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A single-institution retrospective analysis was undertaken to assess long-term results of definitive surgical reconstruction for major bile duct injuries and risk factors for restenosis.Patients treated between January 1995 and October 2020 were reviewed retrospectively. The primary outcome measure was patency.Of 417 patients referred to a tertiary center, 290 (69.5%) underwent surgical reconstruction; mostly in the form of a hepaticojejunostomy (n = 281, 96.8%). Major liver resection was undertaken in 18 patients (6.2%). There were 7 postoperative deaths (2.4%). Patency was achieved in 97.4% of primary repairs and 88.8% of re-repairs. Primary patency at three months (including postoperative deaths and stents removed afterwards) in primary repairs was significantly higher than secondary patency attained during the same period in re-repairs (89.3% vs 76.5%, p 0.01). The actuarial primary patency was also significantly higher compared to the actuarial secondary patency 10 years after reconstruction (86.7% vs 70.4%, p = 0.001). Vascular disruption was the only independent predictor of loss of patency after reconstruction (OR 7.09, 95% CI 3.45-14.49, p 0.001), showing interaction with injuries at or above the biliary bifurcation (OR 9.52, 95% CI 2.56-33.33, p 0.001).Long-term outcome of surgical reconstruction for major bile duct injuries was superior in primary repairs compared to re-repairs. Concomitant vascular injury was independently associated with loss of patency requiring revision.

Background Choledochal cysts are congenital anomalies that can occur at any level of the biliary tree. They carry long-term risk of biliary complications and cancer development. Complete excision of all involved bile ducts is recommended. Methods Patients treated between 1995 and 2019 were reviewed retrospectively. Results Sixty patients; 46 female and 14 male with a median age of 41 years (range 13–83) were included in the study. Mild abdominal pain was the most common presenting symptom (60%). Majority of the patients had Todani type I cysts (67%). Concomitant biliary malignancy was diagnosed in five patients (9%). Eight patients were followed-up conservatively (13%). Twenty-five patients were treated by excision of the extrahepatic bile ducts and Roux-en-Y hepaticojejunostomy, liver resection was added in seven, pancreatoduodenectomy was done in three and liver transplantation in one. There was no perioperative mortality. Postoperative complications developed in 17 patients (34%), two requiring surgical treatment. Four of the five patients with malignancies died at a median 42 months (range 6–95) following surgery. Median 62 months (range 8–280) follow-up was available in 45 surgically treated patients, 19 followed-up for more than 10 years. None of the patients developed malignancy during follow-up. Four patients (17%) were readmitted for anastomotic strictures requiring treatment. Conclusion The majority of choledochal cysts are Todani type-I and early cyst excision is the mainstay of management, which may decrease the risk of malignant transformation.

Living donor liver transplantation may complement cadaveric transplantation in acute liver failure (ALF) patients. Between 2008 and 2017, 89 patients were treated for ALF; 15 patients (17%) recovered with intensive care treatment; 31 (35%) died without transplant. The records of the remaining 43 patients (median (range) age: 14 (1–62)) who underwent transplantation were evaluated. The etiologic factors were toxic agents (10; mushrooms: 8; herbs: 2), hepatitis viruses (7; A: 1; B: 6), Wilson’s disease (7), autoimmune hepatitis (4), and Budd-Chiari syndrome (2); 13 cases were idiopathic. Cadaveric organs (whole, split, reduced) were transplanted to 32 patients; 11 patients underwent living donor transplantation. One patient (2%) died of septic shock on the second postoperative day. Bacterial infection was the most common early (< 3 months) complication in the remaining patients (31/42; 74%), followed by delirium (5/42; 12%) and acute rejection requiring steroid pulse (5/42; 12%). Seven other patients died during median (range) follow-up of 94 (14–142) months: various infections (5), leukemia (1), and acute myocardial infarction (1). The 1-, 5-, and 10-year survival rates were 100%, 96%, and 92% in children and 94%, 82%, and 65% in adults respectively. Cadaveric organ sharing and transplantation from living donors when appropriate yield a high survival rate, despite high early morbidity, in ALF patients whose conditions deteriorate despite intensive care treatment. Efforts to eliminate preventable causes of acute liver failure will lead to more efficient use of health care resources.

