21st Turkish Surgical Association Annual Congress Abstract Supplement: 11–15 April 2018/Antalya

doi:10.5152/turkjsurg.2018.252627

. 2018 Apr 1;34(Suppl-1):S1–S756. doi: 10.5152/turkjsurg.2018.252627

21^st Turkish Surgical Association Annual Congress Abstract Supplement

Conclusion

After LSG, the formation of biliary stones and biliary sludge is quite excessive. While it was found in our study that the demographic parameters such as age, gender, first BMI did not affect postoperative gallstone formation, %EWL was observed to be effective. In the controls after LSG, the presence of possible gallstones should be revealed by performing USG. Gallstone formation has been observed to be more frequent in patients who lose their excess weight, and care should be paid in terms of gallstone complications that may develop in the future in these patients.

TJS. 2018;34(Suppl-1):S6–S7.

OP-010 [Obesity]. The Role of p53 Gene Polymorphism in Obese Patients

While surgery was at the forefront in the period of 2008–2012, it was not required in most of the patients due to successful reduction by colonoscopy in the period of 2013–2017, and surgery-related morbidity and mortality were not observed in this group of patients. The development in medicine can be seen in the table. Colonoscopy was performed in 51 (61%) of patients with sigmoid volvulus in the first period and in 94 (90%) patients in the second period. While the operation rate in the first period was 58%, it was 20 (19%) in the second period. With the transition to colonoscopic reduction and its positive results, the follow-up without surgery has become the first proposal in the literature for sigmoid volvulus. The level of consciousness among the surgeons has also increased, and they tend to colonoscopic reduction. Elective surgery is recommended after the acute emergency surgery problem is solved, and most of the time, the Hartman operation still remains reserved for patients whose ischemia, peritonitis, perforation or reduction is not successful.

Conclusion

Diagnosis was made at a rate of 100% in sigmoid volvulus with SDAG and CT in both periods. Successful reduction with colonoscopy was possible in 81% of patients in the second 5 years. The number of emergency surgery patients in the first 5-year period decreased from 58% to 19% in the second 5 years. The increase in the number of endoscopic procedures, knowledge and experience has reduced the morbidity and mortality in the interventions.

TJS. 2018;34(Suppl-1):S16.

OP-036 [Colon and Rectum Surgery]. Is Robotic Surgery Safe in Rectal Cancer Accompanied by Multiple Co-Morbidities? A Retrospective Cohort Study

Enis Dikicier ^1,^✉, Fatih Altıntoprak ², Mustafa Yener Uzunoğlu ¹, Kemal Gündoğdu ¹, Burak Kamburoğlu ³, Fehmi Çelebi ³

Objective

Minimally invasive approaches whose first practices were in the scope of the general surgery in 1980s have become rapidly widespread and have now become the first choice surgical method for many abdominal surgical procedures. Thanks to the development of patient care; the patients who were previously in the group of patients at risk for open surgery have begun to be evaluated for the possibility of being a candidate for minimally invasive surgery. In this article, when the facts that colorectal cancer patients with multiple co-morbidities are encountered more often and that robotic surgery is being used increasingly are combined; it is investigated whether or not robotic surgery applications are reliable in this group of patients who are evaluated to have high risk.

Material and Methods

We retrospectively reviewed the data of patients who were older than 65 years, had at least 2 comorbid diseases, and who underwent surgical treatment with the diagnosis of early stage rectum cancer at the General Surgery Clinic of Sakarya University between January 2011 and November 2017. The cases were divided into three groups (open, n=41, laparoscopic, n=29 and robotic resection, n=16) in terms of the surgical method that was performed. The patients in three groups were evaluated in terms of age, gender, distribution of comorbid diseases, body mass index, ASA score, duration of operation, postoperative complication, distal and radial surgical margin positivity, number of dissected lymph nodes and mortality.

Results

Of the 86 patients who were evaluated, 34 (39.5%) were female, 52 (60.5%) were male, and the mean age was 70.3 (6586). The most common comorbid disease was DM (65.5%) and HT (56.1%), and ASA score was found to be 3 in 75.9% of them. When evaluated in terms of oncologic and general outcomes; the duration of surgery in the robotic surgery group was significantly longer than the other 2 groups (p<0.001), T-stage was higher in the laparoscopic group (p=0.009), and there was no difference in terms of the mean number of dissected lymph nodes. Although there was no statistically significant difference between the groups in terms of complications separately, the necessity for re-operation was higher in the open surgery and laparoscopic groups than in the robotic group (p=0.046).

Conclusion

Minimally invasive methods have proved to be satisfactory in the surgical treatment of colorectal cancers. We think that the long duration of surgery in robotic surgery is not adversely affecting outcomes in patients who are considered to have high risk due to the presence of co-morbid diseases, and that robotic surgery can also be safely applied in this patient group.

TJS. 2018;34(Suppl-1):S16–S17.

OP-037 [Colon and Rectum Surgery]. The Classification of Pilonidal Sinus Disease According to Physical Examination, Ultrasonography (USG) and Magnetic Resonance (MR) Imaging Findings

Yusuf Yavuz ¹, Mehmet Aykut Yıldırım ¹, Murat Çakır ¹, Ömer Karahan ², Alper Varman ^1,^✉

Objective

Pilonidal sinus is a common disease that arises from the hair follicles located in the sacrococcygeal region, occurs in young ages, and adversely affects the patient’s life. In the literature review, we did not find a study based on the findings of physical examination, ultrasonographic and magnetic resonance imaging in the classification of the pilonidal sinus. In a previous study on classification, imaging studies were not used although the patients were classified according to the physical examination findings. In this study, we aimed to make a classification based on clinical, ultrasonographic and magnetic resonance imaging, which will provide objective criteria for the diagnosis, treatment and recurrence of pilonidal sinus.

Material and Methods

In our study; it was aimed to discuss the solutions related to the evaluation of the forensic reports prepared for the forensic cases in Istanbul Medical Faculty Hospital Trauma and Emergency Surgery Policlinic and to the elimination of their failing sides within the frame of general medical approach, medical ethics and regulations.

Material and Methods

In this descriptive and retrospective study, the reports of adult and child forensic cases referred to Istanbul Medical Faculty Trauma and Emergency Surgery Policlinic between July 01, 2014 and June 30, 2017 were assessed by means of a checklist created in terms of the features to be included in a forensic report, and the data were recorded.

Results

It was found that 21500 patients were admitted to Trauma and Emergency Surgery Policlinic between the dates included in the study, and 5399 reports were issued; 25 of the existing reports were excluded from the study because they could not be read, and 410 of them could not be reached in the archive. When the distribution of the evaluated 4964 forensic reports was examined according to event types; it was found out that 39.5% of them were caused by traffic accidents and 9% of them were sharp object injuries. It was detected that details such as admission date in 96.6%, admission time in 95.2%, type of admission in 5.5%, date of event in 88.3%, time of event in 81.3%, and story of event in 12.9% had been recorded, and 4% of the cases of falling down from height/falling were evaluated as forensic cases. In forensic reports, it was determined that there were information deficiencies such as report number, date-time of issuing report, reason for referral, identification of the examined person, story of the event, date-time of examination, location of lesions, and lesion dimensions.

Conclusion

While the physicians in emergency polyclinic service give curative services in forensic cases, they have to fulfill their forensic medicine responsibilities such as keeping complete forensic records, investigating and keeping any material that carries medical evidence after the examination, reporting to judicial authorities and preparing legal reports. It is clear that the deficiencies found in the judicial reports will cause a failure in the judicial process. This shortcoming brings both institutional and personal responsibility. It is necessary to document the traumatic changes in the body of the forensic case and to prepare a detailed and justified report in accordance with the basic approach stated in the health and legal regulations. Yoğun For a standardized forensic case management in accordance with the current conditions; providing this service with a team of forensic medicine discipline by separating this burden from the treatment service will contribute to the maintenance of in-service training on approach to forensic cases after graduation and to eliminating the identified shortcomings of the multidisciplinary approach.

TJS. 2018;34(Suppl-1):S20.

OP-046 [Emergency Surgery and Trauma]. Is Follow-up Possible with Tomography After Penetrant Left Thoracoabdominal Trauma?

Cemal Seyhun ^1,^✉, Sina Ferahman ¹, Bahadır Kartal ¹, Mehmet Abdussamet Bozkurt ¹, Mehmet Emin Güneş ¹

Traumatic diaphragmatic injuries (TDI) are rare but significant thoracoabdominal injuries that are life-threatening, independent of incision size. Untreated and/or undiagnosed cases may often result in herniation into organs in the thoracic cavity, shortness of breath, and even death. Surgical treatment options have not changed much from past to present. However, the development of radiology and imaging techniques has made it easier to diagnose TDI.

When the literature is reviewed, the incidence of TDI is observed to be between 10% and 15% after penetrant injuries. However, 6038 (0.63%) patients were seen to have diaphragm injuries in a review in which 565 trauma centers participated and which was conducted with 952,242 patients. It is difficult to give the true incidence of TDI because of missed out and delayed diagnoses.

The aim of our study is to investigate the diagnosis of TDI through urgent CT taken prior to surgery.

We found that 317 patients were admitted to our clinic due to sharp object injuries (SOI) in the past 5 years. It was seen that there were 145 (46%) patients who were hemodynamically stable, injured in the left thoracoabdominal region and underwent diagnostic laparoscopy (DL). The data of these patients were retrospectively scanned from their files. Ages, genders, pre-operative abdominal/thoracic computed tomography (CT), durations of operation, length of stay in hospital and the operations performed in the patients were reviewed.

The mean age of the patients was 30 (max: 71, min: 14) and male-female ratio was 19:1 (n: 137: n: 8). The mean duration of operation was 102 minutes (max: 270 min, min: 30 min) and the duration of hospitalization was 4 days (max: 21 min: 1).

