMS: There are few anatomical studies on hepatic vein compared to hepatic artery and portal vein. The aim of this study is to clarify the branching patterns of hepatic veins, supra and infra-diaphragmatic course of suprarenal inferior vena cava and its relation with the liver. METHODOLOGY: Between March and May 2008, 103 consecutive autopsy examinations were included in the study. Hepatic vein anatomy was classified according to the Broelsch classification. The anatomic relations of supra-diaphragmatic and infra-diaphragmatic (suprarenal) inferior vena cava were revealed. RESULTS: Majority of subjects have Type a (42.7%) variation. The inferior right hepatic vein was presented alone in 26 and together with middle right hepatic vein in 15 subjects. Most of the phrenic veins were drained to the right-anterior sidewall of inferior vena cava (n=21/25 above the diaphragm and, n=144/306 below the diaphragm). Drainage of the right adrenal vein directly into the right side of the inferior vena cava was found in 82 subjects (80%). Most of subjects had 2 lumbar branches in the posterior sidewall of infradiaphragmatic inferior vena cava (n=92/103). CONCLUSIONS: The proposed classification of hepatic veins and obtained anatomical details from this study provides useful assistance for hepatic surgeons in phases of operative planning and vascular control maneuvers required in liver surgery.

Open adrenalectomy: A 20-year review of our experience in a developing country.

Introduction: The aim of this study was to present our 20-year experience regarding open adrenalectomy (OA) during laparoscopic era in a developing country Turkey. Materials and Methods: A retrospective and descriptive study of patients with adrenal mass undergoing OA in the surgery department of our hospital, between January 1993 and January 2013, was carried out. All operations were performed by two surgeons. Results: Ninety patients who underwent OA in our clinic were reviewed retrospectively. The mean number of adrenal operations per month during this period was 0.38 ± 0.12. The patient included 35 men (38.8%) and 55 women (61.2%), with a mean age of 46.4 ± 17 years. The mean body mass index was 28.4 ± 5.25, and the mean American Society of Anesthesiologists score was 2.6 ± 0.57. The mean operative time was 88 ± 27 min. The mean maximum diameter of all the lesions was 4.8 ± 1.3 cm (range: 1.2-21 cm). The mean blood loss was 118 ± 23 ml during the operations. Postoperative complications were observed in four patients (5.5%). There was no mortality. The length of hospital stay was 6.2 ± 2.1 days. The most frequent type of the histological type was benign adenoma (48.8%). Conclusion: OA in a developing country is a safe method as an alternative for laparoscopic adrenalectomy which has a difficult learning curve.

RésuméIntroduction: Le but de cette étude est de présenter nos 20 ans dæexpérience de læadrénalectomie ouverte (OA) lors de la laparoscopie dans un pays en développement. Matériaux et méthodes: Une étude rétrospective et descriptive a été prévue dans le service de chirurgie générale de notre hôpital, incluant des patients ayant subi entre janvier 1993 et janvier 2013 une adrénalectomie ouverte pour une masse adrrénalienne. Toutes les opérations ont été effectuées par 2 chirurgiens. Résultats: Quatre-vingt-dix patients qui ont subi une adrénalectomie ouverte dans notre clinique ont été évalués rétrospectivement. Le nombre moyen dæopérations adrénaliennes par mois au cours de cette période était de 0,38 ± 0,12. Læâge moyen des patients était de 46,4 ± 17 ans: 35 (38,8%) étaient des hommes et 55 (61,2%) étaient des femmes. Læindice de masse corporelle (IMC) moyen était de 28,4 ± 5,25 et le score moyen de læAmerican Society of Anesthesiologists (ASA) était de 2,6 ± 0,57. La durée moyenne d'opération était de 88 ± 27 minutes. Le diamètre moyen de toutes les lésions était de 4,8 ± 1,3 cm (entre 1,2 et 21 cm). La quantité moyenne de saignements rencontrés au cours des opérations était de 118 ± 23 ml. Des complications postopératoires ont été observées chez quatre patients (5,5%). La mortalité næa été observée chez aucun des patients. La durée moyenne dæhospitalisation était de 6,2 ± 2,1 jours. Le type histologique le plus courant était læadénome bénin (48,8%). Conclusion: Dans un pays en développement, læadrénalectomie ouverte est une alternative sûre à læadrénalectomie laparoscopique qui a une courbe dæapprentissage difficile.

