P-1206
A rare complication after gastrectomy: Unilateral intrathoracic leak
Ahmet Can Yaşar
Clinic of General Surgery, İzmir City Hospital, İzmir, Türkiye
ABSTRACT
Objective: The incidence of postgastrectomy complications is 14% and ranges from superficial surgical site infection to septic shock. Anastomotic leakage from esophagojejunostomy after total gastrectomy is 1.51% and causes intra-abdominal abscess, peritonitis and enterocutaneous fistulas. Management of anastomotic leakage is important for prognosis.
Material and Methods: We report the nonoperative management of isolated right pleural anastomotic leakage from esophagojejunostomy in a patient who underwent total gastrectomy.
Results: A 60-year-old male patient with hypertension and BPH was hospitalized in our clinic because of a malignant diagnosis of biopsy and gastroscopy performed due to upper gastrointestinal bleeding, and gastroscopy revealed a mass causing gastric retention. Preoperative staging revealed a T4N3M1 tumor localized to the pylorus. Histopathological diagnosis was adenocarcinoma. Pet-ct showed metastatic lymph nodes in the upper lobe of the right lung. Total gastrectomy + Roux-en-Y esophagojejunostomy was performed. In post operative follow-up, the patient tolerated the r2 diet started on post op day three. On post op day five, dyspnea developed, and bilateral pulmonary effusion was observed on thorax CT. On post op day eight, right thoracic tube was inserted due to development of right hydropneumothorax. Piperacillin-tazobactam treatment was started by infectious diseases. On the 14th postoperative day, a 20 cm nitinol-coated stent was applied due to the detection of a defect in the esophagojejunostomy line on endoscopy. The patient was started on enteral nutrition with nasojejunal tube. On post op day 17, the thoracotube was replaced with a heimlich valve system and one additional drain was placed. Imipenem, teicoplanin and caspofungin were started on post op day 20. Daily lavage with sterile sf was performed in the thoracic tube. On post op day 34 oral intake was started. It was seen that he tolerated it. He was discharged on post op day 38 with drains. Drains were terminated at post op day 48. He was taken to oncology follow-up.
Conclusion: Anastomotic leaks after gastrectomy are a cause of mortality and morbidity. It should be kept in mind that leaks may be intraabdominal or intrathoracic, and diagnostic methods should be used accordingly. Early detection of leaks, shaping the treatment according to the localization and choosing the right treatment method are important in the management of patients. In conclusion, in addition to antibiotic therapy, washing and drainage through the thoracic tube provides treatment of empyema caused by intrathoracic leaks without the need for thoracoscopy or thoracic surgery.
Keywords: Gastrectomy, anostomotic leakage, gastrointestinal stent
P-2181
Incidental detection of jejunal diverticulum: A case report
Gökay Çetinkaya1 , Miraç Barış Erzincan1 , Mert Demirci2 , Mert Tezcan2 , İbrahim Burak Bahçecioğlu1 , Mehmet Ali Gülçelik1
1 Clinic of Surgical Oncology, Gülhane Training and Research Hospital, Health Sciences University, Ankara, Türkiye
2 Clinic of General Surgery, Gülhane Training and Research Hospital, Health Sciences University, Ankara, Türkiye
ABSTRACT
Objective: Jejunal diverticulosis was first described by Sommering and Baille in 1794. It is a rare upper gastrointestinal tract disease with an incidence of 0.06%-5%. It is most common in the 6th and 7th decades. Although it is usually asymptomatic, it may cause abdominal pain, nausea, vomiting and malabsorption. Diverticulitis is very rare due to the nature of the small intestinal contents. In this case report, it was aimed to present a patient with jejunal diverticulitis who was followed and treated in our clinic in the light of the literature.
Results: A 79-year-old male patient was admitted to the emergency department with complaints of abdominal pain, nausea and vomiting ongoing for two days. Laboratory tests revealed WBC 14 x 103 /μl and CRP 102.4 mg/L. Physical examination revealed tenderness in the left upper quadrant, but no defense and rebound were detected. The patient underwent opaque computed tomography for splenic infarction. CT scan revealed mesodontic contamination in the area localized in the anus of the proximal jejunum, minimal free fluid and an appearance compatible with diverticulum. The patient was hospitalized due to advanced age and presence of comorbidities. Oral intake was stopped and IV replacement and antibiotherapy was started. The patient’s mouth was opened gradually with no regression in infection parameters and no pathologic findings on physical examination. The patient who tolerated was discharged with recommendations.
Conclusion: Jejunal diverticulosis accounts for 8% of all small bowel diverticula. The incidence is 0.06%-5% in autopsy series and 0.02%-2.3% in radiologic examinations. The majority of patients are 70 years of age and older. It is considered a pseudodiverticulum. Factors such as peristalsis abnormalities and high intraluminal pressure are thought to play a role in the pathogenesis. They are usually asymptomatic. Depending on the extent of the diverticula, complications such as diverticulitis, perforation, intestinal bleeding and intestinal obstruction may occur. Patients with uncomplicated small bowel diverticulitis can be managed conservatively, similar to patients with colonic diverticulitis. Surgical treatment is the golden option in cases of jejunal diverticulitis perforation.
Keywords: Jejunal diverticulum, incidental
P-2544
Repair of tracheal coagulation necrosis defect with tutopatch: Case report
Miraç Barış Erzincan1 , Osman Bardakçı1 , Mehmet Dinçay Yar2 , Şebnem Çimen2 , Gökhan Giray Akgül1 , Şevket Barış Morkavuk1 , Mehmet Ali Gülçelik1
1 Clinic of Surgical Oncology, Gülhane Training and Research Hospital, Health Sciences University, Ankara, Türkiye
2 Clinic of General Surgery, Gülhane Training and Research Hospital, Health Sciences University, Ankara, Türkiye
ABSTRACT
Objective: Tracheal necrosis (TN) is a rare life-threatening complication of thyroidectomy. It is usually diagnosed in the early postoperative period with neck swelling or subcutaneous emphysema. To date, a limited number of cases have been reported worldwide. In delayed cases, severe stridor may be seen due to infection and edema. In this article, it was aimed to present a patient who developed tracheal necrosis after total thyroidectomy, bilateral central and left lateral lymph node dissection and reconstruction with tutopatch.
Results: A 50-year-old male patient was admitted to our clinic with a diagnosis of thyroid papillary ca. Pathologic lymph nodes were detected at left cervical level 2, 3 and 4. Total thyroidectomy + central lymph node and left lateral lymph node dissection was performed. On the 1st postoperative day, the patient complained of swelling and pain in the neck. Cervical CT was performed because of subcutaneous emphysema on physical examination. Loss of wall integrity was observed on the anterolateral side of the trachea. The patient was followed up conservatively, primarily with oral stop. Re-exploration was performed on the 2nd postoperative day due to an increase in emphysema. A loss of wall integrity due to electro-coagulation thermal damage of approximately 2-3 mm in the left anterior aspect of the trachea was observed. Since the tissues were severely edematous and fragile, primary closure and strep muscle flap were not considered. The defect was closed with Tutopatch after debridement. No recurrent emphysema or infection findings were observed in the follow-up of the patient. The patient was discharged on the 6th postoperative day.