Amac: Karaciger kist hidatiginde total perikistektomi uygulanan hastalarin sonuclarini irdelemek. Gerec ve Yontem: 1999-2019 yillari arasinda yatirilarak tedavi edilmis hastalarin verileri incelenerek, total perikistektomi yapilan hastalar calismaya dahil edilmistir. Bulgular: Toplam 308 hastanin 32’sinde (17 kadin, 15 erkek, ortanca yas 44 (17-73)) perikistektomi yapildigi saptandi. Perikistektomi endikasyonlari, ulasimi kolay anatomik yerlesim (20), albendazol toksisitesi (4), albendazole cevapsiz kist (4), kistik tumor kuskusu (2), hamilelik (1) ve albendazol kullanimina uyumsuzluktu (1). Ortanca kist boyutu 75 mm (42-100), ortanca kist sayisi 1 (1-8) saptanirken, 14 hastada birden fazla kist vardi. Yirmi uc hastaya sadece total perikistektomi uygulanirken 9 hastada mevcut ek kistlere de drenaj uygulandi. Sadece perikistektomi uygulanan 23 hastadan 18’ine kapali, 5’ine acik perikistektomi yapildi. Perikistektomi sirasinda 10 hastada ortanca 36 dk (12-78) Pringle klampaji uygulandi. Ortanca yatis suresi 6 gundu (1-60). Uc hastada dusuk debili (

Developmental cysts are a subgroup of perirectal cysts seen extremely rarely. They have no symptoms in 50% of cases, and mostly occur among middle-aged women. The ratio of male to female is approximately 1/3. In the differential diagnosis, malignancies and pilonidal cysts are common. Although they usually occur as benign lesions, 30% of cases are reported as malignant in literature. Preoperative diagnosis is quite challenging, but may be essential for appropriate treatment. The main treatment is surgical removal of the entire cyst for the prevention of complications and the potential for malignancy. In addition to the trans-sacral or perineal approach, anterior laparoscopy can be performed as an optional surgical technique. Herein, we report two consecutive patients with two different developmental cyst pathologies. A 17-year girl, who had no specific symptoms for a retrorectal giant cyst, was admitted to this clinic because of pilonidal cyst disease. A giant retrorectal cyst was diagnosed through pelvic MRI,which was performed upon her reporting a mild fullness feeling. The other cyst was diagnosed in a 30-year woman who had mild gastrointestinal symptoms that could not be related to the cyst. Both underwent surgery via the trans-sacral approach. The cysts were completely removed without abdominal intervention. Key Words: Epidermoi cyst, Pilonidal cyst, Tail-gut cyst, Retrorectal Space.

Cholangiocarcinoma (CCA) is a type of cancer, which 5-year survival is lower than 20 %, and which is detected mostly in advanced stage of the disease. Unfortunately, there are no diagnostic tools, which could show changes in the body indicating the development of the disease. Therefore, in this study, we investigate Raman spectroscopy as a promising analytical tool in medical diagnostics and as a method, which would allow to distinguish between healthy patients and patients suffering from cholangiocarcinoma. The obtained Raman spectra showed, that lower intensities of peaks corresponding to amino acids and proteins, as well as higher intensities of peaks originating from lipids vibrations were observed in healthy individuals in comparison with cancer patients. Moreover, Partial Last Square (PLS), Principal Component Analysis (PCA) and Hierarchical Component Analysis (HCA) of Raman spectra indicate that the ranges between 800 cm-1 and 1800 cm-1, 3477 cm-1 -3322 cm-1 and 1394 cm-1 -1297 cm-1 allow to distinguish cancer patients from healthy ones. The obtained results showed, that Raman spectroscopy is a good candidate, to become in future one of the diagnostic tools of Cholangiocarcinoma.

OBJECTIVE The aim of this study was to determine the nature of spontaneous regression of liver hemangiomas. PATIENTS AND METHODS The records of the liver hemangioma patients who attended the out-patient clinic between 1988 and 2018 were evaluated. The data of the 716 adult patients who were followed for at least 3 years with cross-sectional imaging were analyzed. RESULTS Spontaneous regression was documented in 46 patients (6.4%). Twenty-eight patients had a single hemangioma (61%), eight (17%) had two hemangiomas; the other 10 patients had 3-6 hemangiomas. Of the 87 lesions in 46 patients, 69 actually regressed during the study. Twelve patients with more than one lesion exhibited discordant courses - one of the hemangiomas of a patient with multiple lesions regressed, whereas the other enlarged or remained stable. Eleven of the regressed hemangiomas exhibited enlargement first, followed by spontaneous regression. Fourteen (20%) of the regressed hemangiomas acquired atypical characteristics that would have suggested a malignancy had the original films been unavailable. CONCLUSION Spontaneous regression of liver hemangiomas is an underrecognized phenomenon. Enlargement should not be a straightforward indication for intervention because it may be followed by regression. A regressed hemangioma should be considered in the differential diagnosis of liver lesions suspicious for malignancy.