Dopamine-secreting adrenal ganglioneuroma presenting with paroxysmal hypertension attacks.

Adrenal ganglioneuromas are rare tumors originating from the neural crest tissue of the sympathetic nervous system. The clinical presentation for most patients is asymptomatic, and most of these tumors are hormone silent. We report a case of dopamine-secreting adrenal ganglioneuroma associated with paroxysmal hypertensive attacks in an adult patient. A 46-year-old woman was admitted to our hospital with a 2-month history of right flank pain, and a 2-year history of paroxysmal hypertensive attacks associated with headaches, palpitations, nervousness, and sweating. Abdominal CT and MRI revealed a solid round tumor approximately 4 cm in diameter on the upper pole of the right kidney. Urinary levels of dopamine and homovanillic acid were slightly elevated, although urinary levels of metanephrine and normetanephrine were suppressed. The urinary levels of epinephrine, norepinephrine, and vanillylmandelic acid were within normal limits. Right adrenalectomy was performed for treatment purposes. Histological diagnosis of the tumor was a ganglioneuroma originating from the adrenal medulla. In conclusion, this is a case of dopamine-secreting adrenal ganglioneuroma associated with paroxysmal hypertensive attacks in an adult patient.

A 20-year study on 190 patients with primary hyperparathyroidism in a developing country: Turkey experience.

The aim of this study was to present our 20-year experience regarding primary hyperparathyroidism (PHPT). PHPT patients who underwent parathyroidectomy in our clinic were reviewed retrospectively. There were 190 PHPT patients, of whom 137 were asymptomatic (72%). The mean serum calcium at the time of diagnosis was 11.9 ± 2.2 mg/dL. The mean parathyroid hormone (PTH) level was 467 ± 78 pg/mL. Ultrasonography (USG) identified all abnormal glands accurately (82.6%) and Technetium-99m sestamibi scintigraphy (MIBI) was used in 89.4% of the patients and magnetic resonance imaging (MRI) in 61%. The common use of USG and MIBI detected 92% of the lesions. Bilateral neck exploration (BNE) was performed in 12.2% of the patients and focused unilateral neck exploration (FUNE) in the remaining 87.8%. Surgical intervention was unsuccessful in 1 patient (0.5%). The conversion ratio from FUNE to BNE was 5.2%. The mean operation time and mean hospital stay decreased significantly in patients with FUNE. Pathologic examination revealed single adenoma in 93% of the patients. New imaging techniques result in the conversion of surgical treatments of PHPT. FUNE in parathyroidectomy performed by an experienced surgeon may provide successful treatment rates.

[A case of acute abdomen due to ventriculo-peritoneal shunt infection]. / Ventrikülo-peritoneal sant enfeksiyonu nedeniyle gelisen akut batin olgusu.

Peritonitis is a rare complication of ventriculoperitoneal shunt. Shunt infection may be the cause in patients with ventriculoperitoneal shunt, who have acute abdomen. Specific clues taken from patient's history, physical examination and some further investigations may clarify the diagnosis. This case is a 25-years-old male with a ventriculoperitoneal shunt who presented symptoms of acute abdomen. The patient was admitted with complaints of abdominal pain. There were no neurologic signs or symptoms. Physical examination on admission revealed a mass in the right lower abdomen and abdominal muscular guarding with rebound tenderness. Laboratory studies showed leukocytosis of the peripheral blood. Abdominal ultrasound demonstrated a mass and the preoperative diagnosis was appendicitis. On abdominal exploration, appendix was found to be normal but a catheter infection related omental necrosis was present. Surgical therapy was carried out by withdrawal of the catheter and segmental resection of the omentum. The patient was discharged on seventh day postoperatively.

A study on 107 patients with acute mesenteric ischemia over 30 years.