Conclusion: Tracheal injury is a rare but mortal complication of thyroid surgery. This risk increases especially in cases with tracheal invasion. Although the use of bi-polar cautery reduces this risk, it does not reduce it to zero. Early diagnosis and treatment is life-saving. Treatment of tracheal necrosis is not standardized because of the rarity of complications. Treatment options depend on the severity of necrosis and the number of segments involved. The strep muscle flap can be rotated for small defects and the pectoralis flap can be used for larger defects. Repair with tutopatch is not yet available in the literature.
Keywords: Tracheal necrosis, tutopatch, flap
P-3571
Our experience with simultaneous laparoscopic cholecystectomy and TAPP inguinal hernioraphy
Burak Uçaner, Şebnem Çimen
Clinic of General Surgery, Gülhane Training and Research Hospital, Health Sciences University, Ankara, Türkiye
ABSTRACT
Objective: Laparoscopic cholecystectomy (LC) and inguinal herniorrhaphy with transabdominal pre-peritoneal (TAPP) hernia repair have an important place in general surgical practice. LC has been adopted as the gold standard surgical method for cholecystectomy worldwide. Laparoscopic inguinal herniorrhaphy techniques have also gained acceptance due to their unique advantages. In this study, it was aimed to share our clinical experience in patients who underwent combined LC and TAPP herniorrhaphy.
Material and Methods: Between January 2020 and January 2023, 16 patients with a diagnosis of inguinal hernia and gallstones or polyps in the gallbladder who were operated in the General Surgery Clinic of Gülhane Training and Research Hospital were included in the study. All patients underwent LC and then TAPP herniorrhaphy. The data of the patients were analyzed retrospectively.
Results: All 16 patients included in the study were males. Mean age of the patients was 43 years (29-58). Eleven patients were operated on for unilateral inguinal hernia and cholelithiasis, four patients for bilateral inguinal hernia and cholelithiasis, and one patient for unilateral inguinal hernia and gallbladder polyp. Surgery was performed with five ports in six patients and six ports in 10 patients. Mean operation time was 95 (70-175) minutes. None of the patients developed complications in the postoperative follow-up, and all patients were discharged with recovery. Mean duration of hospitalization was 1.5 (1-3) days.
Conclusion: According to the results of our study, there were no complications due to simultaneous surgery in patients diagnosed with inguinal hernia and cholelithiasis. Simultaneous operations are advantageous because of shorter mean operative time and lower cost. Simultaneous surgery can be safely performed in selected patients with inguinal hernia and cholelithiasis.
Keywords: Transabdominal pre-peritoneal (TAPP), hernia repair, cholecystectomy, laparoscopy
P-4383
Focal localization in a case of recurrent primary hyperparathyroidism: Combined use of Casanova test and indocyanine green angiography
Işık Çetinoğlu, Mehmet Taner Ünlü, Mehmet Köstek, Ozan Çalışkan, Nurcihan Aygün, Mehmet Uludağ
Clinic of General Surgery, Seyrantepe Hamidiye Etfal Training and Research Hospital, Health Sciences University, İstanbul, Türkiye
ABSTRACT
Objective: Recurrent primary hyperparathyroidism (rPHPT) is defined as the recurrence of hypercalcemia after a normocalcemic period of more than six months after parathyroidectomy. In symptomatic patients, the absolute treatment is surgery. Preoperative focal localization should be meticulously determined because of the high complication risk of reoperations. In this study, it was aimed to present the use of intraoperative indocyanine green (ICG) angiography and Casanova test for focal localization in rPHPT cases as a case report.
Material and Methods: A 44-year-old female patient with MEN1 syndrome underwent subtotal parathyroidectomy and thymectomy in 2006. In 2012, remnant resection and left forearm parathyroid transplantation were performed due to recurrence of remnant in the neck. Ultrasonography, scintigraphy and 4D-CT were performed due to the development of recurrence in the follow-up and no foci were detected. Therefore, it was decided to localize the focus by Casanova test. A tourniquet was placed on the proximal part of the left forearm where the remnant gland was located and blood was collected for parathormone (PTH) measurement from the left and right forearms at a systolic pressure of 150 mm-Hg for approximately five minutes. PTH was significantly higher in the left forearm compared to the right forearm. It was decided to remove the remnant in the left forearm. After intraveous ICG was administered to the patient, an uptake area was observed in the left forearm under autofluorescence camera. Foci of involvement were excised and sent for frozen examination. The smallest of the tissues confirmed as parathyroid tissue on frozen examination was transplanted to the right forearm. Intraoperative PTH decrease was also observed and the operation was terminated.
Results: Casanova test is one of the methods used in parathyroid surgery reoperations for focal determination when preoperative imaging methods are inconclusive. In the literature, it is generally used in recurrences of secondary hyperparathyroidism cases. In our study, the patient was operated because of the development of rPHPT due to MEN1 syndrome. The risk of complications increases in reoperations. With the help of ICG, the pathologic focus can be detected early and removed with a smaller dissection area. In our case, Casanova test and ICG angiography were used to reduce complications and to identify the focus, and the operation was completed without complications.
Conclusion: Preoperative localization of recurrent hyperparathyroidism is important for surgical safety. Casanova test can be used to determine the localization in these cases. ICG angiography can be used as an advanced method to reduce surgical complications.
Keywords: Primary hyperparathyroidism, indocyanine green angiography, Casanova test
P-4410
Rare tumors; biphasic synovial sarcoma originating from the abdominal wall
Elifcan Haberal1 , Osman Bardakçı1 , Muhammed Emin Birgün2 , Yasin Gülap2 , Şevket Barış Morkavuk1 , Mehmet Ali Gülçelik1
1 Clinic of Surgical Oncology, Gülhane Training and Research Hospital, Health Sciences University, Ankara, Türkiye
2 Clinic of General Surgery, Gülhane Training and Research Hospital, Health Sciences University, Ankara, Türkiye
ABSTRACT
Objective: Synovial sarcomas (SS) are malignant soft tissue neoplasms representing 5 to 10% of all soft tissue sarcomas with an incidence of 2.75 per 100.000. The adult population has been found to have the highest prevalence rate, with the extremities being the most common sites. The anterior abdominal wall is an unusual site for SS. After liposarcoma and rhabdomyosarcoma, SS is a rare type of soft tissue sarcoma. In fact, a literature review reported only four cases in 55 years. The aim of this case report was to highlight the rarity of this condition, the available treatment options, and to increase knowledge about this difficult malignant tumor among young surgeons. Synovial sarcoma of the abdominal wall is an aggressive type of cancer that often requires aggressive treatment.
Material and Methods: A 38-year-old female patient came to our outpatient clinic with a mass in the right upper quadrant that had been growing on the anterior abdominal wall for about four months, causing distension. Physical examination revealed an immobile hard swelling with a diameter of 8 cm which was thought to be associated with the anterior abdominal wall causing deformity in the right upper quadrant. As a result of the examinations, a 12.5 x 12.5 x 8.5 cm heterogeneous mass with a lobulecontoured 12.5 x 12.5 x 8.5 cm entering the abdominal cavity, which was thought to originate from the rectus sheath, was noted. Then the patient underwent total excision of the mass, including the anterior sheath of the rectusabdominis muscle, partial rib resection and repair with dual mesh.
