[Show abstract][Hide abstract] ABSTRACT: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. They can arise from any part of the tract as well as the omentum, mesentery or retroperitoneum. In this study, we present a case of a GIST originating from an extraordinary site, the pancreas. Evaluation of 30-year-old man with complaints of abdominal distension revealed a cystic, distal pancreatic lesion 13 cm in diameter. There were no intra-abdominal or distant organ metastases. The patient was operated with a diagnosis of cystic pancreas tumor, distal pancreatectomy and splenectomy was performed. The lesion was diagnosed as gastrointestinal stromal tumor upon histopathological examination. He was discharged on the sixth postoperative day without any complications and is being followed up for 21 months without systemic or local recurrence. Extragastrointestinal GISTs are reported rarely. To our knowledge, only one pancreatic GIST has been reported previously in the English literature.
Preview · Article · Apr 2013 · Turkish Journal of Surgery
[Show abstract][Hide abstract] ABSTRACT: Background:
Pregnant women may experience an acute presentation of hepatic hydatid disease. The available literature is limited to case reports.
The charts of 7 patients who underwent urgent treatment for hepatic hydatid disease during pregnancy between 1992 and 2010 were reviewed.
The median patient age was 27 (range 23-39) years and median gestational age was 18 (range 13-24) weeks. The symptoms were severe abdominal pain (4), vomiting (2), jaundice (2), pruritus (2) and severe dyspepsia (1); in the asymptomatic patient, a closed intraperitoneal rupture had been detected during gynecologic ultrasonography. Surgical drainage of the cysts was performed in all cases. The two patients with frank biliary rupture underwent choledochoduodenostomy or Roux-Y hepaticojejunostomy. Four patients required postoperative tocolysis. Albendazole was not used. All mothers gave birth to healthy babies at term. The patients were followed for a median of 9 (range 4-19) years. Two patients developed recurrences at 2 and 7 years; these were treated with surgical drainage and albendazole.
This entity entails the responsibility of two human beings. Although it imposes limitations on the routine diagnostic and therapeutic options due to risk of premature labor or teratogenicity, acceptable results can be obtained in collaboration with the department of obstetrics and gynecology.
Full-text · Article · Mar 2013 · Ulusal travma ve acil cerrahi dergisi = Turkish journal of trauma & emergency surgery: TJTES
[Show abstract][Hide abstract] ABSTRACT: Pheochromocytomas can be a part of familial neoplastic syndromes, in which case they tend to be multiple and involve both adrenal glands. Therefore, sparing adrenocortical function represents a major concern while dealing with these hereditary lesions. Herein, we describe the clinical characteristics and the management strategy of a patient with von Hippel-Lindau (VHL) disease who had multiple, bilateral pheochromocytomas as well as bilateral renal masses, pancreatic masses, and a paracaval mass. Only a portion of the left adrenal gland has remained in situ after two consecutive open surgeries and a percutaneous radiofrequency ablation which have been performed to treat the various components of this syndrome. No adrenal or extra-adrenal pheochromocytoma recurrences have been detected during a follow-up period of more than 2 years. Pancreatic and adrenal functions were normal throughout the postoperative period and never necessitated any replacement therapy. Adrenal cortex-sparing surgery is a valid option for VHL disease patients who present with synchronous bilateral adrenal pheochromocytomas.
Full-text · Article · Oct 2012 · Case Reports in Medicine
[Show abstract][Hide abstract] ABSTRACT: Primary pancreatic lymphoma (PPL) is a rare tumor that usually presents with the clinical picture of advanced adenocarcinoma but has a much better prognosis. A 38-year-old man was referred after percutaneous transhepatic external biliary drainage for obstructive jaundice. Abdominal magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography had revealed a 5-cm pancreatic head mass that caused biliary tract dilation. Computed tomography angiography showed that the mass encased the celiac trunk as well as the common hepatic and splenic arteries. MRI also revealed a metastatic lesion at the third lumbar vertebra. Serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels were within normal range. The initial diagnosis was inoperable pancreatic adenocarcinoma; however, Tru-Cut pancreatic biopsy showed a large B cell lymphoma. After 6 sessions of chemotherapy and 21 sessions of radiotherapy, both the pancreatic mass and the vertebral metastasis had disappeared. However, he had persistent distal common bile duct stricture that could not be negotiated by either the endoscopic or percutaneous route. A Roux-en-Y hepaticojejunostomy was performed. The patient stayed alive without recurrence for 52 months after the initial diagnosis and 45 months after completion of oncologic treatment. In conclusion, a large pancreatic mass with grossly involved peripancreatic lymph nodes, without ascites, liver or splenic metastasis, should alert the clinician to the possibility of PPL. Cure is possible by chemoradiotherapy even in the presence of vertebral metastasis. Persistent stricture in the distal common bile duct may require a biliodigestive anastomosis.