Of the 145 patients who were operated on, 74 (51%) had diaphragm rupture and the diaphragm was repaired during the operation. In the CTs of these patients taken before the surgery, 12 (16%) patients were suspected to have diaphragmatic rupture. Although no suspicious rupture was seen in 62 (84%) patients in CT, diaphragmatic rupture was detected in the operation.

Sensitivity of CT in left penetrant TDI was found as 16% and specificity as 97%. It is seen in the literature that the sensitivity is between 17 and 87.2%, and the specifity is between 72.4 and 97%. We consider that this was caused by the fact that tomographies taken for diaphragmatic rupture were reassessed and that the radiologist paid attention to this matter.

In our study, it is seen that the rate of diaphragm injuries in left thoracoabdominal SOI is higher. We think that the admissions and/or referrals of specific and deep injuries to our clinic have caused this situation.

As a result, left thoracoabdominal SOI cases should be evaluated as emergency conditions and decisions should be taken accordingly. In most studies in the literature, the radiologist interprets tomography under elective conditions, and this increases the diagnostic rate of the radiologist through tomography. However, this is not consistent with today’s practice. For this reason, despite the developing technological and radiological methods, DL is still an indispensable method for diagnosis and treatment of the left thoracoabdominal sharp object injuries, even if the tomography is negative.

TJS. 2018;34(Suppl-1):S20–S21.

OP-047 [Emergency Surgery and Trauma]. A Service Hospital or an Outpost Surgery Hospital: A One-Month Temporary Duty Experience

Vahit Onur Gül ^1,^✉, Sebahattin Destek ², Şahin Kaymak ¹

The treatment of patients with giant hepatic hemangioma is controversial. The usual treatment for symptomatic giant hemangioma is surgery; however, minimally invasive techniques have recently been proposed as an alternative treatment. In this study, we aimed to assess the effect of embolization with bleomycin-lipiodol mixture on the symptomatic healing and the size of hemangiomas in the treatment of symptomatic giant liver hemangiomas.

Material and Methods

Seventeen patients with symptomatic giant hemangiomas [10 female, 7 male; Age range 35–67 (mean 46,41±2,6)] who were admitted to our clinic between August 2014 and October 2016 were prospectively assessed. Bleomycin was administered along with lipiodol in selective arterial embolization. The patients were followed up by clinical, laboratory and abdominal tomography (mean 14.47±2.21 months). Statistical analysis was performed using SPSS version 15.0 and p=0.05 was considered statistically significant.

Results

While the mean volume before hemangiomas was 1799.3 cm³ (ranging from 480 to 9925.1 cm³), it was 405.7 cm3 (ranging from 38.7 to 3856 cm³) one year after the intervention. Mortality or morbidity related to treatment was not observed. Symptomatic improvement was observed in all patients and significant volume reduction was achieved (p=0.001).

Conclusion

Minimally invasive bleomycin embolization is an alternative and effective treatment for surgery in patients with giant symptomatic hepatic hemangiomas.

TJS. 2018;34(Suppl-1):S23–S24.

OP-052 [Hepatobiliary Surgery]. Treatment Options in ERCP Perforations: Surgical or Conservative Treatment?

Bünyamin Gürbulak ^1,^✉

Objective

ERCP is an invasive method for the diagnosis and treatment of pancreatobiliary diseases. With the introduction of less invasive imaging modalities such as MRCP and endoscopic ultrasonography, ERCP has been started to be used rather for therapeutic purposes. Complications related to ERCP have been reported to be between 0.08% and 10% in the literature. The most common complication is perforation. Perforation rates have been reported to be between 0.08% and 2% in the literature and mortality between 3% and 20%.

We aimed in our study to evaluate the management of perforation and the perforation cases due to ERCP performed in our hospital in the last 10 years.

Material and Methods

Between January 2006 and January 2018, 8568 ERCP cases performed in the General Surgery endoscopy unit were examined. ERCP reports and hospital records were evaluated retrospectively and a total of 10 cases of perforation due to ERCP were detected during this period. Chest X-ray, plain abdominal x-ray, intravenous (IV) and/or oral contrast enhanced abdominal tomography were taken; complete blood count, biochemical values, amylase, lipase and C reactive protein (CRP) values were evaluated. The durations of hospitalization, the duration between diagnosis and surgery, the duration between ERCP and diagnosis, the type of intervention, the rate of morbidity and mortality, and the clinical course of the patients were evaluated.

Close monitoring, intermittent examination, laboratory and radiological examinations were performed in the patients who were followed up in a conservative way. The patient was scheduled for an emergency operation in the case that he/she has at least 2 criteria of SIRS.

Results

Of the 8568 ERCP patients, ten patients with post-ERCP abdominal pain were hospitalized with the prediagnosis of perforation after ERCP. Perforation diagnosis after ERCP was made when free air and leakage of contrast material in the abdomen and/or in the retroperitoneal area were detected in the IV and/or oral contrast enhanced tomography, along with fever and/or leukocyte and CRP elevation. Four patients were followed up conservatively, and 6 patients were operated. Two patients with type 4 injuries were operated due to general condition impairment. Two patients died.

The mean age of these 10 patients was 59.8 (19–79) years, and 9 (90%) of them were female and 1 (10%) was male.

The average duration between ERCP and perforation diagnosis was 6.7 hours (1–36). The average duration of hospitalization was 9.7 days (2–27). The average duration of hospitalization was 8.5 days in 4 patients in whom medical treatment was applied and it was 10.5 days in 5 patients who underwent surgery.

Conclusion

Timing and correct diagnosis are very important in post-ERCP perforations. Clinical symptoms, imaging modalities and the mechanism of injury occurrence should be evaluated together and the decision of operation should be made accordingly. Close follow-up and medical treatment in patients without septic picture will decrease unnecessary surgery costs and morbidity, and early surgery of the patients who do not respond to medical treatment and in whom infection signs develop may prevent mortality and morbidity.

TJS. 2018;34(Suppl-1):S24–S25.

OP-053 [Hepatobiliary Surgery]. The Efficacy of Percutaneous Cholecystostomy Catheter in High-Risk Patients with Severe Acute Cholecystitis

Tevfik Avcı ^1,^✉, Hakan Yabanoğlu ², Hüseyin Onur Aydın ¹, Erdal Karagülle ³, Gökhan Moray ¹, Ali Harman ⁴

Objective

In our study, we aimed to evaluate the efficacy of percutaneous cholecystostomy in the treatment of the patients diagnosed with acute cholecystitis.

Material and Methods

Between January 2011 and January 2018, medical records of 84 patients who were diagnosed with severe acute cholecystitis and in whom cholecystostomy was inserted in Başkent University Medical Faculty General Surgery Clinic were reviewed retrospectively.

Results

Of the patients who were diagnosed with severe cholecystitis and in whom cholecystostomy catheter was inserted in our clinic, 51 (60.7) were male and 33 (39.3) were female. The mean age was 71.2 (28–94). While all patients had the complaint of pain at the time of admission to the hospital, 15 (17.8%) patients had nausea and vomiting, and 12 (14.3%) patients had fever. The duration beginning from the onset of complaints to the time of admission to the hospital was 5.7 (1–30) days on average, and the duration until the insertion of cholecystostomy was 6.8 (1–36) days on average. Seventy-eight (92.9%) patients had at least one additional systemic disease (hypertension in 47 (55.9%) patients, coronary artery disease in 22 (26.2%) patients, diabetes in 21(25%) patients, chronic obstructive pulmonary disease in 19 (22.6%) patients, chronic renal failure in 9 (10.7%) patients, malignancy in 6 (7,1%) patients, and other systemic diseases in 44 (52.4%) patients). Acute-stoned cholecystitis was detected in 68 patients (81%) at the time of admission and cholecystostomy catheter was inserted in 16 patients (19%) with the diagnosis of acalculous cholecystitis. Biliary wall thickness was found to be 5.1 mm (3–13) on average in the ultrasonography of the patients performed at the admission. Cholecystostomy-related minor complications developed in sixteen (19%) of the patients. Cholecystectomy was performed in thirty-two (38.1%) patients an average of 79.5 (20–705) days after cholecystostomy insertion (20 patients underwent laparoscopic surgery, conversion to open surgery was required in 5 patients, 7 patients underwent open surgery). A cholecystostomy catheter was inserted again because recurrence developed cholecystitis in 6 of 52 (61.9%) patients in whom cholecystectomy had not been performed.

Conclusion

Cholecystostomy catheter is an effective treatment modality for the control of inflammation in high-risk patients with severe cholecystitis. It can be used as a definitive treatment in patients who can not be operated or who do not accept surgery.

TJS. 2018;34(Suppl-1):S25.

OP-054 [Hepatobiliary Surgery]. Immunregulation in Systemic Inflammatory Response Syndrome in Patients With Acute Calculous Cholecystitis

Cabbar Hajiyev ¹, Novruz Hajiyev ¹, Zeynab Mammadova ¹

Objective

The frequency of posteprative complications (10%–45%) and the mortality rate (11.8%) after acute calculous cholecystitis make this pathology one of the current problems in abdominal surgery. The number of disappointing results is growing in the case of acute calculous cholecystitis complicated with systemic inflammatory response syndrome (SIRS). However, adequate methods in the regulation of cytokine profile changes in patients suffering from acute calculous cholecystitis and its complications associated with SIRS have not been developed yet.

The aim is to investigate the effects of metabolic immunomodulator glucutoxim on the cytokine imbalance in patients with acute calculous cholecystitis and its complications associated with SIRS.

Material and Methods

The presence of various forms of SIRS on the background of acute calculous cholecystitis and its complications were identified on the basis of clinical and laboratory findings suggested at the ACCP–SCCM consensus conference (Chicago, 1992). Depending on the type of conservative therapy carried out postoperatively, the patients were divided into two groups: 32 patients were included into Group I (SIRS 2, 11 patients; SIRS 3, 8 patients; SIRS 4, 7 patients; and septicemia in the background of acute calculous cholecystitis, 6 patients) that received generally accepted conservative therapy, and 30 patients included Group II (SIRS 2, 14 patients; SIRS 3, 9 patients; SIRS 4, 7 patients; and with sepsis, 6 patients) who received complex conservative therapy with glucoxime in different doses, taking into account the depth of cytokine immunosuppression and SIRS forms. In each of the two groups, in dynamics the proinflammatory (TNFα, IL-6) and anti-inflammatory (IL-4, IL-10) cytokines were identified in blood serum.