Results: The pathology result was in favor of abdominal wall biphasic synovial sarcoma. The lesion size was 12 cm. Surgical margins were normal. After nine months of follow-up, no complications were observed.
Conclusion: Synovial sarcoma is a rare pathology with no specific findings both clinically and radiologically. The main treatment modality is surgery with healthy resection margins. Synovial sarcoma of the abdominal wall is among the rare tumors, so it is difficult to obtain a positive preoperative diagnosis due to the lack of specific clinical and radiological findings. Surgical treatment with intact surgical margins is the main treatment modality, followed by multidisciplinary management with appropriate chemotherapy and radiotherapy to prevent recurrence.
Keywords: Synovial sarcoma, abdomen, excision
P-4606
Posterior reversible encephalopathy syndrome after thyroidectomy: Case report
Elifcan Haberal1 , Gökay Çetinkaya1 , İlgin Demir2 , Bilgi Karakaş2 , Ebru Esen1 , Mehmet Ali Gülçelik1
1 Clinic of Surgical Oncology, Gülhane Training and Research Hospital, Health Sciences University, Ankara, Türkiye
2 Clinic of General Surgery, Gülhane Training and Research Hospital, Health Sciences University, Ankara, Türkiye
ABSTRACT
Objective: Posterior reversible encephalopathy syndrome (PRES) is a transient clinical picture that can be diagnosed by neurological examination and radiological imaging methods. Symptoms such as rapidly progressive headache, mental status changes, visual disturbances, paresis, nausea and generalized seizures are usually accompanied by hypertension. The pathophysiologic mechanism has not yet been fully clarified. Cases have been reported after pregnancy toxemia, organ transplantation, immunosuppressive therapies, systemic inflammatory response syndrome (SIRS), autoimmune diseases, porphyria, chemotherapy treatments and shock. In this article, it was aimed to present a patient who developed visual loss after thioidectomy operation and was diagnosed as pres.
Results: A 40-year-old male patient was admitted to our clinic with a diagnosis of toxic diffuse goiter. In his anamnesis, it was learned that he was treated for HT and epilepsy. Bilateral total thyroidectomy was performed under general anesthesia. The patient who showed hypertensive course in the postoperative period was taken to the intensive care unit. The patient described sudden visual loss in the 2nd postoperative hour. Neurologic examination revealed blurred consciousness and loss of orientation. The patient was consulted with the ophthalmology clinic and pupillary light reflex was normal and bulbus movements were free. The patient who had a history of epilepsy was consulted with neurology. Cranial tomography and MRI were performed. MRI showed edema in bilateral parietal-occipital lobes consistent with PRES. Antiedema treatment and antihypertensive treatment were administered and visual functions improved at the end of 24 hours. The patient was taken to the ward and discharged on the 4th postoperative day.
Conclusion: PRES is clinically characterized by nonspecific findings such as headache, nausea, vomiting, visual and mental changes, but radiologically it is characterized by diffuse cerebral edema which is more prominent in the occipital and parietal regions. The pathophysiology is the development of cytotoxic edema after cerebral vascular spasm secondary to sudden hypertension. PRES is a condition whose clinical and radiologic findings can be reversed rapidly with prompt diagnosis and treatment. With early diagnosis, the disease can be reversed without leaving sequelae.
Keywords: PRES, hypertension, reversible
P-4751
Ectopic parathyroid adenoma-our CTF experience
Selen Soylu Yalıman1 , Serkan Teksöz1 , Ömer Faruk Sağlam2 , Ezel Erşen2
1 Department of General Surgery, Cerrahpaşa Faculty of Medicine, İstanbul University-Cerrahpaşa, İstanbul, Türkiye
2 Department of Thoracic Surgery, Cerrahpaşa Faculty of Medicine, İstanbul University-Cerrahpaşa, İstanbul, Türkiye
ABSTRACT
Objective: Ectopic parathyroid adenoma causes diagnostic and therapeutic difficulties in the management of patients with hyperparathyroidism. Diagnosis with imaging and surgery is difficult in these lesions. It is the cause of unsuccessful first surgical intervention.
Material and Methods: Eight patients with ectopic parathyroid adenoma who were examined for primary hyperparathyroidism between 2017 and 2021 were retrospectively analyzed.
Results: The mean age of the patients was 48 years (range= 35-70), with seven females and one male. The diagnosis was primary hyperparathyroidism in five patients and persistent hyperparathyroidism in three patients. Scintigraphy was used for preoperative imaging in six patients, PET in one patient, and 4-DCT in one patient. Partial sternotomy was performed in one patient, Kocher necklace incision in one patient and VATS in six patients. Pathology revealed parathyroid adenoma in seven patients and no parathyroid gland in one patient.
Conclusion: Choosing the most appropriate preoperative imaging modality and the right surgical approach in patients with ectopic parathyroid adenoma is important for successful patient management.
Keywords: Ectopic, parathyroid, sternotomy
P-4803
A patient with food residue in the drain incision after abdominal drainage catheter withdrawal: A case report of drain migration
Sümeyra Güler1 , Meltem Hızal2 , Çılga Ecem Lamba2 , Yasin Hatipoğlu2 , Şevket Barış Morkavuk1 , Mehmet Ali Gülçelik1
1 Clinic of Surgical Oncology, Gülhane Training and Research Hospital, Health Sciences University, Ankara, Türkiye
2 Clinic of General Surgery, Gülhane Training and Research Hospital, Health Sciences University, Ankara, Türkiye
ABSTRACT
Objective: Abdominal drains are routinely used after abdominal operations to provide drainage of peritoneal collection, bleeding and possible anastomotic leakage in the closed cavity. The continued use of drains following surgical procedures is still a controversial issue. However, many surgeons prefer long-term drain use, especially in major abdominal surgery patients. In addition to complications such as pain, infection and obstruction, strangulation and organ perforation may be rare complications of long-term abdominal drain use. A limited number of case reports of luminal organ migration have been reported in the literature. It was aimed to present a patient with intestinal abdominal drain migration in a patient who underwent pelvic exenteration in the light of the literature.
Material and Methods: A 57-year-old female patient who underwent low anterior resection operation for colon cancer was diagnosed with pelvic recurrence two years later. Pelvic exenteration was performed together with the urology clinic. After receiving adjuvant treatment, the patient underwent a repeat operation due to a solid mass filling the pelvis completely. No distant organ metastasis was detected. The operation was terminated after placement of an abdominal drainage catheter as the mass invaded the iliac vascular structures and multiple metastatic implants were seen in the small intestine segments.
Results: In the follow-up of the patient, the oral was opened after postoperative spontaneous gas stool discharge. Active peritoneal ascites was obtained from the drain and the patient was discharged with the drain. In the follow-up, the patient’s drain was removed after the ascites drainage was under control in the 2nd postoperative week. After removal, food residue compatible with parsley was detected at the drain incision site. Abdominal CT was performed with suspicion of intestinal perforation. No intraabdominal free air or appearance compatible with abscess was observed. The patient was followed up considering drain migration and drain epithelialization tract between the intestine and abdominal cavity. No pathologic findings were detected in imaging studies and routine laboratory tests. The patient was referred to the medical oncology clinic and discharged.