Acute mesenteric ischemia (AMI) is a life threatening cause of acute abdomen. The purpose of this study is to define risk factors that predict the adverse outcome of AMI and to present our experience in the last 30 years. Hospital records and clinical data of 107 patients undergoing surgical intervention for AMI during the last 30 year period were reviewed and clinical outcomes as well as factors influencing mortality were analyzed. Mesenteric arterial thrombosis, arterial embolism and nonocclusive mesenteric ischemia (NOMI) were the cause of AMI in 68 (63.6%), 28 (26%), and 11 patients (10.2%), respectively. Abdominal pain was the most common presenting symptom (90.6%). Peritonitis was observed in 96 patients (89.7%) and 24 patients (22.4%) were in shock. Abdominal ultrasonography was performed in 46 patients (42%), abdominal CT angiography in 36 patients (33%) and mesenteric angiography in 12 patients (10.5%). All patients were operated and 11 (10%) patients underwent a second-look operation. Bowel resection was necessary in 101 patients (93.4%) during the initial operation and in seven patients (6.5%) during the second-look operation. The hospital mortality was 55.1%. Mortality was mainly due to multiorgan failure (43%). Diabetes mellitus, use of digoxine and antiplatelet drugs, duration of the symptoms until before surgery, existence of shock, low levels of the pH and bicarbonate and re-laparotomy were found to be negative predictors of the perioperative mortality. The use of total parenteral nutrition and CT angiography was found to be a protective factor against mortality. A high index of suspicion with prompt diagnostic evaluation with CT angiography may reduce time prior to surgical intervention which may lead to improved patient survival.

Adrenal ganglioneuroma: report of a new case.

Although adrenal ganglioneuroma (GN) is a rare tumor originating from the neural crest tissue of the sympathetic nervous system, detection of this tumor has increased, as imaging procedures such as ultrasonography (US) and computed tomography (CT) have become prevalent. The clinical presentation for most patients is asymptomatic, and most of those tumors are hormone silent. We describe a case of adrenal GN incidentally diagnosed in a 68-year-old female patient. Physical examination, routine laboratory studies, and hormonal tests were within normal ranges. Abdominal CT and magnetic resonance imaging showed a solid oval tumor approximately 6 x 4 cm in the left adrenal gland without remarkable signs of malignancy. Left adrenalectomy was performed for treatment purposes. Histological diagnosis of the tumor was a ganglioneuroma originating from the adrenal medulla. Adrenal GN occurs rarely in adults and preoperative diagnosis is difficult, especially in asymptomatic cases. It needs careful evaluation and surgical treatment. According to our knowledge, this is the fifth case of adrenal GN in an adult patient from Turkey in English literature.

Familial paraganglioma.

Paragangliomas are unusual tumors that are sometimes familial. We treated a family who exhibited multiple head and neck paragangliomas (HNPGs) and pheochromocytomas. The purpose was to determine the clinical characteristics of paragangliomas with familial history and to define a better standardized proceeding in the management of these tumors. Patients diagnosed with head and neck paragangliomas and identified retrospectively through clinical otolaryngology practices were given a medical and family history questionnaire. We studied a family who exhibited familial paragangliomas. This relationship was examined by reviewing the medical records of family members with verified tumors, carrying out neck computed tomography or magnetic resonance imaging on their relatives to look for tumors that had been unrecognized in the past. All patients underwent a complete head and neck examination. The initial evaluation usually included CT and/or MRI. Computed tomography and magnetic resonance imaging contributed additional information about tumor extension. Angiography was performed in every patient with carotid body tumor, with one undergoing therapeutic embolization to reduce the tumor size. Eleven tumors were identified in four patients with a familial history. Familial disease was initially determined by pedigree analysis. Four patients with a median age of 31 years (range: 25-42) underwent surgery. Median follow-up was 5 years (range 2-14); carotid angiography provided essential mainstays for the definite diagnosis. All patients underwent successful surgical resection of the tumor after the appropriate preoperative preparation. There were no perioperative deaths or hemiplegia. Three patients had bilaterality carotid body paragangliomas. One patient had three paragangliomas, and two patients had bilateral carotid body paragangliomas associated with pheochromocytoma. Clinically functioning tumors and malignant tumors were not identified, and none of the patients died after surgery. During follow-up, none of the patients developed recurrence or metastatic disease. The carotid body paraganglioma (CBPG) and glomus vagale manifested as asymptomatic neck masses. The clinical pheochromocytomas typically present with uncontrolled hypertension. In conclusion, paragangliomas are rare, with multicentricity being more common in patients with a familial history. In patients with familial paragangliomas, high-resolution computed tomography and magnetic resonance imaging are recommended for early screening and contributed additional information about the tumor extension and definitive treatment. Early surgery is recommended to minimize major risks.