Full-text · Article · Sep 2011 · Case Reports in Gastroenterology
[Show abstract][Hide abstract] ABSTRACT: To investigate the eligible management of the cystic neoplasms of the liver.
The charts of 9 patients who underwent surgery for intrahepatic biliary cystic liver neoplasms between 2003 and 2008 were reviewed retrospectively. Informed consent was obtained from the patients and approval was obtained from the designated review board of the institution.
All patients were female with a median (range) age of 49 (27-60 years). The most frequent symptom was abdominal pain in 6 of the patients. Four patients had undergone previous laparotomy (with other diagnoses) which resulted in incomplete surgery or recurrences. Liver resection (n = 6) or enucleation (n = 3) was performed. The final diagnosis was intrahepatic biliary cystadenoma in 8 patients and cystadenocarcinoma in 1 patient. All symptoms resolved after surgery. There has been no recurrence during a median (range) 31 (7-72) mo of follow up.
In spite of the improvement in imaging modalities and increasing recognition of biliary cystadenoma and cystadenocarcinoma, accurate preoperative diagnosis may be difficult. Complete surgical removal (liver resection or enucleation) of these lesions yields satisfying long-term results.
Full-text · Article · Jan 2011 · World Journal of Gastroenterology
[Show abstract][Hide abstract] ABSTRACT: We report our success with somatostatin and propranolol to treat small-for-size syndrome that occurred despite splenic artery ligation. A 48-year-old woman with cirrhosis due to autoimmune hepatitis underwent living-donor liver transplant; her graft-to-body weight ratio of the right lobe was 0.91%. After arterial reperfusion, portal pressure and flow were 24 cm H20 and 2.22 L/min (ie, 360 mL/100g graft/min), respectively. Following splenic artery ligation, the portal pressure decreased to 16 cm H20 and portal flow to 1.74 L/min (ie, 282 mL/100g graft/min). On the second postoperative day, small-for-size syndrome was diagnosed based on the marked prolongation of prothrombin time (international normalized ratio, 4.4), hyperbilirubinemia (359.1 micromol/L), rapid escalation of transaminases (alanine aminotransferase 2488 U/L, aspartate aminotransferase 1075 U/L) and very high portal flow rate (> 90 cm/sec). Oral propranolol (40 mg/day b.i.d.) and somatostatin infusion (250-microgram bolus followed by perfusion at a rate of 250 microgram/h for 5 days) were started. Prothrombin time and transaminase levels began to decrease the following day, although the bilirubin level increased to 495.9 micromol/L before returning to normal. The patient was discharged in excellent health 5 weeks after surgery. Despite reduction of portal pressure by splenic artery ligation, small-for-size syndrome may develop in patients with persistent high portal flow. To the best of our knowledge, this is the first report of the successful treatment of small-for-size syndrome by somatostatin and propranolol in the clinical setting.
No preview · Article · Dec 2007 · Experimental and clinical transplantation: official journal of the Middle East Society for Organ Transplantation
[Show abstract][Hide abstract] ABSTRACT: Human cystic echinococcosis (CE) continues to be a major health problem in developing countries. A review of current literature discloses four alternatives for the management of active CE, consisting of surgery, percutaneous treatment (PT), chemotherapy, and follow-up without intervention, but no clear guidelines for directing patients to the different management options. Palliation of symptoms or prevention of complications is the main rationale for the treatment of CE. Surgery has long been considered as the gold standard treatment. However, a meta-analysis comparing the clinical outcomes of patients treated with PT with those of a control group treated with surgery found PT to be more effective, safer, and cheaper. Medical therapy is considered to be ineffective when the criterion of success is defined as the disappearance of the lesion. However, medical therapy seems to be effective when the goal of therapy is defined as the prevention of complications in asymptomatic patients. We propose an algorithm for therapy planning in CE where the first line of therapy for patients with active lesions is PT. Patients with lesions unsuitable for PT are directed to surgery if they are symptomatic, have complicated lesions or have lesions that are prone to rupture. Asymptomatic patients with uncomplicated lesions are directed to medical therapy. Medical therapy failures are redirected to surgery.