Conclusion: Postoperative surgical drainage by surgeons is a traditional technique and dates back to Hippocratic times. However, the use of drains is not without complications. Some of these complications include drain site cellulitis, bleeding, kinking that may require surgical removal of drains, intestinal obstruction, incisional hernia, erosion of adjacent structures and fistula formation. The literature on migration of drainage catheters into the intestinal tract is very limited and all of the publications in the Pubmed database are case reports. In the etiology, improper fixation of the drain, low abdominal pressure and the pressure of body weight on the drain when the patient lies on the same side as the drain have been held responsible, but none of these factors is accepted as a definite factor.
Keywords: Drain, migration, foreign body
P-4851
Efficacy of plantago major in an experimental ischemic colitis model
Hatice Büşra Özdilek, Meryem Günay Gürleyik
Clinic of General Surgery, Haydarpaşa Numune Training and Research Hospital, Health Sciences University, İstanbul, Türkiye
ABSTRACT
Objective: There are studies in the literature suggesting that plantago major extract reduces ischemia reperfusion injury. Pentoxifylline (PTX) is known to be effective on ischemic colitis. In this study, it was aimed to investigate the effects of plantago major extract and PTX in an experimental ischemic colitis (IC) model in rats.
Material and Methods: In the study, 30 male Wistar Albino rats weighing between 200-250 grams were used. The rats were randomly divided into five groups (Sham, placebo, high dose plantago major, low dose plantagomajor and pentoxifylline group). The experimental ischemic colitis model was established as described by Griffen and Hagihara. Group 1 (high dose plantago major) received 2000 mg/kg/day plantago major extract with orogastric cannula for three days (n= 6) after laparotomy and ischemic colitis model, Group 2 (low dose platago major) received 1.000 mg/kg/day plantago major extract with orogastric cannula for three days (n= 6) after laparotomy and ischemic colitis model, Group 3 (pentoxifylline group) received 50 mg/kg/day pentoxifylline by intraperitoneal injection for three days (n= 6) after laparotomy and ischemic model, Group 4 (placebo group) received 10 mg/kg 0.9% NaCl by oralgastric cannula for three days (n= 6) after laparotomy and ischemic colitis model. In Group 5 (Sham group), only laparotomy was performed and closed (n= 6). After 72 hours, rats were sacrificed by intracardiac blood sampling and relaparotomy was performed. Total antioxidant level (TAS), total oxidant level (TOS), oxidative stress index (OSI), total thiol (TT), native thiol (NT), matrix metalloproteinase 1 (MMP1), matrix metalloproteinase 7 (MMP7) and stromelysin 2 levels were measured in tissue and serum samples. Pathologically ischemic colon segment was evaluated after resection using macroscopic damage assessment, wallance scoring, ischemic area measurement, Chi scoring.
Results: In our study, intestinal dilatation, presence of acidic fluid and serosal changes were observed more in the sham group than in the other groups in the ischemic colitis model (p< 0.05). However, perforation and adhesion findings indicating severe ischemic colitis were not observed in any group. However, macroscopic damage scoring (MVD) defined by Wallace et al. did not show a significant difference between the groups. In our study, TOS was not significantly different between the plantago major groups and the pentoxifylline group and was lower than the placebo group, while total antioxidative levels were negatively correlated with TOS.
Conclusion: The findings of our study show that the use of plantago major and pentoxifylline is effective in the ischemic colitis model in rats compared to the placebo group. Statistically similar results were obtained between the groups despite different doses in the plantago major groups. However, this is thought to be due to the small sample size. With this, antioxidant and anti-inflammatory activity of plantago major extract was demonstrated and no statistically significant positive effect on ischemia was found.
Keywords: Ischemic colitis, experimental ischemic colitis model, plantago major
P-5280
A rare benign lesion of the breast: Pseudoangiomatous stromal hyperplasia: Case report
Igbal Osmanov
Clinic of General Surgery, Memorial Ankara Hospital, Ankara, Türkiye
ABSTRACT
Objective: Pseudoangiomatous stromal hyperplasia is a benign breast lesion first described by Vuitch et al. in 1986 in nine cases. It is usually found incidentally in 23% of breast biopsy material in premenopausal women. The mass-forming form is encountered in lower rates. It is generally asymptomatic. Rarely, it is found in men with gynecomastia. Pathologically, the lesion is defined as benign proliferation of stromal myofibroblasts. It consists of small vessel-like (pseudoangiomatous) clefts surrounded by dense collagen stroma and spindle cells lining them. They are generally free of atypia and are not considered to increase the risk of breast cancer. This study aimed to report a case of pseudoangiomatous stromal hyperplasia in which we found a small focal atypical ductal hyperplasia at the border of the lesion on pathologic examination after excision of the palpable mass detected ultrasonographically.
Material and Methods: A 30-year-old female patient presented with swelling and pain in the right breast six months ago. Her medical history included normal delivery 1.5 years ago and breastfeeding for four months. She had normal menstrual cycle and no history of hormone use. She had a rare smoking history. There was no history of breast cancer in her family history. Physical examination revealed a 2 cm mobile mass at nine o’clock in the right breast. USG showed a lesion with solid and cystic components at a distance of 2 cm from the areola at the nine o’clock level of the right breast, clustered microcalcifications were observed in the vicinity of the cystic component, and dense vascularization was observed in the solid component, with a total size of approximately 25 x 15 mm (Figure 1). USG-guided tru-cut biopsy of the lesion was compatible with pseudoangiomatous stromal hyperplasia.
Results: The patient was operated with these findings, and the mass was removed together with the surrounding intact breast tissue. Final pathology revealed a 4.5 x 4 x 2.5 cm lumpectomy material microscopically showing a well-circumscribed multilobulated mass consisting predominantly of areas of pseudoangiomatous stromal hyperplasia. Atypical ductal hyperplasia characterized by proliferation of small monotonous cells in an area of epithelial hyperplasia was detected in a small focus at the border of the lesion (Figure 2).
Conclusion: Pseudoangiomatous stromal hyperplasia is a rare benign breast lesion mostly found in premenopausal women. It is usually detected incidentally in biopsy materials performed for other breast lesions. More rarely, it may present with a palpable mass. In our case, the patient presented with a palpable mass. There is no specific radiologic appearance. It is usually detected as a smoothly circumscribed, calcification-free lesion on mammography and a slightly heterogeneous, hypoechoic lesion on ultrasonography. Because of this appearance, it may be confused with fibroadenomas and phylloides tumors in the differential diagnosis. On macroscopic examination, PASH is a lesion with smooth borders and a wide range of sizes (1-18 cm). In our case, a 25 x 15 mm lesion with solid and cystic components, microcalcifications and dense vascularization was found. There was also an area of cellular atypia within the borders of the lesion.
Keywords: Pseudoangiomatous stromal hyperplasia, benign breast lesions
P-5368
Isolated diverticulum of the cecum: A rare case report
Miraç Barış Erzincan1 , Ahmet Kamburoğlu2 , Deniz Çil2 , Sümeyra Güler1 , Müjdat Turan2 , Mehmet Ali Gülçelik1
1 Clinic of Surgical Oncology, Gülhane Training and Research Hospital, Health Sciences University, Ankara, Türkiye
2 Clinic of General Surgery, Gülhane Training and Research Hospital, Health Sciences University, Ankara, Türkiye
ABSTRACT
Objective: Isolated cecal diverticulum was first described by Potier in 1912. The etiology and incidence are not clearly known. Uncomplicated cases usually have an asymptomatic course. Clinical findings often mimic acute appendicitis. The diagnosis is often made incidentally during surgery or colonoscopy. In this report, it was aimed to present a case of isolated cecal diverticulum discovered during colonoscopy in the light of the literature.
