Turkish Journal of Surgery - 2007; 23(4)

Our patients with hepatic hydatid cyst rupturing into bile ducts

2007-10-01

Purpose: Rupture of the hydatid cyst of the liver into bile ducts is a rare and serious complication of hepatic hydatid disease. Operative treatment of intrabiliary ruptured hydatid cysts has many differences to uncomplicated cysts. We report our experience, including surgical approach to the intrabiliary ruptured hydatid disease. Materials and Methods: Between January 1985 to December 2005, 640 patients with hydatid cysts of the liver underwent surgery, and 62 patients (13 %) with intrabiliary rupture of hepatic hydatid cysts were retrospectively reviewed. Results: Of 62 patients, 35 were men and 23 were women. Their average age was 39 (28-74) for men and 43 (15-63) for women. Biliary ruptured hydatid cysts were all in liver. The right lobe of the liver was involved in 48 patients (77 %), the left lobe in 12 (19 %) and both lobes in 2 patients. Each had only one cyst except one patient who had two cysts in two lobes. One patient had recurrent hepatic hydatid cyst who had been operated on 7 years ago. The most common clinical manifestations were right hypocondrial pain and tenderness in the right hypocondrium on physical examination. Methods used for diagnosis were ultrasonography, computed tomography and endoscopic retrograde cholangiopancreatography (ERCP). Five of the patients healed after ERCP and endoscopic sphincterotomy. In these patients common bile duct (CBD) was explored and it was drained by a T-tube in 35 patients, by a choledochoduodenostomy in 8 patients and hepaticojejunostomy in one patient. Bile fistula orifice was sutured in 12 patients. Twelve patients had wound infection and 2 patients had bile leak postoperatively. There was no mortality. Conclusion: The low mortality and morbidity rates in the treatment of intrabiliary rupture of hydatid cysts can be obtained with surgical intervention to CBD with T-tube drainage and choledochoduodenostomy. In selected cases ERCP and endoscopic sphincterotomy are adequate methods for diagnosis and treatment of intrabiliary ruptured hydatid cysts.

Gail model for determination of the risk factors of breast cancer

2007-10-01

Purpose: The aim of the presented study was to determine the hormonal and familial risk factors that might play a role in development of breast cancer in Turkish population and to evaluate the reliability of Gail Model in our society. Materials and Methods: Patients over 35 years old and in whom all breast cancer risk factors are known were selected as the study group, among them; patients who had breast biopsy at least 5 years ago with a diagnosis of non-proliferative lesion was called as Group 1; control patients as Group 2; patients in Group 1 and 2 who were free of breast cancer at the end of the 5 years follow up were called as Group 3; and the patients who had been operated for breast cancer were named as Group 4. Individual risk of breast cancer was calculated for 5 years by Gail Model for the patients in Group 1 and 2, and the patients in whom breast cancer developed during this time period were determined within these groups. Besides, for the determination of the risk factors in development of breast cancer in Turkish Society, all known risk factors of the patients in Group 3 and 4 were evaluated with the multiple regression test. Results: In Group 1 (n=343), breast cancer developed in the 2.6% of low-risk patients according to Gail Model, while the rate was 12% in high-risk patients (RR=5). In Group 2 (n=601), breast cancer developed in 4.7% of the low-risk patients, and the corresponding rate was 11.7% in high-risk group (RR=2.6). After evaluation of all the risk factors of Group 3 (n=896) and Group 4 (n=630), risk factors which were found to be significant were the first degree family history for breast cancer; second degree family history for breast cancer, nulliparity, nonbreast-feeding and age (p<0.05). Conclusions: It is found that Gail Model is a reliable model in calculation of individual risk for development of a breast cancer for Turkish Society. It has come to a decision that the main risk factors that determine the risk of a breast cancer development in Turkish Society are familial or genetic factors rather than the hormonal ones, and with the increasing age risk of breast cancer development increases evidently.

Comparison of blue dye, lymphoscintigraphy and intraoperative gamma probe, and combined technique for sentinel lymph node biopsy in breast cancer

Volkan Gen�, �zlem K��k, Atilla Halil Elhan, Serpil Dizbay Sak, Rag�p �am — 2007-10-01

Purpose: Determination of lymphatic spread is the most important prognostic factor in breast cancer. The concept of sentinel lymph node dissection was introduced to determine the status of the lymph nodes in axilla without dissection. We searched which technique is more effective and correct. Materials and Methods: Vital dye, lymphoscintigraphy + intraoperative gamma probing; and combined techniques were performed randomized on 3 groups made of 20 patients. Patent blue violet was used as vital dye and 1 ml each was injected to 4 quadrants surrounding the tumor and also subdermally. Albumin marked with Tc 99m sulphur colloid total 1 ml(200 MBq) was used as isotope and injected to the 4 surrounding quadrants again. During operation intraoperative gamma probing was used in 2nd and 3rd groups. The lymph node that has a minimum 10 fold value from the background measurement was accepted as sentinel lymph node. The obtained lymph nodes analyzed using routine hematoxylin and eosin study and immunohistochemical study. Results: In vital dye group, the rate of identification was 85% and false negative rate of 16,7%. The rates were 95%, 0% in lymphoscintigraphy + intraoperative gamma probing group and 100%, 0% in combined group, respectively. Conclusions: We determined % 100 identification rate in combined group due to applicating 5 ml. blue dye to peritumorally + subdermally and applicating 1 ml. isotope to peritumorally. We propose to combine technique with this applicating road for sentinel lymph node biopsy.