Purpose We aimed to evaluate the results of the fistula-tract laser closure associated with primary closure of internal orifice. Materials and methods The surgical objective was to seal the fistula tract using laser energy and closing internal orifice with purse-string suture. Between January 2017 and December 2018, 35 consecutive patients who underwent the laser closure plus internal orifice suturing included. In all 35 patients, the laser procedure was applied then internal orifice was primarily closed with 2-0 polyglactin suture after the debridement of necrotic tissue. Results Among 35 patients (11 female, 24 male), mean age was 43.9±12.9 years. Median follow-up was 11 months (6.0 to 17.6 mo). According to the Park classification; 21 patients (60%) had intersphincteric fistula, 12 (34%) had transsphincteric fistula, 2 (6%) had suprasphincteric or extrasphincteric fistula. There were low/simple and high/complex fistula in 21 (60%) and 14 patients (40%), respectively. Overall, 15/35 (42.9%) patients showed complete healing, 12/35 (34%) had slight drainage with minimal symptoms, 8/35 (22%) patients had persistent symptomatic drainage, and there was no patient with painful symptomatic drainage. On the basis of the Jorge-Wexner continence score, there was no significant difference in patients before and after the procedure. The perfect continence rate was achieved in 32 patients (91%). Conclusion Although the absence of major and minor complications after Fistula Laser Closure (FiLaC) procedure seemed to be a major advantage, we thought that closure of the internal opening by primary suturing has no positive effect on the healing of the perianal fistula.

Solid pseudopapillary tumor (SPT) is a rare pancreatic neoplasm, classified as low-grade malignant tumor by the World Health Organization in 2000.

Although mortality after pancreatectomy in high-volume centers is less than 3%, morbidity is still as high as 18-52%. Postpancreatectomy vasculary complication is less frequent but much mortal than anastomotic problems. Postpancreatectomy vasculary complication is a life-threatening entity and it must be managed urgently. Here we report a case treated with emergent laparotomy for delayed liver ischemia and massive bleeding after total pancreatectomy. Patient was discharged without any complication at the 3rd week of emergent laparotomy for aneurismatic hemorrhage.

A 47-year-old woman underwent laparotomy with the diagnosis of cholestasis and suspected stone image in the common bile duct. No stone was found in the biliary tract; however, a pancreatic head mass was discovered. It was considered unresectable.

To investigate the long-term results of shunt surgery in the treatment of Budd-Chiari Syndrome. Medical records of patients treated with Budd-Chiari Syndrome between 1993 and 2006 were reviewed. Thirty-seven patients (26 female, 11 male) were identified, with a median age of 30 years (range 14–51). Median duration of symptoms was 3 months (range 1 month to 10 years). Twenty-five patients, all in acute or subacute stages of disease, were treated surgically. Constructed shunts were mesoatrial in 17, portocaval in five (one was converted from a failed portorenal shunt) and mesocaval in three. Median portal pressure decreased from 44 cm H2O (range 31–55) to 20 cm H2O (range 5–27). Seven patients (28%) died in the perioperative period. Eighteen patients (72%) were followed up for a median of 186 months (24–241 months). Seven patients died during follow-up, five due to reasons related to the underlying cause and treatment. Remaining 11 patients (61%) were alive at a median of 18 years (13–25 years) with patent shunts. One-, 5-, and 10-year survival rates in patients undergoing shunt surgery were 78%, 72%, and 66%, respectively. Portosystemic shunts may still be considered when expertise for transjugular intrahepatic portosystemic shunt or liver transplantation is not available.

Background/aims Helicobacter pylori infection is very common in Eastern countries. Little is known about the impact this infection has on bariatric surgery outcomes. This retrospective cohort study conducted on obese Turkish adults who underwent sleeve gastrectomy at a single center aimed to determine the prevalence of H. pylori infection and the effect of this infection on the rate of early major postoperative complications. Materials and methods All consecutive patients who underwent sleeve gastrectomy for obesity between 2014 and 2015 and who had complete data were enrolled. A single surgeon performed all procedures. All resected specimens were sent to pathology for analysis. Results Of the 460 patients who met the eligibility criteria, 326 (71%) were female. The average (±standard deviation) age and body mass index were 37.5±10.0 years and 42.7±7.7 kg/m2, respectively. Histology revealed that 150 (33%) patients had H. pylori infection. The H. pylori-infected group developed two complications (leakage and intra-abdominal collection). The uninfected group developed three complications (all bleeding related). The two groups did not differ significantly regarding postoperative complication rates (1.3% vs. 1.0%; p=0.717). Conclusion H. pylori infection did not affect the rate of early complications after sleeve gastrectomy. This suggests that H. pylori screening or eradication policy is not essential for asymptomatic candidates who have undergone sleeve gastrectomy.