Results

In the preoperative period, the peripheral blood TNFα concentration was 8 times (p<0.001); IL-6, 15.5 times (p<0.001); and IL-4, 8.7 times higher compared to healthy individuals in Group I, but the level of IL-10 was less than 42.2% (p<0.001). After surgery, although the cytokine imbalance extended to the 3rd day in patients from this group, it was subsequently normalized, but on the 7th day of the study, a statistically accurate level of TNFα was found to be 6.2 times; IL-6, 13.1 times; IL-4, 5.5 times; and IL-10 concentration was 16.8% lower than in healthy individuals.

Due to the immunoregulation with glucotoxim in patients from Group II, on the postoperative 7th day, the levels of TNFα, IL-6, and IL-4 statistically decreased compared to Group I and were 44.8%, 73.2%, and 61.9% lower, respectively. The level of IL-10 significantly approached the normal level.

It should be noted that the extent of cytokine imbalance directly depends on the SIRS form and sepsis: When the number of SIRS criteria and time of sepsis are increased, the cytokine dysfunction is extended. Also, the immune-regulating effect of glucoxim directly depends on SIRS forms and sepsis.

Conclusion

On the background of acute calculous cholecystitis and its complications during SIRS, the depth of cytokine imbalance directly depends on the form of SIRS and sepsis, and conventional complex therapy cannot eliminate this imbalance.
Taking into account the SIRS form and sepsis, applying of glucotoxin at different doses in a complex therapy during the postoperative period significantly reduces the cytokine imbalance and decreases the number of irritable-inflammatory complications by 3.4 times.

TJS. 2018;34(Suppl-1):S27–S28.

OP-059 [Colon and Rectum Surgery]. Chronic Anal Fissure: A Retrospective Study Comparing the Effectiveness of Medical Treatment and Surgical Lateral Internal Sphincterotomy (Complete and Partial)

Turan Acar ¹, Nihan Acar ¹, Feyyaz Güngör ^1,^✉, Erdinç Kamer ¹, Hüdai Genç ¹, Ercüment Tarcan ¹, Osman Nuri Dilek ¹, Mehmet Hacıyanlı ¹

Objective

Anal fissure is a longitudinal scar in the anoderm just below the dentate line and is usually found in the posterior midline of the anus. It is one of the most common pathologies of the anorectal region and can alter the quality of life because it causes pain and emotional stress during defecation.

Basically, the treatment of anal fissure involves reducing the sphincter pressure by physical or chemical ways. The American Society of Colon and Rectal Surgeons (ASCRS) also recommends conservative treatment with stool softeners, high fiber diet and warm water sitting bath as initial treatment. The biggest handicap of medical treatment is high recurrence rates. For this reason, lateral internal sphincterotomy (LIS) is still accepted as the gold standard treatment.

In this retrospective study, we planned to make the comparison of the afficacy of topical ointment with diltiazem and nitroglycerin with the surgical lateral internal sphincterotomy (complete and partial).

Material and Methods

This is a retrospective study of 550 patients treated at our General Surgery Clinic between January 2010 and October 2017 for chronic anal fissure.

We randomly separated the patients into four groups:

Group A: Treated with topical nitroglycerin ointment
Group B: Treated with topical diltiazem ointment
Group C: Complete lateral internal sphincterotomy was performed
Group D: Partial lateral internal sphincterotomy was performed

By reviewing the patient files retrospectively; demographic data (gender, age), anamneses, symptoms and findings at the time of admission, the examinations in the first-second-fourth and eighth weeks, responses to the treatment (relief of pain and the assessment of fissure erythema and/or inflammation), side effects of the treatment and disease recurrences were evaluated.

Results

The clinical characteristics of 550 patients (310 males) included in the study are given in Table 1. Accordingly, there is no significant difference among the groups in terms of gender and age distribution. The primary complaint of many patients was pain and bleeding during defecation, while the other major complaints were constipation, itching and perianal discharge. There was no statistical difference among the groups in terms of pain, itching and perianal discharge; however, the complaints of bleeding and constipation were higher in the surgical groups.

Pain relief and fissure healing results are given in Table 2 and Table 3, respectively.

During the treatment period, there were intermittent headache in a total of 22 patients in group A, and it was severe in 6 of them. Three patients had nausea and 2 patients had arrhythmia in Group B. It was observed that 8 of the 14 patients who did not recover in group C had recurrence, 4 had incontinence (gas incontinence in two patients, fluid incontinence in two patients) and 2 patients had perianal abscess. In group D, 6 of the patients who did not recover had recurrence and gas incontinence developed in 1 patient in the early period. While 4 of the patients in whom recurrence developed were reoperated, the complaints of the patient who had incontinance recovered 6 months after the operation.

Conclusion

The results of this study support that complete LIS is the most effective method for chronic anal fissure treatment.

TJS. 2018;34(Suppl-1):S28–S29.

OP-060 [Colon and Rectum Surgery]. Is Lung Graphy Needed Despite Thoracic Tomography in Colorectal Cancer Patients?

Sadettin Er ¹, Kazım Şenol ^2,^✉, Sabri Özden ¹, Umut Fırat Turan ¹, Metin Yalaza ¹, Mesut Tez ¹

Objective

In this study, it was aimed to question the preoperative pulmonary imaging in clinical staging of the patients who were scheduled for operation with the diagnosis of colorectal cancer.

Material and Methods

In the result of the retrospective analysis of 680 patients diagnosed with colorectal cancer between January 2010 and December 2017; preoperative pulmonary imaging examinations, laboratory, clinical and pathological results of 101 patients with suspicious lung mass incidentally detected in postoperative thorax tomography were investigated. The records were evaluated with SPSS statistical program.

Results

The mean age of the patients was 61.2±12.2 years and the male-female ratio was 0.48 (33/68). The mean follow-up duration was 27.7±19.1 months (range: 1–72 months), and 67 (66.3%) patients lost their lives during follow-up. The expected median overall survival was 32 months (95% CI 23.65–40.34) and 1, 3 and 5-year overall survival rates were 90%, 73.4% and 52.8%, respectively. The tumor was located in the ascending colon in 23 (22.8%) patients, in the transverse colon in 4 (4%) patients, in the descending colon in 32 (31.7%) patients, in the rectosigmoid region in 41 (40.6%) and in the entire colon (FAP) in 1 patient. R0 resection was targeted in all patients. The preoperative Ca 19–9 and CEA median levels were 20 and 10 IU/L. The median values of the number of total and metastatic lymph nodes in the specimen were 14 and 2, respectively. There were lymphatic invasion in 59.4% of the patients, venous invasion in 42.6%, and neural invasion in 30.7%. As a result of pathological staging, 88 patients (87.2%) were reported as stage IIIA. When preoperative chest X-rays were analyzed retrospectively, suspicious nodules were detected in chest x-rays of 24 (23.8%) patients. In the one-way analysis, the presence of preoperative lung and liver metastasis, advanced age, high CEA, CA 19–9, and the presence of metastatic lymph node were statistically significant (p<0.05). In multivariate survival analysis, suspicious nodule in preoperative chest x-ray was observed to be the most effective parameter on mortality with a risk factor of 1.1 (HR: 1,12, 95% CI: 0,169–0,943, p=0,036).

Conclusion

Pulmonary metastases are observed in approximately 10% of colorectal cancers, and the nodules located in the lower lobe of the lungs are frequently interpreted in favor of metastasis. The incidence of primary colorectal cancer and lung cancer is 0.6%, and pulmonary metastases alone are observed in only 1–3% of patients. Thorax tomography is more sensitive than chest X-ray in detecting colorectal cancer metastasis (75% vs 33%). In the presence of negative chest radiography before the liver resection, the benefit of the routine use of thorax tomography was questioned until today, because of its low positive predictive value and low advantage. However, as of 2017, thorax tomography is recommended as a routine in the current NCCN Guideline. In this study, the prognostic and clinical importance of pulmonary metastases detected in chest X-ray taken prior to the surgery was tried to be demonstrated, and the predictive value of preoperative chest X-ray was revealed.

TJS. 2018;34(Suppl-1):S29.

OP-061 [Colon and Rectum Surgery]. Surgical Treatment of Pilonidal Sinus Disease with Reverse ‘D’ Incision Technique

Sami Doğan ^1,^✉, Mehmet Fuat Çetin ¹

Objective

Different results are obtained with different techniques in pilonidal sinus surgery. The aim is to provide a successful radical treatment with the least recurrence rate. The aim of this study is to investigate the early results of surgical technique applied through reverse ‘D’ (CI ) incision, subcutaneous excision and primary suture in the treatment of chronic pilonidal sinus.

Material and Methods

Uncomplicated primary cases with chronic pilonidal sinus were included in the prospectively planned study. The study was carried out on a total of 80 cases. The records of patients who underwent surgery between June 2014–September 2017 were kept prospectively. Surgical excision technique was applied with (CI ) incision and primary suture methods in all patients. In addition to (CI) incision, circular elliptical incisions were made around the sinus mouths. The sinus structure was totally removed along with the mouths on the skin after subcutaneous dissection. The skin incisions were closed with primary suture after drain was inserted. Drain was removed on the second day, and skin sutures were removed on the seventh day. Age, gender, family history, duration of disease, pre-operative intervention history, complaints at the admission, number and localization of sinus mouths, early and late complication findings, durations of hospitalization and return to work and recurrence rates were investigated. The patients were followed up for 26.5 (6–45) months on average.