Full-text · Article · Nov 2007 · CardioVascular and Interventional Radiology
[Show abstract][Hide abstract] ABSTRACT: Major bile duct injury during cholecystectomy represents potentially severe complications with unpredictable long-term results. If these lesions are not treated adequately, they can lead to hepatic failure or secondary biliary cirrhosis therefore requiring liver transplantation. We report a patient who required liver transplantation 15 years after open cholecystectomy. A l0-year old girl underwent open cholecystectomy and duodenal repair for cholelithiasis and cholecystoduodenal fistula. She required two surgical interventions, hepaticojejunostomy which was performed in another center and portoenterostomy for biliary stricture at our institution seven years after the cholecystectomy. Eight years after the third operation, she required recurrent hospitalization for treatment of hepatic abscesses. The extremely short intervals between the three life threatening episodes and the rapid progression to severe sepsis were taken into consideration and liver transplantation was performed at the age of 25. She is leading a healthy life at 4 years post transplantation. Although iatrogenic biliary injury can usually be treated successfully by a combination of surgery, radiological and endoscopic techniques, patients with severe injuries develop irreversible liver disease. This case report and review of the literature suggest that liver transplantation is a treatment modality for a selected group of patients with end-stage liver disease secondary to bile duct injury.
Full-text · Article · Sep 2006 · The Tohoku Journal of Experimental Medicine
[Show abstract][Hide abstract] ABSTRACT: Obstruction of a major hepatic vein, or major portal vein, or biliary tree branch causes atrophy of the related hepatic region, and frequently, hypertrophy in the remaining liver-the atrophy-hypertrophy complex (AHC). Whether hydatid cysts can cause AHC is controversial. The records of 370 patients who underwent surgery for hepatic hydatid disease between August 1993 and July 2002 were evaluated retrospectively. Excluding six patients with previous interventions on the liver, AHC had been recorded in the operative notes of 16 patients (4.4%); for all patients, a cyst located in the right hemiliver had caused atrophy of the right hemiliver and compensatory hypertrophy of the left hemiliver. The computed tomography images of seven patients were suitable for volumetric analysis. The median (range) right and left hemiliver volumes were 334 (0-686) ml and 1084 (663-1339) ml, respectively. The median (range) cyst volume was 392 (70-1363) ml. AHC due to Echinococcus granulosus was confirmed by objective volumetric analysis. The presence of AHC should alert the surgeon to two implications. First, pericystectomy may be hazardous due to association with major vascular and biliary structures. Second, in patients with AHC, the hepatoduodenal ligament rotates around its axis; this should be considered to avoid vascular injury if a common bile duct exploration is to be performed.
Full-text · Article · Apr 2006 · Journal of Gastrointestinal Surgery
[Show abstract][Hide abstract] ABSTRACT: A 55-year-old man was investigated for right upper abdominal quadrant pain. He had no history of abdominal trauma or surgery. Imaging studies showed a common hepatic artery aneurysm involving the gastroduodenal artery. Following aneurysmectomy, examination with a hand Doppler apparatus yielded clear arterial signals from the liver surface. Therefore, vascular reconstruction was not performed. He had an uneventful postoperative course.
Full-text · Article · Mar 2006 · The Journal of Medical Investigation
[Show abstract][Hide abstract] ABSTRACT: Iatrogenic factors became the leading mechanisms of severe cholangitis in a referral center.
The records of the 58 patients treated for severe cholangitis between 1996 and May 2004 (inclusive) were evaluated.