The aim of our study was to compare short-term outcomes of robotic and laparoscopic sphincter-saving total mesorectal excision (TME) in male patients with mid-low rectal cancer (RC) after neadjuvant chemoradiotherapy (NCRT). The study was conducted as a retrospective review of a prospectively maintained database, and we analyzed 14 robotic and 65 laparoscopic sphincter saving TME (R-TME and L-TME, respectively) performed by one surgeon between 2005 and 2013. Patient characteristics, perioperative recovery, postoperative complications and and pathology results were compared between the two groups. The patient characteristics did not differ significantly between the two groups. Median operating time was longer in the R-TME than in the L-TME group (182 min versus 140 min). Only two conversions occurred in the L-TME group. No difference was found between groups regarding perioperative recovery and postoperative complication rates. The median number of harvested lymph nodes was higher in the RTME than in the L-TME group (32 versus 23, p = 0.008). The median circumferential margin (CRM) was 10 mm in the R-TME group, 6.5 mm in the L-TME group (p = 0.047. The median distal resection margin (DRM) was 27.5 mm in the R-TME, 15 mm in the L-TME group (p = 0.014). Macroscopic grading of the specimen in the R-TME group was complete in all patients. In the L-TME group, grading was complete in 52 (80 %) and incomplete in 13 (20 %) cases (p = 0.109). R-TME is a safe and feasible procedure that facilitates performing of TME in male patients with mid-low RC after NCRT. © 2015, Springer-Verlag London.

Cholangiocarcinomas are the second most common primary liver malignancies. The lymphatics are the common route of metastatic spread for cholangiocarcinomas. The most frequent sites of metastasis are the liver, abdominal lymph nodes, peritoneum and lungs. Cutaneous metastasis of cholangiocarcinoma is rare, and most commonly occurs following percutaneous biliary drainage. Brain or skull metastases from this tumor are uncommon. However, these rare metastatic lesions may occasionally be the first disease manifestation, although scalp recurrence following curative treatment is uncommon. We herein present the cases of two patients with cholangiocarcinoma, who were evaluated as resectable based on the criteria for cholangiocarcinoma resectability, and developed scalp recurrence following curative hepatectomy. Therefore, although scalp recurrence is a rare occurrence following curative treatment for cholangiocarcinoma, metastases should be included in the differential diagnosis.

Purpose This study was designed to evaluate the impact of a standardized laparoscopic total mesorectal excision (TME) on the long-term oncologic outcome of unselected patients with rectal cancer (RC). Methods Unselected consecutive patients with histologically proven RC underwent a standardized laparoscopic TME with medial to lateral approach encompassing 9 sequential steps: (1) ligation of inferior mesenteric vessels, (2) mobilization of the left colon and sigmoid colon (medial to lateral), (3) posterior dissection of the rectum, (4) lateral mobilization of the sigmoid, left colon, and splenic flexure, (5) left and right side dissection of the rectum, (6) anterior dissection of the rectum, (7) transection of the rectum, (8) delivery of the specimen, and (9) colorectal anastomosis. Results From 2005 to June 2012, laparoscopic sphincter-preserving TME was attempted in 217 patients with a 6.5% conversion rate. There were 91 women and 126 men, aged 58.3 years (range, 22 to 84 y), with body mass index of 26.10 (range, 20 to 45), operative time was 150.4 minutes (range, 60 to 330 min), and 24.7 (range, 4 to 98) lymph nodes were harvested. Length of stay was 7.56 days (range, 3 to 32 d). Complication rate was 17.05%. The mean follow-up time of all patients was 36.12 months (range, 1 to 89 mo). Local recurrence rate was 3.6% and distant recurrence rate was 8.7%. The 5-year disease-free survival rates were 81.5%. Conclusions A standardized laparoscopic sphincter-preserving TME resulted in a favorable short-term outcome in unselected patients with RC.