Results

The mean age of the 80 patients, 63 male and 17 female, was 27 years (17–60). There was family history in 18 (22.5%) patients. During the preoperative period, the mean duration of the disease was 2.1 years (2 months–20 years) and 22 cases (27.5%) had a history of local intervention and drainage. The average number of sinus mouths was 1.97 (1–4). Wound infections developed in 3 cases and hematoma developed in 2 cases as a local complication in the early postoperative period. The average length of stay at the hospital was 2.5 (2–4) and the average duration to return to work was 2.27 (2–4) days. Recurrence was seen in 1 (1.25%) case during the follow-up period.

Conclusion

Group 1: The control group (n=24)
Group 2: The group with transverse scar (n=12)
Group 3: The group with oblique scar (n=12)

Following transverse and oblique scar formation in the left flap pedicle, the right flaps forming the control group and the left flaps forming the study group were elevated on the 30th day, and they were sutured in the site where they were elevated. At the end of the 4th day, rats were anesthetized with ether and euthanized. The surviving flap areas on both sides were measured in millimeters. Biopsies including the scars were taken from the study and control flaps for histopathological examination.

Results

The total area of each flap was 1200 mm². While the mean flap area with necrosis in scarred flaps was 80.8% in the rats with transverse scars, this ratio was found as 57.6% in scarless flaps. In the rats with oblique scar, the mean flap area with necrosis was 83.9% in the scar group whereas it was 63.3% in scarless control group.

As histopathological findings; while epidermis and dermis components in normal structure were seen in the scarless control group, atrophy in epidermis and dermis, loss of adnexal structures, and fibrosis involving reticular dermis were seen in both scar groups.

Conclusion

Scar is a factor that negatively affects the random-flap viability. The direction of the scar did not change the rate of necrosis. It has been concluded that only half of a skin flap, which is normally expected to survive, could survive in the distal region of a scar.

TJS. 2018;34(Suppl-1):S33–S34.

OP-069 [Breast Diseases and Surgery]. Breast Cancer in Turkey: The Analysis of 20000 Patients

Vahit Özmen ¹, Tolga Özmen ², Volkan Doğru ^3,^✉

Objective

Breast cancer is the most common cancer in women and the most common cause of death in Turkey. In this study; the demographic, clinical and pathological features, and the survival data of approximately 20.000 women with invasive breast cancer between May 2005 and April 17, 2015 were analyzed.

Material and Methods

In the National Breast Cancer Database of Turkish Federation of Breast Diseases Societies, 576 parameters under 242 different titles were evaluated.

Results

The mean age of the women diagnosed with breast cancer was 51.8 (±12.6), and 16.4% of them were under 40 years old and 37.2% were premenopausal. Histopathologically, 76.9% of them were invasive ductal, 6.5% were invasive lobular, and 8.2% were mixed type breast cancer. Of the patients, 45.4% were histologically grade III and 25.6% were grade III–IV breast cancer. The mean tumor diameter was 25.2 (SD±17,3) mm. Pathological axillary negativity (pN0) rate is 47.2%. Estrogen receptor (ER) was found positive in 72.6% of the patients, progesterone receptor (PR) was found positive in 62.7% and HER-2 receptor was found positive in 21.8%. Modified radical mastectomy was performed in the patients at a rate of 52%, breast conserving surgery (BCS) at a rate of 39% and simple mastectomy at a rate of 8%. Radical mastectomy (43 patients), subcutaneous mastectomy (110 patients) or only axillary dissection (16 patients) are the other operations that were performed. The mean follow-up was 4.3 years and the 5-year survival rate was 86%.

Conclusion

In İstanbul Florence Nightingale Breast Center, there were 2124 patients, and 2032 (96.26%) of them were treated with the diagnosis of invasive breast cancer and 122 patients (5.74%) of them with the diagnosis of ductal carcinoma in situ (DCIS). The mean age of patients diagnosed with invasive breast cancer was 51.4±12.98, and their menopause age was 48.98±4.54. Of the patients, 49,6% were premenopausal. The clinical stages at the time of diagnosis were: 68,7% Stage I cancer, 19,5% Stage II cancer, 1,4% Stage III cancer and 9,5% Stage IV cancer. Pathological stages from Stage 0 to Stage IV were 0,7%, 63,6%, 21,7%, 8,6%, and 5,3%. The mean tumor diameter of the patients who were diagnosed with invasive breast cancer was 24,80±16.42 mm, the distance to the surgical margin was 10.39±22.74 mm in those who underwent BCS, the number of SLNB removed was 1.99±2.11, and the number of lymph nodes removed was 14.76±8.32 in those who underwent axillary dissection. The tumor was multifocal in 16.8% of the patients, and multicentric in 1.4. The average number of positive lymph nodes in patients with positive axillary biopsy was 3.07±5.46. Axillary dissection rate was 55.3%. The positivity of ER, PR and HER-2 receptors were 76.9%, 65.8% and 21.8%, respectively.

After the oncoplasty breast surgery was started in the Istanbul Florence Nightingale Breast Center in 2010, the rate of BCS increased from 66% to 75% and the rate of mastectomy decreased from 33% to 25%. In particular, the application of the mini latissimus dorsi flap increased the chances of protecting the breast. In 70-month follow-up of 1,400 patients who underwent BCS, local recurrence was seen in 53 patients and 41.5% of these patients were under 40 years of age. The rate of true recurrence (in the vicinity of the primary tumor cavity) was 62.3%, and the 5-year overall survival rate was 74.7% in these patients. The 5-year survival rate in patients with new primary tumor was 95% (p<0,033).

TJS. 2018;34(Suppl-1):S34.

OP-070 [Breast Diseases and Surgery]. The Comparative Analysis of Intraoperative Ultrasonography Performed by the Surgeon in Patients in whom Neoadjuvant Treatment was and was not Performed

İlhan Taşdöven ^1,^✉, Ramazan Kozan ¹, Hüseyin Engin ², Burak Bahadır ³, Güldeniz Karadeniz Çakmak ¹

Objective

The success criterion in breast conserving surgery (BCS), which is the preferred method for the current treatment of breast cancer, is to provide the intact surgical margin in the first operation with acceptable cosmetic results. Negative surgical margin is one of the most important parameters in prognosis in addition to the fact that it eliminates the need for mastectomy. For this reason, the methods recommended for achieving this aim with the least loss of tissue are attracting great interest. Excision performed through the real-time guidance of intraoperative ultrasonography (IOUS) is an important technique that serves to provide a negative margin in a single-stage surgery. Neoadjuvant chemotherapy (NAC) is a current approach in local advanced breast cancer, and it gives clinicians valuable information related to the biology of tumor; however, it does not provide decrease in the stage of the tumor. The aim of our study was to compare IOUS in terms of intact surgical margins in patients in whom NAC was and was not performed in order to determine the strengths and weaknesses of the technique.

Material and Methods

Among the patients who received BCS under the guidance of IOUS between 2014 and 2017; the data of 208 patients in whom NAC was not applied (NAC-) and 194 patients in whom NAC was applied (NAC+) were compared. The confirmation of whether or not there was residual tumor tissue through intraoperative real-time sonographic surgical margin surveillance performed by the surgeon, through sonographic and macroscopic evaluation of each margin of the specimen, and through sonographic analysis of the tumor bed, as well as cavity sampling taken from six separate margins of the tumor bed for permanent evaluation were the standart steps of our methodology. The method was the same regardless of being palpable. No tumors at the surgical margin stained with ink in invasive tumors, and no tumors up to the distance of>2mm from the surgical margin in ductal carcinoma in situ (DCIS) were considered as sufficient in the permanent pathologic analysis.

Results

The sensitivity of IOUS in accurately detecting the tumor localization was found to be 100%, independent of NAC uptake. IOUS provided an intact surgical margin in 96.3% of 112 patients with NAC+pathological complete response and in 91.8% of NAC-208 patients. While intact surgical margin was provided with the specimen sonogram at a rate of 98.9% (665/672) in the NAC+group, it was found at a rate of 97.6% (1218/1248) in the NAC-cases. When compared on a case-by-case basis, the positive margin was accurately determined in 71.4% (5/7) of NAC+patients and in 95.4% (16/17) of NAC-patients. While the permanent section results of the two patients in whom specimen sonography could not specify the margin correctly in the NAC+group were reported as invasive lobular carcinoma, DCIS was detected in addition to pure or invasive ductal carcinoma in NAC-patients. Secondary surgery was required in 2.4% of the NAC-patients, but additional surgery was not necessary in the NAC+patients because the cavity samples were negative. None of the groups had mastectomy because of margin positivity.

Conclusion

IOUS-guided BCS is a highly effective and useful method independent of neoadjuvant therapy in terms of ensuring intact surgical margin during initial surgery and eliminating the need for reoperation and mastectomy. While cavity sampling is a factor that reduces the need for re-excision especially in NAC+patients in terms of eliminating possible margin positivity; it should be emphasized that DCIS or lobular histology is the most important parameter questioning the diagnostic accuracy of sonography.

TJS. 2018;34(Suppl-1):S35.

OP-071 [Breast Diseases and Surgery]. The Effect of the Use of Acetylsalicylic Acid on Periprosthetic Capsule and Contracture Developing due to Radiotherapy

Didem Karaçetin ^1,^✉, Didem Can Trabulus ², Canan Kelten Talu ³, Mehmet Ali Nazlı ⁴, Uğur Durukan ²

Objective

In patients in whom silicone implant is placed after mastectomy, as a result of the postoperative radiotherapy, the silicone implant is contracted due to the effect of capsular fibrosis occurring around. In this study, it was evaluated in an experimental animal model whether or not the development of pericapsular fibrosis and contracture decreased with the use of acetylsalicylic acid.

Material and Methods

In the study, 32 Sprague-Dawley female rats weighing 250–300 gr were used. Four groups were formed, each containing 8 rats. A silicone implant was placed in the subcutaneous pocket created in the right thoracodorsal regions of all subjects. They were divided into 4 groups as Group 1: Control group, Group 2: The group receiving radiotherapy after the implant, Group 3: The group receiving radiotherapy and acetylsalicylic acid after the implant and Group 4: The group receiving only acetylsalicylic acid after the implant.

