Turkish Journal of Surgery - 2010; 26(1)

De�erli Meslekta�lar�m�z

�skender Sayek, Feza Remzi, Ertu�rul G�ksoy, Sad�k K�l��turgay — 2010-01-01

Mechanical intestinal obstruction: etiology and clinical results

B�lent Kaya, Yal�m U�tum, R�za Kutani� — 2010-01-01

Purpose: To find out the etiology and clinical findings of patients who were operated due to mechanical intestinal obstruction Patients and Methods: A total of 68 patients operated for mechanical intestinal obstruction between 2001 and 2008 were studied retrospectively. Patients were evaluated with the medical history, physical examination, hemogram, biochemical tests, and abdominal Xray. The data about etiologies, clinical features, treatment modalities, morbidity and mortality rates were collected. Results: There were 36 men (52.9 %) and 32 women (47.1 %). The location of obstruction was the small intestine in 83.8 % and the large bowel in 16.2 %. Abdominal wall hernias were the most common (52.9 %) cause of intestinal obstruction in this study. Adhesions (19.1%) and malign lesions (18%) were the other common pathologies. The most common postoperative complication was wound infection. Sepsis, multiorgan disfunction, ileus and pneumonia were other complications. Mortality occurred in 3 patients (4.3%). Conclusion: Incarcerated abdominal wall hernias comprised the most common etiological factor in mechanical intestinal obstruction in our country. Figuring out the causes of morbidity and mortality will increase the success rates of the treatment.

The importance of magnetic resonance imaging in multifocal/multicentric breast cancers

S�leyman Bozkurt, Harun Altunta�, Mehmet Altan Kaya, Tuba Atak, Halil Co�kun — 2010-01-01

Purpose: To assess the sensitivity of diagnostic tools in detection of multicentric/multifocal foci in breast cancer. Patients and Methods: The study is conducted retrospectively in 209 breast cancer patients operated in our clinic between 2006 – 2009 to detect multicentric/multifocal tumors. The ages of patients, the number of tumor foci, the sizes of tumor foci and the invasiveness of the carcinoma have been identified. Evaluation of the sensitivity of the diagnostic methods in detecting the tumor foci was performed based on the pathological reports of the breast cancer patients. Results: Forty patients out of the 209 breast cancer cases were detected to have multifocal/multicentric tumor foci and the number of foci detected was 88. The mean age of the patients was 54.1�14.87 years and the age range was 33 – 87 years. The most prominent number of foci is 2 (85%). The tumor was invasive in nature in 81.8% of the foci. The most sensitive imaging technique to detect the multifocal/ multicentric foci was magnetic resonance imaging (94.3%). The sensitivity of ultrasonography, mammography and physical examination in detection of multifocal/multicentric foci were 80.7%, 78.4% and 48.9%, respectively. Moreover, magnetic resonance imaging was found to be successful in detecting all tumor foci over 5 mm in size, independently from the invasiveness of the carcinoma. Conclusion: Magnetic resonance imaging is a successful imaging method in effective surgical treatment of breast cancer for detecting multifocal/multicentric tumor foci.

Complications after thyroidectomy and the affecting factors related with the surgeon

2010-01-01

Purpose: In this study we investigated the complications after thyroidectomy operations performed in our clinic and 7 other clinics, and the affecting factors related with the surgeon. Patients and Methods: In our study we investigated 265 patients who underwent thyroidectomy between January 2008 and October 2009. and were followed for at least 12 months. The surgeons were classified into two groups as experienced (Group 1), who work in a center performing at least 40 thyroidectomy operations in one year; and less experienced (Group 2), who work in a center performing less than 40 thyroidectomy operations in one year. Experience of the operation team (the surgeon), and duration of the operation were assessed for their effects on paralysis of the vocal cord and hypocalcaemia. Results: Of the 265 patients 222 (83.7%) were female and 43 (16.3%) were male. Mean age was 44.72�11.32 years. Twelve patients had vocal cord paralysis. Three patients from Group 2 and one from Group 1 experienced seroma and wound infections were observed in both groups. One patient from Group 1 and eleven patients from Group 2 complained about changes in voice. In cases where the operations had lasted longer than 90 minutes, the increase in nerve injury incidence was statistically significant (p=0.03) in group 1. While the effect of the operation team's experience was statistically significant (p=0.005) on the laringeal n.recurrence injury, no statistical significance was noted (p=0.82) on temporary hypocalcaemia. Permanent complication(s) occurred in 3.7% in our series (hypoparathyroidism [n=6] and n. recurrence injuries [n=4] in group 2). Overall, the most frequent complication following thyroidectomy was temporary hypocalcaemia, observed in 6.3% of the patients. It was followed by failure in voice pitching detected in 4.5% of the cases. Conclusion: Experience, obsession and cautiousness are the most important factors that may decrease the complication risk in total thyroidectomy.