The objective of this study was to evaluate the clinical significance of serum ADP-ribosylation and NAD glycohydrolase activity in patients with colorectal cancer (CRC). A total of 108 patients with CRC who underwent curative surgery and 20 healthy volunteers were enrolled in this study. ADP-ribosylation and NAD glycohydrolase activ- ity levels were determined. The association of ADP- ribosylation and NAD glycohydrolase with clinical and labo- ratory factors and their impact on overall survival (OS) and disease free survival (DFS) were shown. The preoperative ADP-ribosylation and NAD glycohydrolase activity levels were significantly higher in patients with CRC than in the control group (p

Repeat laparoscopic liver resection (R-LLR) can be technically challenging. Data on this topic are scarce and many investigators would question its feasibility and outcomes. The aim of the present study was to evaluate the safety, feasibility, oncological efficiency and outcomes of R-LLR. We reviewed a prospectively collected database of 403 patients undergoing 422 laparoscopic liver resections (LLRs) from August 2003 to August 2013. Data of 19 patients undergoing R-LLR were analyzed and compared to the primary resection (P-LLR) in these patients. Demographic and clinical data were studied. A subgroup analysis was done for minor resections. Twenty R-LLRs were performed in 19 patients (female 58 %; mean age: 57.5 years; age range: 23–79 years). Colorectal liver metastases (CRLM) were the commonest indication for R-LLR (60 %), followed by neuroendocrine tumor liver metastases (NETLM) (20 %) and hepatocellular carcinoma (HCC) (10 %). The majority (90 %) of resections were for malignant disease (18/20). There were three conversions (15 %), and two patients developed complications (10 %). The operative time (p = 0.005) and blood loss (p = 0.03) were both significantly greater in R-LLR compared to P-LLR, whereas length of stay (median 4 days; p = 0.30) and complications (p = 0.58) did not differ between the groups. R0 resection rates for P-LLR and R-LLR were 95 and 90 %, respectively (p = 0.73). Repeat LLR is safe, feasible, and can be performed with minimal morbidity. It appears to be technically more challenging than P-LLR, but without any increase in complications or length of hospital stay.

The aim of the study was to retrospectively evaluate the potential benefit on survival outcomes of selective intraarterial radionuclide therapy (SIRT) with Yttrium-90 microspheres as a salvage therapy in liver metastasis of different tumors.Sixty-one patients who had unresectable liver metastases from colorectal carcinoma (n=23), neuroendocrine tumor (NET; n=12), cholangiocarcinoma (n=9), and others (n=17) received yttrium-90 microspheres. All patients were treated in a salvage setting with an 11-month mean follow-up. Early metabolic treatment response was evaluated by 18F-Fluorodeoxyglucose positron emission tomography (FDG PET-CT) in the sixth week after treatment.Of the 61 patients, 32 were alive at the end of the study; median overall survival (OS) was 17.0 ± 2.5 months (95% confidence interval: 11.9-22.0). A subset analysis of colorectal and noncolorectal groups demonstrated median OS rates of 14.0 ± 5.8 and 17.0 ± 4.8 months, respectively (p=0.543). The mean OS for patients with NET and cholangiocarcinoma was 29.0 ± 3.1 months and 17.7 ± 3.2 months, respectively (p=0.010). According to the early metabolic treatment response, the mean OS of responder and nonresponder groups was 32.0 ± 5.6 months and 11.4 ± 2.1 months, respectively (p=0.054). Eastern Cooperative Oncology Group performance status1 (p=0.018) and chemotherapy-naive patients (p=0.008) showed significant correlation with survival.SIRT is an effective treatment option for patients with metastatic liver disease in a salvage setting with acceptable toxicity.

Idiopathic granulomatous mastitis (IGM) is a rare chronic inflammatory disease of the breast, and its etiology remains not fully elucidated. IGM is observed more often in patients with autoimmune disease. Hyperprolactinemia is observed during pregnancy, lactation, and a history of oral contraceptive use. A 39-year-old patient with no history of oral contraceptive use presented with complaints such as redness, pain, and swelling in her left breast. Ultrasound and magnetic resonance imaging (MRI) revealed a suspicious inflamed mass lesion. Core biopsy was performed to exclude breast cancer and to further diagnose. The breast abscess was drained and steroids were given for treatment. In order to monitor any progression during the three months of treatment, hormone levels were routinely examined. Prolactin level was above the reference range, and pituitary MRI revealed a pituitary prolactinoma. After treatment with prolactin inhibitors, IGM also improved with hyperprolactinemia. This report emphasizes attention to hyperprolactinemia in cases of IGM diagnosis and treatment.