In the subjects of the 2nd and 3rd groups, on the 7th day of the operation, radiotherapy was applied in a single fraction of 2 Gy/min using LINAC with 22 Gy and 6 MV photon energy in such a way that the implant region is covered. In the subjects of the 3rd and 4th groups, acetylsalicylic acid was given once a day for 3 weeks starting from the day following the operation, and its dose was calculated according to an adult human weighing 70 kg and administered in gavage method. All subjects were sacrificed in the 12th week. Implants were removed with the surrounding capsule, examined under light microscope, and fibrosis was assessed.

Results

Results

TJS. 2018;34(Suppl-1):S65.

OP-123 [Obesity]. Is ASA Inadequate in Predicting Mortality in Patients in whom Sleeve Gastrectomy is Performed? OS-MRS Results of 1107 Cases

Evrim Kucur Tülübaş ^1,^✉, Yasemin Tekdöş Şeker ¹, Mehmet Emin Güneş ², Halil Alış ³

Objective

Especially in the last quarter of the century; the rapid development of healthcare industry, better understanding of the anatomy, surgeons aiming for greater benefits with fewer incisions and increasing demands of the patients for fewer incisions have led to great strides in minimally invasive surgical techniques. Minimally invasive surgical technique in many different branches has become a gold standard today. Despite all these developments, restraints on the application of minimally invasive surgical techniques in some challenging cases push surgeons into different pursuits. In addition to this; as a result of the ease of access to information and the increased awareness of patients about surgical treatment options, the development of classic minimally invasive surgical techniques necessitate surgeons and other disciplines to collaborate. In recent years, advances in imaging techniques have led to a more detailed anatomical review, and real-like three-dimensional structurings have led to a shift to a different dimension in the field of surgery. Further pre-operative mapping and navigation of the lesions can be achieved with real-like three-dimensional imaging. Thanks to the further development of 3D printers that have been used for many years in the industry and the combination of 3D imaging and 3D printing, it is possible to make minimally invasive surgical procedures relatively easy in difficult situations. In our clinic, a paraganglioma with aorto-caval location in the retroperitoneal region was treated with this technique. Although atypical and difficult localization of the mass led to many difficulties in terms of surgical technique, access to mass, and patient position; three-dimensional reconstruction of a computerized tomography image and the provision of a real-like printout with a 3D printer made a significant contribution to the successful completion of the surgery laparoscopically. It was possible to map the localization of the mass in this way, to explain the difficulty of the case to the patient in a concrete way preoperatively, to determine the patient position, and to determine the navigation and dissection plan. We believe that improving the three-dimensional imaging and printing technique and using it more widespreadly especially in difficult cases in the clinic will be a significant contribution to informing the patient before the surgery, developing the surgical strategy and to surgical training.

TJS. 2018;34(Suppl-1):S70.

OP-131 [Surgical Area Infection, Surgical Intensive Care]. The Results of Negative Pressure Closure System in Intensive Care Unit

Yasemin Tekdöş Şeker ^1,^✉, Evrim Tülübaş ¹

Objective

Today, surgical negative pressure closure (VAC) systems are frequently used in various wound types and to form a system closed to external environment (1). We wanted to share our experience with patients in whom VAC system was applied in our general surgery clinic and who were followed up in our intensive care unit.

Material and Metods

Following the ethics committee approval, the files of the patients who were admitted to intensive care unit and in whom VAC was used between 2012 and 2017 were retrospectively reviewed. The patients who were under 18 years of age and followed up less than 48 hours in intensive care unit were excluded from the study. Patient demographic data, discharge patterns, length of hospitalization, reproductions, tracheostomy needs, hemodiafiltration needs, APACHEII and SOFA scores at the time of the discharge from the hospital were recorded. The SPSS16.0 program was used for the statistical analysis of the study.

Results

A total of 4880 patient files were reviewed in 5 years. It was found that VAC had been applied in 123 patients. Seventeen patients were excluded from the study because they died within the first 48 hours. Of the remaining 106 patients, 59 were male (56%), and 47 were female (44%); the mean age was determined as 77±15.5 years. While 83 patients (78%) died, survival was provided in 23 patients (22%). While the mean age of the lost patients was 63.9±14.7 years, it was 55.3±19.6 years in those who survived, and the difference was statistically significantly low. Continuous renal replacement therapy was performed in 61 of 106 patients (58%), and 40 patients (38%) died. The reasons for the establishment of VAC were contaminated abdomen in 87 (82%) in the first place, increased abdominal pressure in 16 (15%) in the second place, and necrotizing fasciitis necrotizing fasciitis in 4 (3%) in the third place. While there was no reproduction in 17 patients (16%), gram negative pathogen was found in 51 patients (48%), yeast in 30 patients (28%) and gram positive pathogen in 8 patients (8%). When Apache II and SOFA scores were examined; the admission and discharge scores of the patients who died were found to be statistically higher than those of the surviving patients. In addition, it was determined that the length of stay in intensive care unit in patients who died was statistically significantly shorter than in those who survived.

Conclusion

Results

All operations were performed through laparoscopic method. The mean duration of surgery was 105 min (150 min-85 min). Of the 90 patients (43 men/47 women), 56 (62.2%) used insulin or insulin+oral antidiabetic (OAD) and 34 (37.8%) patients used only OAD. The mean preoperative BMI was determined to be 34.2, FBS was 213, HbA1C was 8.8, total cholesterol was 203.9, and triglyceride was 273,8. At the end of the 24^th month, the mean BMI was 25, FBS was 123.3, HbA1C was 6.5, total cholesterol was 166.9, and triglyceride was 128.4. In the 24^th week, 72% complete remission and 25.7% partial remission (97.2% improvement in general) were observed in hypertension, which is one of the in comorbid data; 66.6% complete remission and 61.5% partial remission (90.3% improvement in general) was observed in diabetes, and the rate of insulin discontinuation was seen as 100%. A 100% of recovery rate was found in apnea and this rate was found to be 81.2% in hypercholesterolemia/triglyceridemia. None of the patients had any loss of vitamins/minerals that would require regular replacement. Morbidity was 0.8% (bleeding in 2 cases requiring opration, leakage in 1 case, permanent diarrhea in 2 cases) and the mortality was 0.4% (MI in 1, thromboembolism in 1, and MOF in 1).

Conclusion

We believe that TB surgery is a highly effective and reliable procedure that does not lead to any absorption impairment in the surgical treatment of Type 2 diabetes mellitus.

TJS. 2018;34(Suppl-1):S79.

OP-144 [Obesity]. 5-Year Results of Laparoscopic Sleeve Gastrectomy in 1113 Patients at Bariatric Surgical Center of Excellence

Burçin Batman ^1,^✉, Hasan Altun ¹, Didem Dal ², Serpil Salman ³, Yelda Tayyareci ⁴, Ferah Ece ⁵, Tuğçe Hürkal ⁵

Laparoscopic sleeve gastrectomy (LSG) has recently become widespread in the world. In this study, we retrospectively evaluated the results of patients undergoing laparoscopic sleeve gastrectomy due to obesity at the bariatric surgical center of excellence. All patients who underwent LSG between July 2013 and January 2018 were evaluated retrospectively. Preoperative and postoperative variables and comorbidities were recorded. In the study, 1113 patients were included. The mean age was 38.3 years and the mean body mass index was 41.44 kg/m². Of the patients, 71% (790) were female. The most frequent preoperative comorbidities were diabetes (22.7%), hyperlipidemia (20.8%), hypertension (19.8%) and obstructive sleep apnea syndrome (20.1%). The recovery rates of comorbidities during the follow-ups were 80.6%, 74.4%, 82.9% and 94.3%, respectively. The postoperative rates of losing excess weight in the 1st, 3rd and 6th months, and in the 1st and 2nd years were 29.76%±11.56%, 54.94%±18.18%, 77.55%±27.25%, 93.58%±24.71%, and 91.52%±41.06%, respectively. Intra-abdominal hemorrhage occurred in 6 patients in the early period; laparoscopy was performed in 3, and conservative follow-up was performed in 3 of them. Wound infection was found in 1 patient, and percutaneous drainage catheter was placed due to intra-abdominal abscess in 1 patient; fat necrosis was detected in 1 patient and early leakage in 1 patient. A stent was placed in the esophagus endoscopically. Stricture was detected in two patients in the late period, and it was treated with endoscopic balloon dilatation. There was no mortality. LSG is an effective method to lose weight and for the improvement of comorbidities.

TJS. 2018;34(Suppl-1):S79–S80.

OP-145 [Emergency Surgery and Trauma]. The Factors Affecting Survival in Open Abdomen Caused by Abdominal Sepsis

Seracettin Eğin ^1,^✉, Berk Gökçek ¹, Metin Yeşiltaş ¹, Semih Hot ¹, Sedat Kamalı ¹, Rıza Gürhan Işıl ¹, Hasan Tok ¹, Servet Rüştü Karahan ¹

Objective

We aimed to investigate the factors affecting survival in patients with intra-abdominal sepsis treated with open abdomen (OA) and negative pressure system (NPS). Our hypothesis is that NPS and OA applications reduce mortality in patients with severe intra-abdominal sepsis (SIAS).

Material and Methods

We retrospectively reviewed 40 OA patients who were managed with NPS for SIAS between January 2013 and September 2017 in our clinic. Living and mortal groups were compared in terms of the parameters of age, gender, body mass index (BMI), SIAS etiology, Apache II score, Mannheim peritonitis index (MPI) score, Bjorck classification, fascia score, abdominal defect size, the presence of stoma and fistula, fistula type, and the duration of NPS application. Whether these parameters were effective on survival was analyzed with SPSS software version 23.0. The patients who had preoperative SIAS or septic shock and who were treated with NPS were included in the study.