Minimally invasive procedures in thyroid surgery

Mete D�ren, Serdar Giray, Adem Karata�, Haluk Toygarl�, Erol D�ren — 2007-10-01

Purpose: Since T. Kocher (1841-1917) bilateral/unilateral lobar resection is the golden standard of thyroid surgery. Nevertheless there are attempts to introduce minimal invasive surgery into endocrine surgical procedures. Regarding surgical procedures, minimal access thyroidectomy (MAT) or videoassisted thyroidectomy (MIVAT) can be performed if there is a solitary nodule, smaller than 35 mm, low risk papillary cancer smaller than 1.5 cm and thyroid volume is 20 ml or less.Relative contraindications are history of irradiation, previous thyroid surgery, thyroiditis and a short neck. Material and Method: Between January 2005-June 2007 154 patients were operated using minimal access technique and videoassisted techniques. Between January 2006 and June 2007 52 thyroidectomies using videoassisted technique were performed. These were 15 % of the whole series of thyroidectomized patients during the same period (52 MIVAT, 102 MAT). Result: There were 132 female-22 male patients with a mean age of 35 (21-52) years. The mean operative duration was for lobectomy 37 min (22-53) p<0.001, for bilateral thyroidectomy 48 min (40-62) . The mean nodule diameter was 3.1cm (0,5-3,9). The pathology of the resected specimen were 41 colloid nodules, 73 follicular adenoma, 11 H�rthle cell adenoma, 1 Follicular thyroid cancer, 4 Basedow-Graves, 23 papillary thyroid cancer. Patients with history of previous thyroid operation, with thyroid cancer larger than 1.5 cm, with benign thyroid nodule larger than 3,5 cm were excluded.Completion thyroidectomy was performed in one patient after two months. A pretracheal hematoma occurred in one patient, transient nerve injury occured in 1,3% ( 3 months ), transient hypoparathyroidism occurred in 8,4 %, no persistent hypoparathyroidism and no persistent paralysis was observed. Thyroid volume (>25cc) was found to be the most important limitation and contraindication for the technique. Conclusion: As for today, MAT or MIVAT is significantly superior regarding operative duration to standard surgery based on the technology used for vascular occlusion.It is an important advantage of the technique to reduce the incision up to 75 %.Regarding complications, hospitalization and pain medication there is no significant difference between minimal access, videoassisted and standard techniques.

Retrograde intussusception into the jejuno-jejunal anastomosis

Alper Akcan, H�z�r Aky�ld�z, Erdo�an S�z�er, Can K��k, Y�cel Ar�ta� — 2007-10-01

In this study, two cases of retrograde intussusception of distal efferent limb into jejuno-jejunal anastomosis are presented. To the best of our knowledge, these are the first two cases of jejuno-jejunal retrograde intussusception without gastric resection and a predisposing lesion. Patients was 37 and 33 year old men who were admitted with epigastric pain and vomiting for 2 and 3 days. Patients had a history of non-resective gastric surgery 6 and 11 years before admission due to peptic ulcus. In first and second case, manual reduction, and segmental resection with end-to-end anastomosis were performed, respectively.

A rare cause of intestinal obstruction: Paracecal hernia

Nilay Sefa U�ar, B�lent C. Y�ksel, Yi�it Y�ld�z, S�leyman Hengirmen — 2007-10-01

Intestinal obstruction due to internal herniations is rare. Internal herniations either congenital or acquired account for a small portion of small bowel obstruction ranging from 0.6 to 5.8 %. Approximately, paracecal herniations are responsible for 2% of these. It is usually diagnosed at laparotomy and emergent surgical therapy is needed. Four areas are reported for paracecal herniations: 1) superior ileocecal recess 2) inferior ileocecal recess 3) retrocecal recess 4) paracolic gutter. Sixty-two years old male patient who had an appendectomy 50 years ago was admitted to emergency service with acute abdomen. Clinically, there was mechanical ileus secondary to the internal herniation due to the defect in paracolic gutter; at the laparotomy what we have found was ileum necrosis. In the recent reviews one case was reported due to herniation at paracolic gutter after appendectomy. In conclusion; paracecal herniation should be considered in adult patients with intestinal obstruction and previous appendectomy.

“Multinod�ler guatr nedeniyle ameliyat edilen hastalarda insidental tiroid karsinomu”

Bekir Kuru — 2007-10-01

“Hacettepe �niversitesi T�p Fak�ltesi Genel Cerrahi Anabilim Dal�”

Atilla Engin — 2007-10-01