Material and Methods: A 54-year-old male patient was admitted to our clinic with abdominal pain. A minimal decrease in Hgb value was detected in the tests performed. Physical examination revealed no findings except tenderness in the right quadrant. Lower gastrointestinal tract colonoscopy was planned for the patient who had a family history of colon cancer. Colonoscopy revealed two diverticula located in isolated cecum. No mucosal or luminal pathology was observed in other segments. The patient who had no symptoms of active diverticulitis was discharged with a follow-up protocol.
Results: A 54-year-old male patient was admitted to our clinic with abdominal pain. A minimal decrease in Hgb value was detected in the tests performed. Physical examination revealed no findings except tenderness in the right quadrant. Lower gastrointestinal tract colonoscopy was planned for the patient who had a family history of colon cancer. Colonoscopy revealed two diverticula located in the isolated cecum. No mucosal or luminal pathology was observed in other segments. The patient who had no symptoms of active diverticulitis was discharged with a follow-up protocol.
Conclusion: Although the exact frequency of cecal diverticula is unknown, it has been reported as one case for every 34-300 appendectomy cases. They are usually asymptomatic lesions located mostly in the anterior wall of the cecum. In 80% of cases, they are within 2.5 cm from the ileocecal valve. In contrast to diverticula located in the distal colon, cecal diverticula are mostly congenital. They are often true diverticula involving all layers of the colonic wall. Single diverticulum is seen in the majority of cases. There is no clear consensus in the literature on the treatment of cecal diverticulitis. It has a spectrum ranging from conservative medical treatment to right hemicolectomy.
Keywords: Cecum, diverticulum, colonoscopy
P-5545
A rare case: Gastric antral diverticulum
Elifcan Haberal1 , Gökay Çetinkaya1 , Kübra Nur Doğru2 , Ahmet Kürşat Gören2 , Ebru Esen1 , Mehmet Ali Gülçelik1
1 Clinic of Surgical Oncology, Gülhane Training and Research Hospital, Health Sciences University, Ankara, Türkiye
2 Clinic of General Surgery, Gülhane Training and Research Hospital, Health Sciences University, Ankara, Türkiye
ABSTRACT
Objective: Gastric diverticulum is a rare entity. It is the rarest diverticulum of the gastrointestinal tract and is a very rare anatomical abnormality in general. They are usually discovered incidentally during routine diagnostic tests. Detection rates vary depending on the method used to detect them. Most patients are asymptomatic. Upper gastrointestinal endoscopies have a detection rate of 0.01-0.11%.
Results: A 79-year-old male patient was admitted to the general surgery outpatient clinic of our hospital with complaints of bloating. Gastroscopic examination revealed normal cardia, fundus, corpus mucosa and luminal structure. The antrum was hyperemic and edematous and biopsy was taken. A 1 cm gastric diverticulum was observed approximately 2 cm proximal to the pylorus. Pylorus, bulbus and postbulbar region were normal. Helicobacter pylori was detected in the biopsy and eradication treatment was given.
Conclusion: Management of gastric diverticulum largely depends on the severity of presenting symptoms and the size of the diverticulum. Asymptomatic individuals do not require any treatment. The majority of diverticula are congenital, discovered incidentally and are asymptomatic and therefore do not require treatment. Diverticula that cause significant symptoms or lead to complications (these diverticula are usually large) should be resected as there is no other effective treatment. Surgical resection remains the main treatment in cases where the GD is large (>4 cm in diameter), patients are still symptomatic after PPI treatment and complications such as ulceration, upper gastrointestinal bleeding, hemorrhage, perforation and malignant transformation occur.
Keywords: Gastric diverticulum, bleeding, endoscopy
P-5781
A patient developing transient facial paralysis after roll (radionuclide-guided occult lesion localization) marking: A case report
Miraç Barış Erzincan1, Mehmet Mert Hıdıroğlu2 , Sema Horasan2 , Şevket Barış Morkavuk1 , İbrahim Burak Bahçecioğlu1 , Mehmet Ali Gülçelik1
1 Clinic of Surgical Oncology, Gülhane Training and Research Hospital, Health Sciences University, Ankara, Türkiye
2 Clinic of General Surgery, Gülhane Training and Research Hospital, Health Sciences University, Ankara, Türkiye
ABSTRACT
Objective: Radionuclide-guided occult lesion localization (ROLL) is a method generally used to localize breast lesions that cannot be detected by palpation before excision and to confirm complete removal of the lesion after excision. In addition to breast lesions, it is also used for lymph node sampling and localization of parathyroid adenomas. In the ROLL procedure, Tc-99m-labeled human serum albumin is injected into and adjacent to the lesion within 24 hours before the operation and then the lesion is localized and excised by the gamma ray detection probe. Although it is a minimally invasive procedure, local complications may rarely develop. In this article, it was aimed to present a case with thyroid papillary cancer that developed transient facial paralysis after ROLL marking.
Material and Methods: A 16-year-old female patient was admitted to our clinic for total thyroidectomy and left lateral neck dissection with a diagnosis of thyroid papillary cancer. Before the operation, pathological lymph nodes in the left lateral level 2 upper border and level 4 lower border lymph node stations were marked with Tc-99m-labeled human serum albumin. Lateral neck dissection was completed with the help of a gamma probe and excision of the marked pathological lymph nodes was confirmed.
Results: In the postoperative period, the patient complained of numbness on the left side of the face, limitation of movement, and inability to close the left eye. Physical examination revealed facial paralysis consistent with facial nerve buccal and mandibular branch localization. The patient was consulted with the otorhinolaryngology clinic and edema in the peripheral branches of the facial nerve secondary to lateral level 4 ROLL marking and grade 3 peripheral facial paralysis due to this was confirmed. Steroid treatment was started, and the symptoms started to regress on the 2nd postoperative day. The patient was discharged with recommendations on the 7th postoperative day after almost complete regression of symptoms.
Conclusion: Accurate localization is the most important factor in the correct surgical removal of non-palpable lesions. The ROLL method minimizes the amount of healthy tissue removed unnecessarily while maintaining safe tissue margins. In the literature, erroneous localization between 1-5% in the ROLL technique in the presence of an experienced radiologist has been reported. There may be anaphylactic reaction due to Tc-99m and local complications such as seroma or hematoma.
Keywords: ROLL, gamma probe, facial paralysis
P-6445
Giant, submucosal gastric lipoma causing anemia
Igbal Osmanov
Clinic of General Surgery, Memorial Ankara Hospital, Ankara, Türkiye
ABSTRACT
Objective: Gastrointestinal (GI) lipomas occur third most commonly in the stomach after the colon and small intestine. Although gastric submucosal lipomas are rare benign tumors that are usually asymptomatic and detected incidentally during endoscopy, they may be symptomatic as in our case. This study aimed to report a case of a giant gastric lipoma localized in the greater curvature of the stomach causing iron deficiency anemia in a female patient.