Results

Twenty-three patients were in the survival group and 17 patients were in the mortal group. The mean age and BMI were significantly high in the mortal group while there was no significant difference between the two groups in terms of gender The most frequent causes of SIAS were anastomotic failure and small bowel perforations, and it constituted 67.5% of the patients. There was no significant difference between the groups in terms of etiology. There was a significant difference between the two groups according to Bjorck classification The presence of fistula was statistically significant in terms of mortality (p: 0.021). The type of fistula was also significant in terms of mortality. Other parameters were not found to be significant.

Conclusion

We prefer to apply NPS and OA in patients with abdominal sepsis irrespective of the intraabdominal pressure levels before the first operation. Statistically significant differences between groups in terms of age, BMI, Bjorck classification, fistula presence, and fistula type are the most striking findings of our study and are the apparent evidences affecting survival. In the infected OA patients, the mortality rate is more than 50% in the literature. The additional presence of enteroatrophic fistula in the clinical situation further increases mortality and morbidity. Significant differences in terms of the presence and types of fistula showed that survival was directly related to low Bjork stage and the absence of fistula. The limitation of our study was that it was a retrospective research and the number of patients was low. We used strict inclusion criteria in order to form our population with similar patients. The similarity of our patient population, where the same treatment strategies were applied, was the strong side of our study. Age and BMI are the results of the patients that we can not change, but Bjorck stage, and the presence and type of fistula are the results that we can change. Given the changeable outcomes, it is possible that survival increases. The results of our study indicated NPS and OA application before intra-abdominal adhesions for the prevention of fistula formation for better survival.

In conclusion, the 42.5% mortality rate in our study is lower than the mortality rate of abdominal sepsis patients in the literature. Our study showed that NPS and OA therapy increased survival in patients with surgical abdominal sepsis.

TJS. 2018;34(Suppl-1):S80.

OP-146 [Emergency Surgery and Trauma]. Risk Factors for Intra-abdominal Pressure Increase in Patients Operated due to Penetrating Abdominal Trauma

Mustafa Uğur ¹, Erol Kılıç ^1,^✉

Objective

Primary hyperparathyroidism is the third most common endocrine disorder after diabetes mellitus and hypothyroidism, and it affects approximately 0.3% of the general population. The primary treatment of parathyroid adenomas is surgery. As the success rate of localization of the adenoma increases in the surgery, a transition is observed from traditional 4-gland neck exploration to minimally invasive parathyroidectomy. The most commonly used methods for the localization of the parathyroid gland are [99mTc] MIBI SPECT/CT and USG. By adding a single phase contrast to [99mTc] MIBI SPECT/CT study, we aimed to compare the preoperative contrast-enhanced [99mTc] MIBI SPECT/CT results with the surgical results. Twenty-four (21 female, 3 male) patients who were operated after preoperative contrast enhanced [99mTc] MIBI SPECT/CT between 2016 and 2018, and 49 (42 female, 7 male) asymptomatic patients who were not operated were included in the study. The sensitivity and specificity rates of contrast enhanced [99mTc] MIBI SPECT/CT were found to be 100% and 100% when evaluated together with surgical results. The rate of detection in asymptomatic patients was 93.8%. With high contrast [99mTc] MIBI SPECT/CT imaging, high sensitivity and specificity values were achieved in preoperative localization of paratroid adenomas as well as high detection rate was achieved in asymptomatic group. In all patients without contraindications, the use of IV contrast during [99mTc] MIBI SPECT/CT increased the rates of both the preoperative localization of adenomas and the detection in asymptomatic hyperparathyroids.

TJS. 2018;34(Suppl-1):S87–S88.

OP-157 [Endocrine Surgery]. Our Surgical Experience in Insulinomas

Mustafa Gök ^1,^✉, Erdoğan Mütevelli Sözüer ¹, Abdullah Bahadır Öz ¹, Alper Celal Akcan ¹

Objective

The aim of our study is to present our pre-operative findings and surgical experiences in 5 patients operated in our clinic due to insulinoma.

Material and Methods

All of our patients were diagnosed with insulinoma after being discussed and pre-operative evaluations at the council of multidisciplinary endocrine diseases between 2010 and 2016, and were referred to our clinic. The patients underwent routine prolonged fasting test for the purpose of diagnosis. No pathology was found in any patient in USG evaluations performed as imaging method. Computed tomography was able to clearly identify the mass in only one patient. Tomography was not performed in one patient due to contrast allergy. The mass could be demonstrated through MRI in 4 patients. Scintigraphy was applied in the patient in whom the mass could not be detected through MRI, and when the results of this examination was reported as suspicious, angiographic calcium infusion test was performed. Per-operative USG was applied to the same patient in order to determine the mass localization and to evaluate its relationship with the surrounding tissues. Because there was discrepancy in terms of the localization determined in the MRIs performed in an external center and in our clinic, the correlation was provided in one patient with endoscopic USGGA-68 scintigraphy was performed in one patient because there were a large mass volume and liver metastasis in the MRI. All patients were operated with open surgery method and no complications were encountered.

Results

The mean age of the patients was 42.4 (31–59) years. The mean tumor diameter of the 5 patients was 1.6 cm (1.0–2.5 cm). Their locations in the pancreas and the surgeries performed are as indicated. The mean hospitalization period was 12.8 days (5–24 days).

Conclusion

OP-168 [General Surgical Diseases]. Acute Cholecystitis Attacks Make Laparoscopic Cholecystectomy Difficult

Conclusion

In patients with primary hyperparathyroidism, the diameter, histopathology and localization of the pathologic glands affect the accuracy of preoperative imaging techniques. The possibility of the presence of more than one adenoma in surgical exploration increases in cases that cannot be detected by preoperative imaging methods.

TJS. 2018;34(Suppl-1):S105.

OP-188 [Endocrine Surgery]. Comparison of Thyroid Surgery in Young and Elderly Patients

Conclusion

Compared with standard colectomy, it has been demonstrated that CME technique performed with high vascular ligation and embryological plane has better oncological results in terms of local recurrence and survival and this finding has increased the level of attention paid to CME in recent years. CME was firstly performed with open surgical technique, but laparoscopic method was also preferred over the years due to its advantages in the postoperative period. However, transverse colon tumors were ruled out in most of the laparoscopic series because of the less frequent localizations in the colon than other localizations and the technical difficulties in the dissection of the middle colic vessels. Together with the developing technology, the introduction of robotic systems in the field of colorectal surgery has provided important advantages such as stable camera and tissue traction for the surgeon, three-dimensional high-resolution stereoscopic images, wide mobility with angled instruments, and better ergonomics.

The results of our study show that transverse colon CME surgery can be performed with good oncological dissection and acceptable morbidity thanks to the technical advantages offered by robotic surgery.

TJS. 2018;34(Suppl-1):S109.

OP-194 [Colon and Rectum Surgery]. Transanal Endoscopic Surgery in Rectum Tumors: Single Center Experience

Osman Bozbıyık ¹, Safa Vatansever ^1,^✉, Cemil Çalışkan ¹, Tayfun Yoldaş ¹, Erhan Akgün ¹, Mustafa Korkut ¹

Objective

Transanal endoscopic surgery is a preferable technique in the treatment of benign and selected malignant rectal lesions with similar survival rates, but with lower morbidity compared to the conventional surgery.

Material and Methods

Twenty-four patients who underwent transanal endoscopic surgery at Ege University Hospital were included in the study. Data of the patient were obtained retrospectively. The indications were benign rectal lesions and early malignant lesions. The operations were performed by using the transanal endoscopic operation platform (TEO®; Karl Storz, Tuttlingen, Germany).

Results

Of 24 patients, 79% (n=19) were male and 21% (n=5) were female. The mean age was 61 (17–87, SD=15) years. The mean distance of the tumor from the anal entry was 7 cm (3–15, SD=2). The mean tumor diameter was 3 cm (0.5,7, SD=1). Of the lesions, 88% (n: 18) were fully excised in a single piece and 8% (n=2) were excised as fragments. Complete resection could not be achieved in one (4%) lesion. The indication was benign lesion (adenoma) in 18 (75%) patients and adenocarcinoma in the other 6 (25%) patients. Malignant lesion was detected in 75% (n: 18; Tis: 9, T1: 0, T2: 7, T3: 2) of the cases in the pathological evaluation after resection. Malignancy was detected in 12 of 18 patients who were thought to be benign before the operation. In the postoperative period, 3 patients (12%) developed morbidity (perforation in one patient, bleeding in two patients). The lateral and deep surgical margins were tumor-free in all malignant patients. Two (8%) patients with carcinoma in situ were observed to have adenomatous epithelium in the surgical site. The mean length of hospital stay was 3 days (SD=3). The mean follow-up period was 24 months (SD=12). Recurrence adenoma developed in 1 (4%) patient who was operated for adenoma during the follow-up period. Local excision was performed again. Total mesorectal excision was performed in 1 of 7 patients detected to have T2 invasion in the histopathology and others were followed up. No local recurrence or distant metastasis was detected in these patients. Total mesorectal excision was recommended after radiochemotherapy in two patients with T3 invasion in the histopathological evaluation. One patient did not accept the operation and lung metastasis was detected in this patient in the 31st month of the follow-up.

Conclusion

Transanal endoscopic surgery allows the excision of rectal lesions that cannot be excised by a traditional approach (endoscopic or local excision) with a low morbidity rate. Moreover, it provides the establishment of definite histopathological diagnosis with the total excision of lesions the pathology of which cannot be revealed exactly. It can safely be used for the excision of early stage malignant rectum tumors with appropriate surgical margin.

TJS. 2018;34(Suppl-1):S109–S110.

OP-195 [Endoscopy (Gastroscopy, Colonoscopy, ERCP)]. Case Series on Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection and Results

Musa Murat Çalışkan ^1,^✉, Hasan Bektaş ¹, Şükrü Çolak ¹, Bünyamin Gürbulak ¹, Ekrem Çakar ¹, Mert Mahsuni Sevinç ¹

Objective

Today, endoscopy is a part of surgical practice, both as a diagnosis and treatment method. Many surgical pathologies can be treated with endoscopic submucosal resection (EMR) and endoscopic submucosal dissection (ESD). In this presentation, endoscopic treatments of mucosal and submucosal lesions of the gastrointestinal system (GIS) in our clinical practice were presented.