The most frequent underlying diseases were periampullary tumors and mid-bile duct carcinomas (22), followed by proximal cholangiocarcinomas (14). The triggering mechanism was an incomplete endoscopic retrograde cholangiopancreatography (ERCP) in 32 patients, incomplete or inappropriate percutaneous transhepatic biliary drainage (PTBD) in 6, apparently successful ERCP and stenting in 1, and percutaneous transhepatic cholangiography in 1. PTBD was the treatment of choice (38). Mortality was 29% (17/58); the major causes were refractory sepsis (8) and incomplete biliary drainage (advanced tumor, technical failure, or hemobilia) (8).
In this series composed predominantly of patients referred after development of sepsis, ERCP and PTBD complications were the leading mechanisms of severe cholangitis. Nonoperative biliary manipulations are invasive procedures with potentially fatal complications. The decisions to perform such procedures and periprocedural management are responsibilities of an experienced multidisciplinary team.
No preview · Article · Jul 2005 · The American Journal of Surgery
[Show abstract][Hide abstract] ABSTRACT: Autoimmune pancreatitis is an evolving entity.
A patient who had spontaneous regression of a pancreatic head mass and biliary obstruction due to autoimmune pancreatitis is presented.
A 58-year-old diabetic woman with jaundice was referred for pancreatic head carcinoma diagnosed by magnetic resonance imaging (MRI). At laparotomy, a pancreatic head mass (4 x 3 cm) that involved the transverse mesocolon and two other hard masses (1 cm) in the pancreatic body and tail were found. The gallbladder was palpated as a hard tumor mass. Frozen section examination of the gallbladder and pancreatic biopsies revealed cholecystitis and pancreatitis with lymphoplasmacytic infiltration. The common bile duct was brittle and unsuitable for anastomosis. Starting 1 month after the operation, drainage from the biliary catheter decreased gradually and stopped. There was no parenchymal lesion on MRI examination in the 2nd postoperative month. Cholangiography from the percutaneous catheter showed flow of contrast agent into the duodenum. Serum immunoglobulin G, G4 and E levels were increased.
To the best of our knowledge, this is the first report of spontaneous regression of a pancreatic head mass and biliary obstruction due to autoimmune pancreatitis.
[Show abstract][Hide abstract] ABSTRACT: We presented our experience with definitive treatment of traumatic biliary injuries.
Six male patients (mean age 13 years; range 2 to 32 years) who were referred to our unit for definitive treatment of traumatic biliary injuries were retrospectively evaluated. Data were analyzed in terms of demographic characteristics, mechanisms of injuries, associated injuries, previous treatments, symptoms on admission, treatment at our unit, and the results of treatment. Outcome was assessed using modified Schweiser and Blumgart criteria.
The injuries were due to blunt abdominal trauma in all the patients but one who had a gunshot wound. In three patients, biliary injuries were missed at the initial operation. On admission, three patients had external biliary fistulas, two had biliary strictures. One patient was sent following inadvertent ligation of the hepatoduodenal ligament during attempts to control hemorrhage. Roux-en-Y hepaticojejunostomy was performed in three patients. Percutaneous biloma drainage was performed in two patients, resulting in fistula closure in 13 and 40 days, respectively. One patient was treated by endoscopic retrograde cholangiopancreatography and papillotomy, which enabled fistula closure in three days. One patient was lost to follow-up. One patient died from hepatic failure 11 years after the trauma. At the end of a mean follow-up of 49 months (range 15 to 75 months), three patients were in excellent condition, while one patient experienced occasional attacks of cholangitis.
In patients with undetected biliary injuries and in those with unsuccessful repair attempts, biliary reconstruction should be performed in experienced hepatopancreatobiliary surgery units.
Full-text · Article · Nov 2004 · Ulusal travma ve acil cerrahi dergisi = Turkish journal of trauma & emergency surgery: TJTES
[Show abstract][Hide abstract] ABSTRACT: We describe a 5-year-old boy who complained of severe abdominal pain after a car accident. He was sitting on the lap of the driver and his abdomen was pressed closely between the pregnant driver and the steering wheel. At operation, associated injuries to the duodenum and pancreas were detected which could not be repaired. The transected pancreas and extensive duodenal injury underwent a Whipple-type reconstruction. On postoperative day six, the patient was re-operated due to extensive liver necrosis which was detected on abdominal computerized tomography and a partial liver resection was performed. He was discharged on day 16 after the second operation and has done well so far.