Pancreaticoduodenectomy experience in a low-volume center for pancreatic resection

H.Hakan Mersin, Emin Y�ld�r�m, Fikret �rkin, U�ur Berbero�lu, Kaptan G�lben — 2010-01-01

Purpose: The aim of this study was to evaluate the experience in pancreaticoduodenectomy in a low volume hospital for pancreatic resection. Patients and Methods: The hospital charts of the patients with periampullary and pancreatic head and neck cancer that underwent pancreaticoduodenectomy (group 1) or palliative surgical treatment (group 2) from January 1999 to December 2002 were retrospectively reviewed. Morbidity and mortality rates of the surgical procedures, and the patients' outcomes were evaluated. Kaplan-Meier method was used for survival analyses. Results: There were 22 patients in group 1 and 13 patients in group 2. The operative mortality and morbidity rates for group 1 were 13.6% and 34.6%, respectively. There was no operative mortality and/or morbidity in group 2. The median overall survival (OS) rate 41 months (%95 CI: 28-56) for group 1 and 6 months (%95 CI: 5-7) for group 2 (p<0.0001). Whereas 5-year overall survival was 76% (�0.09) in the first group, 6-months overall survival was 31% (�0.1) in the second group (p<0.0001). Conclusion: Although, pancreaticoduodenectomy has a higher mortality in low-volume hospitals for pancreatic resection, as in this study, it still remains the most effective treatment in periampullary and pancreatic head and neck cancers and improves the clinical outcome.

Operative treatment of rectal injuries according to the localization of injury

2010-01-01

Purpose: Controversy still persists regarding the management of rectal injuries. In this study we intend to discuss a selective approach to rectal injuries according to their localization. Patients and Methods: A retrospective analysis of patients with full-thickness rectal injuries managed between 2000 and 2008 was carried out. Etiology, localization, extent of trauma, and treatment modalities were reviewed. Results: Seventeen patients were included in the study. The mechanisms of injuries were penetrating in 12 patients [gunshot (n=7) and stab (n=5)], blunt in three patients, iatrogenic in one patient and foreign body in one patient. Concomitantly, other organ injuries were present in eight (47%) patients. The extraperitoneal wounds (n=12) were managed with colostomy (6), colostomy and transabdominal repair (3), transanal repair (2) and transanal repair with presacral drainage (1). Combined intra- and extraperitoneal lesions (n=1) were treated with colostomy only, whereas intraperitoneal lesions (n=4) were managed with colostomy (1) and transabdominal primary repair (3). Presacral drainage was added to colostomy and primary repair in only three patients. Morbidity occurred in three (17.8%) patients. There was no death. Conclusion: We concluded that most of the intraperitoneal localized rectum injuries can be managed by primary repair alone. Extraperitoneal wounds should be managed by colostomy with primary repair of rectum, when possible. Presacral drainage was added to colostomy in destructive or late extraperitoneal wounds.

The effectiveness of using spot urinary 5-HIAA level in the diagnosis of acute appendicitis

2010-01-01

Purpose: The aim of the study is to investigate the significance of spot urine 5-hydroxy indolacetic acid levels in patients admitted with the suspicion of acute appendicitis. Patients and Methods: Seventy-two patients with a mean age 32.52�12.9 years who were admitted to our emergency surgery clinic between May 2009 and July 2009 with the complaints of abdominal pain were evaluated prospectively. The study was approved by the local ethics committee of our institution. The results were analyzed with NCSS 2007&PASS 2008 statistical software program. Results: After the clinical evaluation, appendicitis was detected in 45 patients and abdominal pain was found to be due to causes other then appendicitis in 26 patients. Spot urine samples were collected in all patients at the admission. The differences in the spot urine 5-hydroxy indolacetic acid levels between the patients with acute appendicitis and other groups were not statistically significant (p>0.05). Spot urine 5-hydroxy indolacetic acid level test was found to be 69.3% sensitive, 40% specific, and had a positive predictive value of 69.23% and diagnostic specificity of 50.7%. Conclusion: Spot urine 5-hydroxy indolacetic acid levels in the diagnosis of acute appendicitis appear to have a limited diagnostic power as a single parameter in adults.