Material and Methods

The results of EMR and ESD performed in our hospital between 2014 and 2018 were discussed. The mean age of 49 patients (22F/27M) was 57.4 years.

Results

In our study, ESD and EMR procedures were applied to 5 different anatomic groups in GIS. EMR-ESD ratios and locations for our case series are presented. These cases included 9 (4F/5M) patients with lesion in the esophagus, 26 (14F/12M) patients with lesion in the stomach, one male patient with lesion in the duodenum, 8 patients with lesion in the rectum (2F/6M), and 5 patients with lesion in the colon (2F/3M). Of these patients, 5 with stomach lesions were performed ESD procedure by double endoscopes.

Endoscopic ultrasonography (EUS) was applied in 6 patients according to the shape and size of lesion before the EMR procedure and in all patients before ESD.

The histopathological diagnoses of our cases.

In one patient who underwent ESD using double endoscope, insitu carcinoma was detected. The patient was followed up because a safe surgical margin was provided.

In one of patients, the duodenum was treated with EMR twice at different areas and at different times. Both pathologies were reported as adenomatous polyps.

In one of our EMR cases with colon localization, in situ carcinoma excised with intact borders was detected.

This study was carried out as a single-arm study in a single center. Adult patients who had symptomatic crypto-glandular perianal fistulas between June 2012 and July 2014 were included in the study. In a polyclinic setting; while the patient was placed in the lateral decubitus position and after the external orifice of the fistula was determined, a catheter was sent to the fistula tract and it was irrigated with 1% silver nitrate solution. The patients were followed-up in a polyclinic for 2 weeks. Irrigation was repeated in the cases where the flow was not discontinued and the external orifice was open. In the follow-up, the discontinuation of the discharge and the closure of the external orifice were evaluated as improvement.

Results

One hundred and eighty-six patients were included in the study. Of the patients, 147 (79%) were male and 39 (21%) were female. The median follow-up was recorded as 50 (7–64) months. In the follow-up of the patients, 82 (44%) of 186 patients had clinical improvement. The median follow-up period of 82 patients without recurrence was found to be 40 (10–62) months. It was found that the rate of recovery in patients (n=19) followed up for 20 months or less after the procedure was 36% (n=7), the rates of imrovement of the patients (n=167) followed up more than 20 months were found to increase to 45% (n=75). The clinical full recovery rate of the patients describing intermittent discharge was found to be significantly higher than that of patients with continuous discharge (59% vs 39%, p<0.001). No side effects related to irrigation were observed.

Conclusion

This study shows that the use of silver nitrate in the treatment of anal fistula has acceptable results. It is a simple, inexpensive, minimally invasive procedure that can be applied without requiring hospitalization, and it is a method that can be used as the first choice in anal fistula treatment because of the improvement rate in long-term follow-up.

TJS. 2018;34(Suppl-1):S116.

OP-205 [Colon and Rectum Surgery]. The Prospective Randomized Comparison of Laser Hemorrhoidoplasty and Stapler Hemorrhoidopexy Methods in Symptomatic Hemorrhoidal Disease

Pelin Basım ^1,^✉, Cenk Ersavaş ¹, Yaşar Özdenkaya ¹

There are various surgical treatment options for symptomatic hemorrhoidal disease that does not respond to medical treatment, and the superiority of the techniques to each other are determined by post-operative recurrence and complication rates. In this study, we aimed to determine the efficacy of stapler hemorrhoidopexy methods and laser hemorrhoidoplasty, which are the most commonly used methods in patients who received operation indications in terms of 1) duration of operation 2) postoperative pain 3) duration of stay in hospital 4) duration for return to daily life and work and 5) recurrences.

Between June 2014 and January 2017, the patients who were operated due to symptomatic grade 3 hemorrhoidal disease underwent prospective randomized laser hemorrhoidoplasty (group 1) and stapler hemorrhoidopexy (group 2); the results were compared. All patients were evaluated in terms of age, gender, duration of operation, postoperative pain, postoperative complications, duration for complete recovery, sitting comfortably, ability to use vehicle, durations for return to work and postoperative satisfaction, and in terms of quality of life and recurrences through SF 36 questionnaire.

A total of 246 patients were operated due to symptomatic grade 3 hemorrhoidal disease. Of the patients, 121 had undergone the conventional hemorrhoidectomy operation in the last 5 years. This patient group was excluded from the study. In 125 patients who participated in the study, the female/male ratio was 1.08/1 and the mean age was 41 years. Sixty patients underwent laser hemorrhoidoplasty and 65 stapler hemorrhoidopexy. While the mean duration of surgery was 16.7 min in Group 1, it was found as 20.16 min in Group 2. The durations for return to daily life and work were found to be shorter in the laser haemorrhoidoplasty group (4.2 and 6.6 days) than in the stapler hemorrhoidopexy group (7.8 and 10.6) (p<0,05). While no bleeding was observed in any patient in Group 1, one patient in group 2 underwent revision due to bleeding. Wound site infection developed in two patients in group 1 and in one patient in group 2; it regressed with advanced medical treatment. There was no statistically significant difference between the two groups in terms of the length of stay in hospital (0.8 vs 0.9 While satisfaction rate was 90% and above in 96% of the patients in Group 1 at the end of the postoperative 1st month, satisfaction over 90% was obtained in 84% of the patients in Group 2. The follow-up period ranged from 11 to 42 months. In this period, 4 (6.6%) of the patients in group 1 and 3 (4.6%) of the patients in group 2 were admitted due to recurrence and single pake excision was performed in the patients. Laser haemorrhoidoplasty technique is a surgical procedure that can be applied easily in operating room conditions, and is more simple and superior than stapler hemorrhoidopexy method in terms of short duration of operation, hospital stay, duration for return to work, patient comfort and satisfaction. However, we believe that a longer follow-up period is needed in order to evaluate the significance in terms of recurrence. We believe that the laser hemorrhoidoplasty technique we have applied can be a good option in the treatment of hemorrhoidal disease.

TJS. 2018;34(Suppl-1):S116–S117.

OP-206 [Colon and Rectum Surgery]. The Prognostic Significance of the “Circumferential Resection Margin” in Colon Cancer

Mücahit Özbilgin ^1,^✉, Selman Sökmen ¹, Sülen Sarıoğlu ²

Objective

The prognostic significance of circumferential resection margin (CRM) involvement in patients undergoing curative resection due to colon cancer was investigated.

Material and Methods

The prospectively recorded clinicopathological data of 339 colon cancer patients (pT3-pT4) who underwent radical resection in Dokuz Eylul University, Faculty of Medicine, Department of Colorectal Surgery between January 2005 and January 2009 were examined. In histopathological examination, CRM was defined as the closest retroperitoneal adventitial soft tissue margin to the deepest penetration of the tumor.

Results

CRM positivity was observed in 117 patients (34.5%). A significant relationship was found between CRM involvement and degree of differentiation, tumor invasion depth, lymph node involvement, venous invasion, lymphatic invasion, tumor invasion border type and local recurrence (p<0.05). In multivariate analysis, it was found that venous invasion positivity and tumor invasion depth were independent prognostic factors on CRM (p<0.05). The frequency of local recurrence was found to be increased in the patients with CRM positivity compared to the patients with CRM negativity (p<0.01). Disease-free survival (355±74 days) was significantly lower in patients with CRM involvement than in patients without CRM involvement (609±45 days) (p<0.05). In multivariate analysis, the presence of metastasis and CRM involvement was found to be an independent prognostic factor on disease-free survival (p<0.01; CI=0.128–0.625 and p<0.05; CI=0.276–0.926).

Conclusion

CRM involvement in colon cancer has been found to be associated with advanced tumor spread, increase in local recurrence and decrease in disease-free survival. CRM positive patients may benefit from postoperative adjuvant chemotherapy and radiotherapy because of increased risk of local and systemic disease. The interpretation of this prognostic factor should be routinely included in standard histopathological reports of patients with colon cancer.

TJS. 2018;34(Suppl-1):S117.

OP-207 [Pancreas Surgery]. The Effect of Hospital Volume on Mortality, Morbidity, and the Number of Dissected Lymph Nodes in Whipple for Periampullary Region Tumors

Veysel Barış Turhan ^1,^✉, Mustafa Kerem ²

Objective

Since it was first performed, pancreaticoduodenectomy (PD) has been known to decrease morbidity, mortality and hospital stay, and increase the number of dissected lymph nodes and discharges from the hospital without complications. It is thought that the improvement of the results of a complex surgery such as PD may be associated with experience and hospital volume.

Material and Methods

Two hundred and thirteen patients who underwent PD with the preliminary diagnosis of periampule region tumor in Gazi University Department of General Surgery between January 2008 and January 2016 were included in the study. The patients were divided into 4 groups according to the years of operation as 2008–2009 (Group A), 2010–2011 (Group B), 2012–2013 (Group C), and 2014–2016 (D group). The rates of pancreatic fistula, duration of postoperative hospitalization, mortality rates, morbidity rates, and dissected lymph nodes were compared in the groups.