No preview · Article · Sep 2004 · European Journal of Pediatric Surgery
[Show abstract][Hide abstract] ABSTRACT: Fatty tissue within the internal cremasteric fascia is frequently encountered during hernia surgery, and it is called a cord lipoma in the surgical literature. Between 1997 and 2001, 128 consecutive patients with 139 indirect inguinal hernias, who underwent open repair, were evaluated. A total of 100 lipomas of the spermatic cord or round ligament were identified and resected in 92 patients. There were no reported neoplastic changes noted in histopathologic examinations of the specimens. The incidence of cord lipoma associated with indirect inguinal hernia was 72.5%. Average body mass index (BMI) was 25.7 in patients with lipoma and 24.6 in patients without lipoma ( P=0.048). The incidence of cord lipoma in large hernias (Nyhus Type II and IIIb) was higher in our patients ( P<0.005). It can be clearly seen during laparoscopic exploration of the preperitoneal space that cord lipoma is a continuation of extraperitoneal fat tissue. We believe that even if there is no peritoneal sac, the herniation of extraperitoneal fat through the inguinal canal should be counted as an inguinal hernia, and it requires treatment.
[Show abstract][Hide abstract] ABSTRACT: To evaluate treatment results in iatrogenic biliary injuries with concomitant vascular injuries.
Between January 1998 and May 2002 (inclusive), angiography was performed in 45 of the 105 patients treated for iatrogenic biliary tract injury. The charts of these 45 patients and 5 other patients in whom vascular injury was diagnosed at operation were evaluated retrospectively. Twenty-nine patients had concomitant vascular injury, the biliovascular injury group (BVI), and the remaining 21 patients had isolated biliary tract injury (IBTI).
The most frequent initial operation was a cholecystectomy. The frequency of high-level (Bismuth III or IV) strictures was 90% in the BVI group and 62% in the IBTI group ( P<0.05). Perioperative mortality was 7% in the BVI group and 5% in the IBTI group ( P>0.05). The morbidity in the BVI group was significantly higher ( P<0.05). Two patients in each group were lost to follow up. During a median (range) follow up of 31 months (5-51 months), a successful functional outcome was achieved in 96% of the BVI group and 100% of the IBTI group with a multimodal approach ( P>0.05).
The frequency of high-level biliary injury and morbidity were significantly higher in the BVI group. However, concomitant vascular injury had no significant effect on mortality and medium-term outcome of biliary reconstruction. Thus, routine preoperative angiography is not recommended.
No preview · Article · Sep 2003 · Langenbeck s Archives of Surgery
[Show abstract][Hide abstract] ABSTRACT: Background: Radical resection is the only potentially curative treatment for hepatic alveolar echinococcosis (AE). Although Turkey is an endemic region, population screening is not performed and early diagnosis is rare. Consequently, surgeons are compelled to explore possibilities such as near-total resection and biliodigestive anastomosis for palliation of jaundice. Methods: Surgery was performed in 32 patients with hepatic AE with the following indications: (1) resection; (2) palliation of jaundice; (3) definite assessment of operability; (4) failure in the management of cavity infection by percutaneous methods. Curative resection (R0 = complete resection of all parasitic mass [n = 9], and R1 = a resection in which a small remnant was left on a vital structure [n = 8]) were performed in 17 patients, intrahepatic cholangiojejunostomy in 7, laparotomy-external drainage in 7, and debulking in 1. Results: Perioperative mortality rates were 2/17, 0/7, 2/7 and 1/1, respectively. Twelve patients in the curative resection group are alive without recurrence/progression of the small remnant during a median follow-up of 59 (range 27–116) months. One patient developed an inoperable recurrence that was treated with albendazole. One patient was lost to follow-up. Long-term albendazole treatment was effective in all R1 patients except a patient who had slow asymptomatic progression. Successful palliation of jaundice was achieved in 5 of the 7 intrahepatic cholangiojejunostomy patients. Conclusions: The results of R1 resection in alveolar hydatid disease are similar to those of R0 resection; a small remnant is successfully controlled by albendazole. In patients with jaundice due to hilar invasion, biliary diversion from segment 3 or 5 is effective for palliation of the jaundice and facilitates albendazole treatment.
No preview · Article · Jul 2003 · Digestive Surgery