Gastrointestinal stromal tumor: Evaluation of 5 cases

2010-01-01

Purpose: The aim of this study was to analyze and discuss the clinical findings and the treatment in five patients with GIST in view of current literature. Patients and Methods: We retrospectively analyzed five patients with GIST who were followed and treated between 2008-2009 in our clinic. Results: We herein report five patients (4 males and 1 female) with a median age of 66.2 years (range, 58-73 years); 4 with tumors located in stomach and 1 in small intestine. Symptoms were not typical and depended on the localization and size of the tumor. Tumor sizes ranged between 3 and 10 cm (average 5.6 cm). Positivity rates for CD117 and CD34 expression determined by immunohistochemical methods were 80%. CD117 and CD34 expression was negative in one patient (%20). Five cases underwent complete tumor resection. In one case, where histopathological results showed low risk, the tumor was resected laparoscopically. The other patients were treated by open surgery. In one case a small intestinal stromal tumor was localised in the ileum. Segmental resection of the involved portions of the intestine was performed. In one patient, enlarged perigastric LNs were detected during laparotomy and the patient underwent total gastrectomy with en bloc perigastric LN dissection. Lymph node metastasis was observed in 5 of 12 resected perigastric nodes. No recurrence or metastasis has been detected during 6 months postoperative follow-up. No lymph node metastases were observed in the other patients. Conclusion: The prognosis of GIST depends on its size and mitotic activity. Surgical resection along with imatinib mesylate therapy is the best treatment for GIST. Complete surgical resection with negative tumor margins is the principal curative procedure for primary and non-metastatic tumors.

Non-operative management of high grade blunt liver trauma: Case report

Mircelal Kaz�mi, Sava� Yakan, Rasim Farajov, Murat K�l�� — 2010-01-01

In spite of its well-preserved anatomical position, liver is the most frequently damaged intraabdominal organ in a blunt abdominal trauma. Blunt liver trauma can be an important cause of morbidity and mortality. Recently, with the progress in the imaging techniques for solid organ traumas and the intensive care units, treatment choices have changed direction from surgical to nonsurgical treatments in hemodynamically stable patients with a blunt liver trauma. In this paper, we report a case admitted to the General Surgery Intensive Care Unit with high grade (Grade 4) liver trauma due to falling from a high place who was treated conservatively and discuss the case in the light of the current literature.

Squamous cell carcinoma of the gallbladder, incidental detection: A case report

Abdullah B�y�k, �zgen Arslan Solmaz, Mehmet Emin Meng�c�k, Oktay Banl� — 2010-01-01

Despite their low incidence, gallbladder cancers have a poor prognosis. About 1.4% to 10.6% of these cancers consist of cancers with squamous differentiation. Although rare, cancers with squamous differentiation have a more aggressive course than the other gallbladder cancers. We present here a case of a 62 years old woman who underwent laparoscopic cholecystectomy with the diagnosis of cholelithiasis. Histopathological examination revealed squamous cell cancer at the gallbladder. Since the case was staged as I according to the TNM classification, no further treatment was done. This patient was incidentally diagnosed to have a squamous cell gallbladder cancer and she is disease-free at the eight-month follow- up visit after the operation.

Gallbladder stone disease developing after orthotopic cardiac transplantation: Is laparoscopic cholecystectomy a safe procedure? A Case Report

Zafer Teke, Orhan Hayri Elbir, Erol Aksoy, Erdal Birol Bostanc� — 2010-01-01

Cardiac transplant surgery is being performed with increasing frequency as a treatment for end-stage heart diseases. In addition to the well-known post-surgical problems of rejection and infection, these patients may present at a future date with other medical problems which require surgical treatment, including biliary stone disease. Patients undergoing heart transplantation may be prone to general surgical complications. Biliary tract diseases are among the most frequently reported complications and may be associated with significant morbidity and mortality, especially in the early period after transplantation. The spectrum of problems ranges from asymptomatic cholelithiasis to fulminant cholecystitis, cholangitis, and gallstone pancreatitis. We herein report a 36-year-old immunosuppressed heart transplant patient who underwent successful laparoscopic cholecystectomy for gallbladder stones.

Merkel cell carcinoma with a rare localization: A case report

Cemal Kara, T�rker Karabu�a — 2010-01-01

Merkel cell carcinoma is a rare cutaneous malignancy. It is quite invasive and presents with high grade local recurrence, regional lymph node and distant metastases. Although the treatment strategy is not clear yet, wide excision of the tumor is the standard procedure. We present a case of a 78 years old male patient. The tumor originating from the subcutaneous tissue was located in the perianal region.

Stoma bak�m hem�iresi

Ayi�e Karada� — 2010-01-01