Proven advantages of laparoscopic surgery and advances in medicine technology triggered the increase of laparoscopic hepatic resection therapy. Despite initial skepticism, improved operative results made laparoscopic approach incorporated to surgical practice and operations increased in frequency and complexity. In this video, we aimed to show the laparoscopic resection of liver metastasis located at s7 in a challenging, morbidly obese patient.

Olfactory abilities of the patients are known to be altered by eating and metabolic disorders, including obesity. There are only a number of studies investigating the effect of obesity on olfaction, and there is limited data on the changes in olfactory abilities of morbidly obese patients after surgical treatment. Here we investigated the changes in olfactory abilities of 54 morbidly obese patients (M/F, 22/32; age range 19–57 years; body mass index (BMI) range 30.5–63.0 kg/m2) after laparoscopic sleeve gastrectomy. A laparoscopic sleeve gastrectomy was performed by the same surgeon using five-port technique. Olfactory abilities were tested preoperatively and 1, 3, and 6 months after the surgery using a standardized Sniffin’ Sticks Extended Test kit. Analyses of variance indicated statistically significant improvement in T, D, and I scores of morbidly obese patients within time factors (preoperative vs. 1, 3, and 6 months; 1 vs. 3 and 6 months; and 3 vs. 6 months; p

Until recently, laparoscopic resection of tumors involving segment 7 (s7) of the liver was seen as a relative contraindication. We analyzed our experiences with laparoscopic resection of tumors in s7. Retrospective analysis of prospective database on operative and postoperative characteristics and surgical outcomes of patients in whom the intention was to remove tumors located in s7 of the liver laparoscopically. We defined two groups: those with laparoscopic metastasectomy of s7 (s7 group) and those undergoing laparoscopic right posterior sectionectomy (RPS group). Of 400 patients undergoing laparoscopic liver resection, 20 patients (5 %) underwent total laparoscopic resections of tumors in s7 (7 metastasectomy of s7 and 13 RPS). The type of resection was decided on the basis of tumor size and location. Median age was 70 years (range 46-82), and the indication for surgery was mainly CRLM (n = 13, 65 %) and HCC (n = 4, 20 %). There was 1 (5 %) conversion. Mean operative times were 252 min (+/- 69) for s7 and 271 min (+/- 102) for RPS. The mean intraoperative blood loss was 400 mL (+/- 493) for s7 and 625 mL (+/- 363) for RPS. A Pringle maneuver was used in 86 % of patients in s7 group and 75 % of patients in RPS group. Mean total hospital stay was 4.6 days (+/- 2.5) in s7 and 6.9 days (+/- 7.8) for RPS. The overall R0 resection rate was 95 % (s7 100 %, RPS 92 %). Although resection of lesions in s7 is technically demanding, a laparoscopic approach can be performed safely and effectively in experienced hands

Ectopic liver tissue (ELT) is a rare condition, which is usually not diagnosed preoperatively, but coincidentally during abdominal surgery. While the location of ELT can vary, it is usually localized on the gallbladder wall or in close proximity. ELT is associated with various complications, a major complication being extrahepatic hepatocellular carcinoma. A 59-year-old female underwent elective surgery for chronic cholecystitis with stones. During laparoscopic exploration, a 2-cm-diameter ELT was detected in the anterior gallbladder wall and a laparoscopic cholecystectomy was performed. The case is presented due to the rare nature of ELT and as a reminder of ELT-related complications.