Material and Methods: A 68-year-old female patient with complaints of abdominal pain, nausea and vomiting was diagnosed with iron deficiency anemia and treated. Colonoscopy revealed no pathology. Endoscopy revealed a 6 x 4 cm wide-based lesion in the corpus distal to the large curvature with a diameter of 6 x 4 cm, a 2 x 2 cm area with a small amount of exudate and an ulcer area depressed from the surrounding tissue. EUS, Doppler USG confirmed a homogeneous, hyperechogenous, thick-based lesion protruding into the lumen, consistent with lipoma, without blood supply in the corpus greater curvature. Biopsy result was compatible with chronic inflammatory process. Abdominal tomography revealed a 62 x 48 mm, fat dense, capsulated lesion protruding into the lumen from the large curvature of the gastric corpus (Figure 1).
Results: The patient was operated with these findings, and wedge resection was performed through the great curvature to include the mass. Oral feeding was started gradually from postop day one. She was discharged uneventfully on postop day four. The final pathology was reported as a submucosal, smoothly circumscribed, 7.2 x 5.1 cm, lipomatous lesion with no mitotic activity, necrosis or cellular atypia causing central ulceration of the mucosa (Figure 2).
Conclusion: The most common findings of symptomatic gastric lipomas larger than 2 cm are abdominal pain, GI bleeding, obstruction and dyspepsia. In our case, a giant lipoma causing iron deficiency with no evidence of active bleeding was presented. Although such lesions are not neoplastic, they should be removed because of the complications they may cause. These lesions can also be excised endoscopically. In this case, since endoscopic excision was not considered by gastroenterology due to the size of the lesion, surgical excision was decided and the mass was removed by wedge resection in the most appropriate way for the patient according to the location of the mass.
Keywords: Iron deficiency anemia, giant submucosal gastric lipoma
P-6682
The fourth case in the literature: Isolated cyst of the cystic duct
Serhat Doğan, Furkan Yazıcı, Gökhan Söğütlü
Department of General Surgery, Malatya Turgut Özal University Faculty of Medicine, Malatya, Türkiye
ABSTRACT
Objective: The patient was operated for laparoscopic cholecystectomy in an external center, and magnetic resonance cholangiopancreatography (MRCP) was performed during the operation because of the possibility of anatomical variation. He was referred to our institution with a prediagnosis of choledochal cyst. We found isolated cystic duct dilatation during the operation, and it was aimed to present this as the fourth case in the literature.
Material and Methods: The patient was prepared for the operation. The operation was started with a classic right subcostal incision.
Results: In the operation, there was a cystic structure next to the gallbladder with separate walls. When it was separated by sharp and blunt dissection, the middle part of the cystic duct was dilated. The cystic structure was seen to be separate from the gallbladder. The cystic structure was split from the gallbladder. When the dissection was continued, a narrow canal was seen coming out of the gallbladder. It was concluded that this was the beginning of the cystic duct. The beginning of the cystic duct was narrow, then a dilated structure and when it was on the choledochal side, it was seen that the cystic duct narrowed again and entered the choledochal duct. The cystic duct was dilated from the middle part. The part where the clip was located in the excised plexus was the junction of the cystic duct and the choledochus. The cystic duct was dilated in isolation. In the literature, three cases of isolated cystic duct dilatation were reported before our case.
Conclusion: Todani’s classification is most commonly used for choledochal cysts. There are five types. Dilatation of the cystic duct is not included in Todani’s classification. Serena et al. named isolated cystic dilatation of the cystic duct as type VI in the modified Todani classification. Ultrasound, computed tomography, cholangio-magnetic resonance image (MRI) and endoscopic retrograde cholangiopancreatography show all malformations of the biliary tree. Biliary abnormalities should be operated because of the risk of complications such as pancreatitis, acute cholecystitis and cholangitis. Treatment of cystic duct dilatations is similar to other dilatations. Surgery is the only option.
Keywords: Isolated, cyst, cystic duct
P-6979
Transient vocal cord paralysis after endotracheal intubation: Case report
Gökay Çetinkaya1 , Sümeyra Güler1 , Asgar Huseyinov2 , Hakan Saydam2 , Müjdat Turan2 , Mehmet Ali Gülçelik1
1 Clinic of Surgical Oncology, Gülhane Training and Research Hospital, Health Sciences University, Ankara, Türkiye
2 Clinic of General Surgery, Gülhane Training and Research Hospital, Health Sciences University, Ankara, Türkiye
ABSTRACT
Objective: Vocal cord paralysis after endotracheal intubation is a complication with an incidence of less than 0.1%, which can lead to aspiration pneumonia and postoperative mortality and morbidity. Bilateral vocal cord paralysis requires extreme caution as it can obstruct the airway and lead to serious respiratory problems. However, there are few reports of bilateral vocal cord paralysis associated with double lumen endotracheal tube (DLT). In this case, it was aimed to present a patient who developed vocal cord paralysis after endotracheal intubation in the light of the literature.
Results: A 63-year-old male patient was admitted to our clinic with a diagnosis of multinodular goiter. The patient was evaluated by the ENT clinic for vocal cord control during preoperative preparation. The patient underwent bilateral thyroidectomy operation. During the operation, bilateral laryngeal nerve integrity was recorded with nerve monitoring. On the 1st postoperative day, decreased voice quality and hoarseness were detected. Cold steam and prednol treatment was started. The patient was consulted with the ENT upon the lack of regression in her symptoms, and bilateral vocal cord was immobilized and paramedian fixed in indirect laryngoscopy. Since nerve continuity was recorded with a nerve monitor during the operation, transient vocal cord paralysis due to endotracheal tube intubation was primarily considered. Oral prednisolone was started for three weeks without respiratory distress and dysphagia. At the postoperative 1st month follow-up visit, the patient’s voice quality improved.
Conclusion: Endotracheal intubation-induced vocal cord paralysis was first described by Ellis and Pallister, who suggested that compression injury caused by an overinflated cuff in the larynx may cause an anterior branch of the recurrent laryngeal nerve passing medial to the thyroid lamina. Conservative approach, steroids and cold vapor therapy is the first approach that comes to mind in treatment. In patients with respiratory distress and asphyxia, tracheostomy and temporary endotracheal intubation are inevitable treatment methods.
Keywords: Endotracheal intubation, vocal cord paralysis
P-7230
An atypical cause of sleep apnea syndrome: Retrosternal goiter
Buse Yıldırım, Gamze Çıtlak
Clinic of General Surgery, Haseki Training and Research Hospital, Health Sciences University, İstanbul, Türkiye
ABSTRACT
Objective: Retrosternal goiter is an ectopic thyroid gland located in the thorax. Although 95% of substernal goiters have retrosternal extension, they are more frequently found in the anterior mediastinum. Most substernal goiters can be removed by the classical cervical approach. However, extracervical interventions such as sternotomy or thoracotomy may be required in some cases. Patients may develop dyspnea and dysphagia due to the increase in the size of thyroid nodules. In this report, it was aimed to present bilateral total thyroidectomy via median sternotomy in a patient who was examined for dyspnea and dysphagia and was found to have a giant retrosternal goiter causing severe narrowing of the trachea.