Carotid body tumors and adrenal pheochromocytomas in siblings of a Turkish family.

OBJECTIVE: This is a report of 2 hypertensive siblings with a history of carotid body tumors and subsequent benign adrenal pheochromocytomas (pheos) in a family where the mother had died of possible adrenal carcinoma. CLINICAL PRESENTATION AND INTERVENTION: The first case was a 35-year-old woman with paroxysmal hypertensive attacks and a right adrenal mass. She had earlier undergone surgery to remove bilateral carotid body tumors. Investigation revealed excessive excretion of catecholamines and their metabolites in the urine. Abdominal MRI and (131)I-MIBG scintigraphy revealed a right adrenal tumor. Right adrenalectomy was performed. The second case, the 45-year-old brother of the first case, was found to have a left adrenal mass on abdominal MRI. Catecholamines and their metabolites in the urine were found to be increased. He had also had surgery to remove bilateral carotid body tumors of the neck. Left adrenalectomy was performed. Both siblings showed no evidence of other familial syndromes, such as multiple neoplasia type 2, von Hippel-Lindau disease or neurofibromatosis type 1. CONCLUSION: Although the combination of familial carotid body tumors and pheo is rare, a patient who remains hypertensive after removal of a carotid body tumor deserves a careful evaluation to exclude pheo. Such tumors may be extra-adrenal or multifocal.

Effects of the tyrosine kinase inhibitor tyrphostin AG 556 on acute necrotising pancreatitis in rats.

OBJECTIVE: To investigate the effects of the tyrosine kinase inhibitor tyrphostin AG 556 on the course of acute necrotising pancreatitis in rats. DESIGN: Laboratory study. SETTING: Medical school, Turkey. ANIMALS: 72 Sprague Dawley rats, 12 in the sham operated (control) group and 20 in each of the three others. MAIN OUTCOME MEASURES: Cardiorespiratory measurements, mortality, effect on the activities of various enzymes in serum and tissue of pancreas and lung, and the histological picture. RESULTS: The four study groups were sham + Ringer's lactate, acute necrotising pancreatitis with Ringer's lactate, tryphostin AG 556, and dimethylsulfoxide (DMSO). There were 12 animals in the first group and 20 in each of the other groups. The induction of pancreatitis increased mortality from 0/12 in the control to 6/20 (30%), 7/20 (35%), 8/20 (40%) in the three experimental groups, respectively. Heart rate, packed cell volume (PCV), serum activities of amylase and alanine aspartate transferase, tissue activity of myeloperoxidase (MPO) and malondialdehyde (MDA) in the pancreas and lung, serum concentrations of urea and calcium, volume of ascites, degree of pancreatic damage, blood pressure, and urine production did no differ between the pancreatitis groups. CONCLUSIONS: Treatment with the tyrphostin kinase inhibitor did not improve the course of acute pancreatitis or reduce the extent of acinar cell injury and is therefore unlikely to be of benefit in patients with pancreatitis.

Adrenal black adenoma associated with Cushing's syndrome.

We report a case of adrenal black adenoma associated with Cushing's syndrome. A 41-yr-old man presented to our hospital with a 6-yr history of severe hypertension and general fatigue, and a 1-mo history of diabetes mellitus. Physical examination disclosed cushing-oid manifestations. His serum cortisol concentrations ranged from 14.0 to 15.4 microg/dL, with an ACTH level <5 pg/mL. Urinary free cortisol level was increased (125 microg/d). Cortisol was not suppressed on the overnight 1 mg oral dexamethasone suppression test (DST), 2-d low-dose DST, and 2-d high-dose DST. Abdominal computed tomography and magnetic resonance imaging studies revealed a solid round tumor approx 3 cm in diameter, located in the left adrenal gland. Left adrenalectomy was performed; the surgical specimen revealed a black ade-noma consisting of compact cells within numerous pigments that seemed to be lipofuscin in nature.