The aim of this study was to identify the axillopectoral muscle anomaly commonly known as Langer's axillary arch, and to understand its importance in surgical procedures of the axilla.Between 2009 and 2011, 758 patients underwent sentinel lymph node biopsy, axillary dissection, or both. Patients with Langer's axillary arch were identified and assessed retrospectively. The decision to cut or preserve the axillary arch was made based on clinical judgment, and patients were followed-up accordingly to monitor for adverse outcomes.Of the 758 patients who underwent axillary procedures, 9 (1.2%) were found to have a Langer's axillary arch. In 2 patients the arch was cut, and in 7 patients it was preserved. No adverse outcomes were identified in any of the patients upon follow-up.Langer's axillary arch is a unique anatomic anomaly of the axillary region that may be problematic due to the potential risks of lymphedema and vascular or nerve compression. It is important for surgeons and radiologists alike to be aware of this anatomic variation in order to properly identify it and respond appropriately based on clinical judgment, and to complete close follow-up of the patient due to the potentially increased risk of adverse outcomes.Ziel dieser Studie war es, die axillopektorale Muskelanomalie bekannt als Langerscher Achselbogen zu identifizieren und ein Verständnis potentieller Auswirkungen dieser Struktur auf chirurgische Eingriffe an der Axilla zu gewinnen.Zwischen 2009 and 2011 wurde bei 758 Patientinnen eine Sentinelknotenbiopsie, eine axilläre Lymphknotendissektion oder beides durchgeführt. Patientinnen mit einem Langerschen Achselbogen wurden identifiziert und retrospektiv bewertet. Die Entscheidung, den Achselbogen zu durchtrennen bzw. zu erhalten, wurde basierend auf der klinischen Gesamtlage getroffen, und die Patientinnen wurden entsprechend weiterverfolgt und hinsichtlich eines nachteiligen Behandlungsausgangs nachbeobachtet.Von den 758 Patientinnen, bei denen ein Eingriff an der Axilla vorgenommen wurde, hatten 9 (1,2%) einen Langerschen Achselbogen. Bei 2 Patientinnen wurde die Struktur durchtrennt, bei 7 Patientinnen wurde sie erhalten. Keine der Patientinnen zeigte einen nachteiligen Behandlungsausgang in der Nachbeobachtung.Der Langersche Achselbogen ist eine einzigartige anatomische Anomalie der Achselhöhle, die auf Grund des potentiellen Risikos der Lymphödementstehung bzw. Einklemmung von Gefäßen oder Nerven zu Problemen führen kann. Sowohl Chirurgen als auch Radiologen sollten sich dieser anatomischen Variation bewusst sein, um sie korrekt zu identifizieren und basierend auf der klinischen Situation entsprechend auf sie reagieren zu können. Der Nachbeobachtung kommt ebenfalls große Wichtigkeit zu, da das Risiko eines nachteiligen Ausgangs potentiell erhöht ist.

Iatrogenic vascular injury rarely occurs during lumbar disc surgery and can be fatal if it is not recognized instantly. In this paper we aim to introduce three iatrogenic vascular injuries that occurred during the lumbar disc surgery. The first case was consulted because of the sudden hypotension attack during lumbar disc surgery. The left common iliac artery and bilateral common iliac vein injuries were detected in emergency laparotomy, and repaired primarily. The second case was consulted to our clinic because of the hypotension attack at the first postoperative day. Left common iliac artery and vein injuries were diagnosed by CT angiography. Left common iliac vein was ligated and left common iliac arterial injury was repaired primarily by laparotomy. The third case was referred to our clinic for left lower extremity ischemia. Left common iliac artery injury was diagnosed by simple physical examination. Reconstruction by PTFE graft interposition was performed. The first patient died due to disseminated intravascular coagulation at the early postoperative period. Pulmonary embolus developed in the iliac vein ligated patient but was well treated by anticoagulant therapy. The last patient was discharged without any problem. Two of the patients are well on long-term follow-up.

BACKGROUND: Pregnant women may experience an acute presentation of hepatic hydatid disease. The available literature is limited to case reports. METHODS: The charts of 7 patients who underwent urgent treatment for hepatic hydatid disease during pregnancy between 1992 and 2010 were reviewed. RESULTS: 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. CONCLUSION: 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.

Gastrointestinal complications such as gastrointestinal bleeding and perforation due to immunosuppressant use are seen more frequently after solid organ transplantation. A 52-year-old male was admitted on the 7th day of a living donor renal transplantation with serous drainage at the incision site. He had no abdominal complaints. He was on triple immunosuppressant therapy. Abdominal plain X-ray and ultrasonography were normal, but diffuse extraluminal air was detected on the computed tomography scan. There were no pathological laboratory findings regarding the function of the renal allograft. We began the operation laparoscopically and then converted to laparotomy. Sigmoid colonic perforation was detected on the antimesenteric side. Neither diverticulitis nor ischemia was observed, and no evidence of iatrogenic injury was seen. There was no transrectal instrumentation history. Omentoplasty and sigmoid loop colostomy were performed. He was discharged on the 9th day following the operation. His colostomy was closed one year after the operation. Gastrointestinal complications can be fatal, but do not seem to influence the long-term survival or renal allograft function. Most of them are seen after using high doses of immunosuppressants to manage the early postoperative period or episodes of acute rejection. Early diagnosis and aggressive treatment play an important role in survival.