Material and Methods: In our presentation, we will present our patient who was referred to Haseki Training and Research Hospital general surgery clinic from internal medicine policlinic in April 2023. After complaints of dyspnea with a history of goiter, retrosternal goiter was detected in the investigations and bilateral total thyroidectomy operation was performed by median sternotomy.
Results: A 55-year-old male patient with a known diagnosis of obstructive sleep apnea syndrome with a history of goiter using CPAP was referred to us from the internal medicine outpatient clinic with the result of thyroid ultrasonography. On physical examination, there was a giant goiter extending to the substernal area. When the patient’s complaints were questioned, shortness of breath was present. Pemberton’s sign was positive. On thyroid ultrasonography, the trachea was markedly narrowed up to 1.5 mm at the level of the thyroid gland; there were multiple hypoechoic nodules, the largest of which was 4 cm on the right and 2.5 cm on the left, and reactive multiple lymph nodes with fatty central hilus. FNAB from the right 4 cm hypoechoic nodule was reported as Bethesda 3. Preop thyroid function tests, anti-TG and calcitonin values were within normal limits. Non-contrast CT of the neck and thorax was performed in extension. Preop vocal cord examination revealed minimal mobility secondary to left vocal cord mass compression. Bilateral total thyroidectomy was performed by median sternotomy. She was transferred to the intensive care unit due to the risk of tracheomalacia in the postoperative period. Post op period Ca= 9 mg/dL, PTH= 4 ng/dL, P= 4.9 mg/dL. He was transferred to the ward on post operative day two and left vocal cord was found to be paralytic. Anti-edema treatment was started in accordance with ENT recommendations. She was discharged on postoperative day seven with recommendations. Terminal pathology was benign. In the follow-up, the patient did not complain of hoarseness in the 2nd month post op and did not have dyspnea and stopped using CPAP.
Conclusion: Retrosternal goiter should be considered in patients presenting to the outpatient clinic with nonspecific complaints such as dyspnea and dysphagia. Further imaging modalities should be used when findings such as narrowing and pushing of the trachea are detected on POAG. Although the risk of complications is higher in retrosternal and giant goiters, the operation can be performed successfully in experienced centers.
Keywords: Retrosternal goiter, shortness of breath, hoarseness
P-7955
Colorectal cancer with MUTHY and MSH6 gene mutation: A case report
Zeki Öğüt1 , Sadık Keşmer1 , Abdullah Böyük2 , Tevfık Tolga Şahin3
1 Clinc of General Surgery, Elazığ Fethi Sekin City Hospital, Elazığ, Türkiye
2 Clinc of General Surgery, Elazığ Medikal Hospital, Elazığ, Türkiye
3 Liver Transplant Institute, İnönü University, Malatya, Türkiye
ABSTRACT
Objective: Many genetic alterations have been identified in colorectal carcinogenesis in the background of polyposis coli. The coexistence of mutations in different genes is becoming increasingly important in understanding cancer risks. The coexistence of the MUTHY gene, which encodes a protein that repairs oxidative damage in DNA, and MSH6 (MutS homolog 6), one of the DNA mismatch repair genes, is one of them. While MUTHY gene is associated with polyposis, inherited mutations in MSH6 gene are associated with Lynch syndrome. In this study, it was aimed to present a case of colorectal cancer (CRC) developing on the background of polyposis in which MUTHY and MSH-6 gene mutations were seen together.
Material and Methods: A 33-year-old male patient presented with rectal bleeding and difficulty in defecation. His family history revealed colon cancer in 2nd and 3rd degree relatives. Digital rectal examination revealed a mass approximately 5 cm from the anal canal. Radiologic imaging showed no extracolonic involvement. Colonoscopy revealed polyposis coli, and biopsy of the mass in the lower rectum was diagnosed as adenocarcinoma. Neoadjuvant three cycles of chemotherapy (FOLFOX) + radiotherapy (28 days) was applied. Laparoscopic proctocolectomy with ileal J pouch was performed. The postoperative period was uneventful, and he was discharged on the 7th day. Histopathologic result was reported as polyposis coli, moderately differentiated adenocarcinoma (pT3N0). The patient received adjuvant chemotherapy and eight-month follow-up was uneventful.
Results: In the literature, there are studies observing that MSH6 mutation is more likely to be found in CRC individuals with MUTHY mutation. However, there are also studies suggesting that the association of these two genes does not increase the risk of CRC. In MUTHY-associated polyposis syndrome, the age at which polyps and CRC develop is older, and cancer development occurs mostly in the proximal colon. The average age of CRC diagnosis in MSH6 mutation carriers is 42-69 years. It is rare to develop cancer at a young age and to have a mass in the rectum as in our case.
Conclusion: It is argued that additional testing for MUTHY gene positivity alone offers no advantage to the carrier. However, for monoallelic MUTHY mutation carriers, the coexistence of the pathogenic DNA mismatch repair (MMR) gene mutation may result in recommendations for increased screening. As the consequences of the MUTHY -MSH 6 mutation association become better understood, it will contribute more to clinical practice.
Keywords: MUTHY, MSH6, colorectal cancer
P-8531
Robotic spleen sparing distal pancreatectomy
Sefa Ergun, Egemen Özdemir, Emin Köse
Department of General Surgery, Cerrahpaşa Faculty of Medicine, İstanbul University-Cerrahpaşa, İstanbul, Türkiye
ABSTRACT
Objective: Robotic surgery applications have been frequently used in hepatobiliary surgery as in many fields of general surgery in recent years. Although pancreatic surgery is a field with its own unique challenges, robotic applications provide us convenience in some difficulties in this field. Although spleen preservation is often not possible in distal pancreatectomy resections, an advantage of robotic surgery is that it provides us with this opportunity.
Material and Methods: We aimed to present a case of robotic spleen-sparing distal pancreatectomy in a patient with IPMN located in the pancreatic corpus and to analyze the technical aspects in the light of the literature.
Results: A 41-year-old female patient was operated on for a 2.5 cm diameter IPMN in the pancreatic corpus and underwent robotic spleen-sparing distal pancreatectomy. The patient was discharged on the 7th day with no post-op follow-up problems.
Conclusion: Minimally invasive robotic system can be used safely and effectively with low mortality and morbidity in experienced centers in pancreatic surgery.
Keywords: Pancreatic surgery, robotic surgery, spleen sparing pancreatectomy
P-9103
An unexpected complication of difficult labor: Spontaneous liver rupture
Emir Yetkin, Gamze Kızıltan
Department of General Surgery, Cerrahpaşa Faculty of Medicine, İstanbul University-Cerrahpaşa, İstanbul, Türkiye
ABSTRACT
Objective: This case report discusses the clinical approach to spontaneous postpartum liver rupture.
Material and Methods: A 33-year-old female patient was hospitalized with placenta previa totalis at 34 weeks of gestation in her second pregnancy. She developed pre-eclampsia and underwent emergency caesarean section on the same day. After the emergency caesarean section, liver rupture and hematoma were detected when she was examined due to increasingly severe abdominal pain. The approach to spontaneous postpartum liver rupture is discussed in this case without a history of trauma and comorbidities.