WOS: 000331512400008, PubMed ID: 23487032, Aim. The purpose of this study is to investigate the effect of intraperitoneal (IP) bevacizumab on colonic anastomosis and evaluate the effects on early postoperative adhesion formation. Materials and Methods. A total of 24 mature female Sprague-Dawley rats were used for this study. Rats were randomly assigned to a control group that received saline (n = 8) or to experimental groups (n = 8 each) that received bevacizumab at a dose of 2.5 mg/kg (group 1) or 5 mg/kg (group 2). Animals were killed humanely on the seventh day after operation, and measurements of anastomotic strength and biochemical variables were performed. Results. The mean adhesion grade was 2.63 +/- 0.92, and 1 +/- 0.93 and 0.75 +/- 0.71 for the control and test groups, respectively. Bevacizumab significantly reduced adhesion formation in both low-dose and high-dose IP applications (P < .05). When all groups were compared, it was found that VEGF levels decreased significantly only in the tissue (P = .001), whereas there was no significant difference in the blood and the IP fluid (P = .73 and .08, respectively). We evaluated hydroxyproline levels, anastomosis bursting pressure, and histopathological healing scores. When each of these parameters were examined, there was statistical difference between groups (P = .01, .004, and .01, respectively). It was found that these parameters significantly decreased depending on increasing drug dose. Conclusion. IP administration of bevacizumab effectively reduced the formation of adhesions and caused significant impairment of anastomotic wound healing when standard doses were administered (5 mg/kg), but the 2.5-mg/kg dosage did not affect the anastomotic wound healing and also effectively reduced the formation of adhesions.

Introduction Venous thromboemboli and bleeding are the complications that threaten the graft and patient's life in the early postoperative period after cadaveric renal transplantation. For this reason, heparin administration after renal transplantation should be administered carefully. The aim of this study was to evaluate the necessity for heparinization after cadaveric renal transplantation. Methods Between March 2009 and October 2010, we formed 2 study groups among 50 recipients who underwent either cadaveric (n = 25) or living donor transplantations (n = 25). We did not observe any risk factors for thromboembolism while group 1 did not undergo heparinization, group 2 received a prophylactic dose of low–molecular weight heparin for 1 week. Doppler ultrasonography (USG) was performed between postoperative 24–48 hours to examine the transplanted kidney vessels, and in one group 1 case for a bilateral lower extremity venous system examination. We were also compared postoperative thromboembolic and hemorrhagic complications, lymphorrhagia, and serum creatinine levels. Results The female/male ratios in group 1 and 2 were 14/11 and 8/17 with mean ages of 36.7 (range, 17–51) and 35.9 (range, 17–59) years, respectively. The mean preoperative serum creatinine levels were 7.9 ± 2.9 mg/dL and 6.8 ± 2.4 mg/dL, and at postoperative week 1, they were 5.1 ± 4.3 mg/dL and 1.2 ± 0.5 mg/dL, respectively. We did not encounter any partial or total thrombus upon doppler USG studies for renal and lower extremity venous systems. No clinical symptoms of pulmonary emboli were detected in any patients. Only 1 subject group 2 experienced massive postoperative bleeding. Conclusion Herein, we have reported that, except for the patients with risk factors for venous thromboemboli, heparinization was not necessary in the early postoperative period and did not add benefits to outcomes of cadaveric renal transplant recipients.

AIM: To investigate the eligible management of the cystic neplasms of the liver. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

INTRODUCTIONPrimary teratomas of retroperitoneum are not usual in the adult population. These tumors most commonly seen at the gonadal and sacrococcygeal regions. Herein we describe a case of an 18-year-old female who had a benign cystic teratoma at the retroperitoneum.PRESENTATION OF CASEThe patient underwent an operation at another hospital following a misdiagnosis of hydatid cyst. The patient was referred to our hospital because of the detection of an unresectable tumor during her operation. A computerized tomography (CT)–angiography revealed a cystic mass, with a diameter of 14cm which was invaded into the retrohepatic suprarenal inferior vena cava and also extended to the posterior aspect of the liver. Additionally the mass invaded the posterior wall of the inferior vena cava and the right renal vein. The tumor was completely resected with a vascular resection. The inferior vena cava was reconstructed with a 12cm Dacron® graft and the renal vein was implanted. The patient's postoperative period was uneventful.DISCUSSIONGerm cell tumors of retroperitoneum are usually seen in children, but there are also some reports of adult cases in the literature. Adult cases are especially seen in females. Imaging studies are paramount for diagnosis, preoperative strategy and safe surgical excision. CT scans and MRIs can identify various components of these tumors.CONCLUSIONEven though primary retroperitoneal teratomas are quite rare in adults. Preoperative radiology imaging and strategy is critical for performing a safe surgery. The gold standard treatment strategy for this neoplasm is the surgical resection.