Results: In the follow-up performed from the morning of the same day, progressive increase in liver function tests, elevated d-dimer and fibrinogen were detected. Coagulation values were not abnormal. In addition to the laceration area detected at the level of segment 7-8 on imaging, a hematoma reaching 5 cm in the widest part of the right lobe of the liver and continuing around the entire liver in the subcapsular area was observed (Figure 1).The patient was operated under emergency conditions due to diffuse intra-abdominal free fluid and expanding hematoma in the right lobe of the liver. During the operation, it was seen that the capsule was opened at the level of the laceration area, diffuse subcapsular hematoma in the liver and abundant hemorrhagic fluid in the abdomen (Figure 2). After placing hemostatic material in the laceration area, which was approximately 2-3 cm wide and 2 cm deep at the level of segment 7-8, “packing” was performed with compresses and waited. Since the bleeding stopped, the operation was terminated by placing two drains into the abdomen without any additional intervention. During the follow-up, the patient had recurrent hypertensive episodes that did not respond to medication and bleeding occurred again and a conservative approach was decided. The patient developed deep vein thrombosis in the right leg on post-op day nine and pulmonary embolism on post-op day 12. Anticoagulant DMAH was started for these reasons. After abdominal drain was removed on post-op day 15, the patient remained stable and was discharged on post-op day 20.
Conclusion: Spontaneous liver rupture during labor is extremely rare. Coagulation disorders secondary to pregnancy may be seen. Cases of subcapsular hematoma have been reported in patients with preeclampsia and HELLP syndrome. In the light of available data, a conservative approach may be preferred in these patients.
Keywords: Liver rupture, spontaneous rupture, emergency cesarean section
P-9107
Watermelon stomach: Gastric antral vessel ectasia, case report
Miraç Barış Erzincan1 , Elifcan Haberal1 , Buse İrem Koç2 , Güzin Bülbüloğlu2 , Şevket Barış Morkavuk1 , Mehmet Ali Gülçelik1
1 Clinic of Surgical Oncology, Gülhane Training and Research Hospital, Health Sciences University, Ankara, Türkiye
2 Clinic of General Surgery, Gülhane Training and Research Hospital, Health Sciences University, Ankara, Türkiye
ABSTRACT
Objective: Gastric antral vascular ectasia syndrome (GAVE), also known as watermelon stomach, is a rare but important cause of severe acute or chronic gastrointestinal blood loss in the elderly. GAVE was first described by Ryder in 1953 as “erosive atrophic gastritis with marked venocapillary ectasia” in gastrectomy specimens of isolated women. Although it is associated with heterogeneous medical conditions such as liver, kidney and heart diseases, its pathogenesis is unknown.
Results: A 37-year-old male patient was admitted to our outpatient clinic to investigate the etiology of anemia. In the anamnesis of the patient, it was learned that he was started on oral iron preparation due to low Hgb in the health center where he applied two weeks ago with the complaint of fatigue. Hgb 10.7 g/dL was measured in the tests performed in our hospital. The patient complained of melanoma, and upper gastrointestinal system endoscopy and lower gastrointestinal system colonoscopy were planned. Endoscopy of the patient, in whom no significant pathology was detected in colonoscopy, revealed multiple angiodysplasias in the antrum extending in a linear radial fashion towards the pylorus without active bleeding (GAVE). The patient, in whom no additional intervention was performed because no active bleeding was detected, was referred to the gastroenterology clinic for the regulation of medical treatment.
Conclusion: Gastric antral vascular ectasia is also called “watermelon stomach” because its lines resemble a watermelon on endoscopic appearance. Although it is a rare cause of gastrointestinal bleeding with an average of 4%, it has a very important place because it may require frequent transfusion. Although the pathogenesis of GAVE is still unclear, mechanical stress, humoral and autoimmune factors and hemodynamic factors are thought to play an active role. Endoscopic techniques such as sclerotherapy with proton pump inhibitors, multipolar electrocoagulation, argon and laser photocoagulation, argon plasma coagulation (APC) are used in the treatment.
Keywords: Vascular ectasia, watermelon stomach, endoscopy
P-9697
Mesh migration, fistula formation, stoma retraction and subileus development after parastomal hernia repair: A demonstrative case of rare but well-known complications of hernia repair and stoma
Elif Jarin Akkoç, Betül Güzelyüz, Egemen Özdemir, Server Sezgin Uludağ, Abdullah Kağan Zengin
Department of General Surgery, Cerrahpaşa Faculty of Medicine, İstanbul University Cerrahpaşa, İstanbul, Türkiye
ABSTRACT
Objective: Parastomal hernia is the most common long-term complication after stoma opening and an important morbidity factor in colorectal surgery. It has been demonstrated that the incidence of parastomal hernia is higher in end colostomies compared with other stoma types. Other stoma complications include peristomal skin irritation findings, stenosis, stoma retraction and malignancy recurrence.
Material and Methods: Clinical examination and imaging modalities such as ultrasonography and computed tomography can be used for diagnosis. There is no common consensus on treatment, and there are different approaches in the literature. Although there are publications suggesting that prophylactic mesh placement during stoma opening prevents the development of parastomal hernia in the long term, there are also studies showing that it does not prevent parastomal hernia.
Results: Main complications that may occur after hernia repair with mesh include recurrence, infection and mesh migration. In this study, we present a case with end colostomy in which mesh migration, fistula formation, stoma retraction and subileus development occurred after parastomal hernia repair with prosthetic mesh.
Keywords: Parastomal hernia, mesh migration, stoma retraction, stoma complications
P-9867
A rare acute abdomen clinic: Giant adrenal cyst
Ahmet Başak, Turgut Anuk
Clinic of General Surgery, Erzurum Regional Training and Research Hospital, Erzurum, Türkiye
ABSTRACT
Objective: Adrenal masses are very rare in adult patients and are usually detected incidentally. These masses may be benign or malignant. Adrenal masses can reach large sizes because they are difficult to recognize. Large adenomas may present in various clinics due to compression of various organs depending on their size. This study aimed to present the case of a patient who was operated on because of an adrenal mass up to 20 cm in size causing acute abdomen clinic.
Material and Methods: The patient was admitted to the emergency department with complaints of abdominal pain, nausea and vomiting ongoing for two days. Physical examination revealed diffuse tenderness and deficiency in the abdomen. Laboratory tests revealed findings in favor of leukocytosis. Abdominal ultrasonography and tomography imaging performed under emergency conditions showed a lesion with a smooth cystic component starting from the pancreatic neighborhood and extending to the left pelvic inlet. Abdominal examination was evaluated as acute abdomen, and emergency operation was decided.
Results: Following laparotomy through midline incision, detailed abdominal exploration revealed a large cystic mass deviating the left kidney and left colon to the right. The mass was completely excised together with its capsule from the left retroperitoneal area. The pathology result of the excised cyst was found to be adrenal cyst. The patient was discharged with healing after no complications were observed during follow-up.
Conclusion: There are many causes of acute abdomen requiring emergency operation. In order to determine the causes of acute abdomen, the differential diagnosis should be determined by evaluating the clinic. When our patient was operated on for acute abdomen, a giant cystic mass was found to be the cause. Pathologic examination revealed an adrenal cyst. Adrenal masses should be considered in the differential diagnosis in similar clinical situations. When an adrenal mass is suspected, hormonal investigations should be performed.
Keywords: Adrenal cyst, acute abdomen