Results

The ages of the patients were between 14 and 87, and the mean age was 59,71±13,23. Of 213 patients, 87 (40.9%) were female and 126 (59.1%) were male. The mean follow-up period of the patients included in the study was found to be 21.53±5.5 months. Hospital stay was minimum 1 and maximum 85 months. According to the distribution of pathologic diagnoses of patients, 63 (29.6%) of the patients had a well-differentiated adenocarcinoma, 52 (24.4%) of the patients had moderately-differentiated adenocarcinoma, and 21 (9.9%) of them had poorly-differentiated adenocarcinoma. In the pathology results of the patients, 107 (50.2%) had T3 tumors, 53 (24.9%) had T2, 15 (7%) had T4 and 12 (5.6%) had T1 tumors. No pathological malignancy was encountered in 26 of the patients (12.2%). In 135 (63.4%) of the 213 patients, the tumor was located in the pancreatic head, it was located in the ampulla in 33 (15.5%), in the distal bile ducts in 24 (11.3%), and in the duodenum in 14 (6.6%) patients. Standart PD was performed in 194 patients and pylorus-preserving PD in 18 patients. Vascular resection was performed in 11 patients (5.2%) including 9 portal vein resections and 3 superior mesenteric vein resections. As pancreatic anastomosis technnique, classic duct-to-mucosa technique was performed in 112 patients (52.6%), Blumgart technique in 90 patients (42.3%), Hieldenberg technique in 6 patients (2.8%), and pancreatic-gastrostomy technique in 5 patients (2.3%).

The quality and duct width of the pancreas tissue were found to be associated with fistula. It was found that 1 and 3-year survival decreased in cases with metastasis positive lymph nodes and cut-off value could be taken as 13 for the dissected number of lymph nodes. It was predicted that a better staging would be performed as the number of dissected lymph nodes increased. It was seen that as the hospital volume increased, mortality and morbidity rates, hospital stay and fistula rates decreased.

Conclusıon

Considering the relationship between the hospital volume and result; the surgeon’s experience increases as the volume increases. A comprehensive knowledge of anatomy can improve the quality of the surgery. As a result; morbidity and mortality rates decrease, the number of dissected lymph nodes increases and the length of hospital stay decreases.

TJS. 2018;34(Suppl-1):S118.

OP-208 [Pancreatic Surgery]. The Evaluation of All Surgical Margins through the Sampling of Pancreatic Surgical Resections with Proper Macroscopic Methods: Surgical Pathology Experience with 285 cases

Özgür Ekinci ^1,^✉

Objective

Objective

Injury of the recurrent laryngeal nerve in parathyroid surgery is an important complication. Experienced surgeons can see and protect the nerves. However, the risk of hemorrhage may also increase during this procedure. In order to avoid these complications, the use of intraoperative nerve monitorization has been increasing in recent years. While these complications are reduced, on the other hand, complaints such as swallowing difficulties occur at a higher cost. In this study, we aimed to investigate the efficacy and necessity of using intraoperative nerve monitoring in parathyroid operations.

Material and Methods

A total of 113 patients who underwent parathyroidectomy operation between January 2016 and December 20117 were included in this study. Intraoperative nerve monitorization was applied in 51 patients in the first group. Monitorization was performed via the endotracheal tube using electrode contacting the glottis. When the tip of the device touches the nerve, a voice and image appear on the device screen by vagal stimulation. A stimulation with the value of 0.5 mAmp is considered positive, and 2 mAmp and above is considered negative if there is no response. The mean age of patients in whom nerve monitorization was performed was 54.9 years. The mean duration of hospitalization was 3.2 days (1–7 days). The indication for surgery was parathyroid adenoma (90.2%) in 46 patients, hyperplasia in 5 patients (9.8%), and the most common localization of the lesion was right lower parathyroid (43.1%). In the second group, parathyroidectomy was performed in 62 patients with a mean age of 46.8 years without nerve monitorization. The hospitalization period was 1.8 days (1–4 days) on average. In this group, the indications for surgery were adenoma in 56 patients (90.3%) and hyperplasia in 6 patients (9.7%). The most common site of the lesion was right lower parathyroid (35.5%). In the nerve monitorization group; while hemovac drainage was used in 15 patients (29.4%), it was used in 7 patients (11.3%) in the group in which monitorization was not performed.

Results

Results

TJS. 2018;34(Suppl-1):S144–S145.

OP-261 [Surgical Area Infection, Surgical Intensive Care]. Evaluation of the Relationship between Neutrophil Lymphocyte Ratio, Mean Platelet Volume, Fournier’s Gangrene Severity Score and Mortality in Patients with Fournier’s Gangrene

Faruk Pehlivanlı ^1,^✉

Objective

Fournier’s gangrene (FG) was first described by Baurienne in 1764. Fournier Gangrene is a necrotizing fasciitis which affects the external genital, perineal or perianal region, developing and progressing rapidly and can have a mortal course. The purpose of this study was to examine the relationship between retrospective analysis, Neutrophil Lymphocyte Ratio (NLR), Mean Platelet Volume (MPV) and Fournier’s Gangrene Severity Score (FGSS) of 23 cases treated due to Fournier’s gangrene in our clinic and mortality with the literature.

Material and Methods

Patients who were treated due to Fournier’s gangrene in our clinic between 2010–2018 were evaluated retrospectively. Twenty eight patients were detected in the examination. Of these patients, 5 of them were excluded from the study because of inadequate records. A total of 23 patients were included in the study. The patients were examined in terms of age, gender, comorbid disease, etiological factor, duration of hospitalization, NLR, MPV, FGSS, number of debridement, need for ostomy, reproduction in culture, complication and mortality. The patients were divided into two groups as those who were discharged (Group 1) and those who resulted in mortality (Group 2) and the comparison results between the groups were examined. Statistical analysis was performed using SPSS 21.0 software.

Results

The mean age of the patients was 65.91 (±16.34) years. Nineteen (82.6%) of the patients were male and 4 of them (17.4%) were female. Hospital admission times were 3.13 (±1.65) days. The most common cause of the disease was perianal abscess (14 patients, 60.9%). The most common comorbid disease was Diabetis Mellitus (DM) (11 patients, 47.8%). Escherichia colii was the most frequently isolated pathogen in wound culture (17 patients, 73.9%). Most frequent postoperative complication was pulmonary embolism (6 patients, 66.66%). When the groups were compared, NLR, FGSS, number of debridement and complication rate were significantly higher in Group 2 (p<0.05). In terms of the underlying cause, there was a significant difference between the groups in terms of perianal abscess in Group 1 and in terms of rectal cancer in Group 2 (p<0.05).

When the results were evaluated, it was seen that the majority of the patients’ being at advanced age, male gender, developing on the ground of perianal abscess and DM being the comorbid disease was in line with the literature. In our data, when the comparison between the groups was done, it was seen that if the underlying cause was rectum cancer, the mortality rate was higher. Complications during treatment were higher in patients with mortality. However, the number of debridement was found to be significantly higher in patients with mortality, which we think may be used to assess the severity of the disease for the continuation of the treatment. There was no significant difference in MPV rates of the patients between the groups, whereas the NLR values were significantly higher in patients with mortality. Likewise, FGSS rates were significantly higher in this group.

Conclusion

We believe that NLO values in addition to FGSS at the time of admission will contribute to the assessment of the severity of the disease.

TJS. 2018;34(Suppl-1):S145–S146.

OP-262 [Surgical Area Infection, Surgical Intensive Care]. Evaluation of the Predictive Value of Omentin in Surgical Intensive Care Patients

Yücel Gültekin ¹, Afig Gojayev ^2,^✉, Selen Yılmaz Işıkhan ³, Yusuf Alper Kılıç ², Halil Kaya Yorgancı ²

Objective

The aim of this study was to determine serum omentin value in patients in the general surgery intensive care unit and to evaluate its usefulness as a prognostic factor.

Material and Methods

A total of 428 blood samples were collected for omentin from the 153 patients hospitalized in the general surgery intensive care unit during hospitalization and in new clinical conditions such as sepsis, hemorrhage, infection, mechanical ventilation during intensive care. Prealbumin, procalcitonin, CRP were analyzed simultaneously from the blood taken. When blood samples were taken for APACHE II and every omentin when the patients were hospitalized, SOFA score was calculated and recorded.

Results

A total of 153 patients, 82 of whom were male and 71 were female, were included in the study and a total of 428 blood samples were collected from these patients. 19 patients developed mortality in intensive care unit. No significant effect of age on omentin concentration was observed (p≥0.05). The mean omentin value of the living patients was 405.15±351.23 ng/mL, while the mean omentin level was 167.37±199.85 ng/ml in patients with mortality. The difference of serum omentin value between the living patients and the patients who developed mortality was statistically significant (p=0.001). There was a negative correlation between CRP, procalcitonin and SOFA score and omentin, whereas positive correlation was found between prealbumin and omentin.

Conclusion

Omentin is among adipokines produced dominantly from the stromal-vascular part of the visceral adipose tissue and visceral adipose tissue. Adipose tissue is the most important mediator of inflammation and metabolism. Adipose tissue, especially in the abdomen, is considered as endocrine tissue. Studies related to omentin are limited in the literature. No study could not be found in the literature especially on the availability of omentin as a predictor of mortality. However, omentines have been evaluated in many human and animal studies and it has been shown that omentin has a predictive value in diseases such as mesenterian ischemia, inflammatory bowel disease and coronary artery disease. It has even been reported that it can be used as a cancer marker in some malignancies. However, the role of omentin in inflammation and metabolism and its mechanism of action are not clear. In our study, the value of omentin was examined in patients in General Surgery Intensive Care Unit during hospitalization and in clinical change and it was detected that omentin was statistically different in living and mortality developing patients in intensive care and that it could be used in mortality prediction. In our study, the relationship between the change in clinical status and omentin was also evaluated in intensive care patients. SOFA scoring system was used for this purpose. There was a negative correlation between the increase in SOFA and the level of omentin. At the end of the study, it was thought that the value of omentin could be used in the estimation of mortality and prognosis of intensive care patients. However, we believe that there is a need for a larger and multi-centered and studies with various patient groups including control group.

TJS. 2018;34(Suppl-1):S146.

OP-263 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Intussusception in Adults: Diagnosis and Treatment Approach

Kenan Büyükaşık ^1,^✉

Results

Of 641 patients, 64.9% were male and 35.1% were female. 31.2% of all the cases consisted of Group 1, 45.7% (n=293) of the cases consisted of Group 2 and 23.1% (n=148) of the cases consisted Group 3. Demographic and clinicopathological features of patients. Patients were also classified according to their stages. Accordingly, 10.1% (n=65) of the patients were stage I, 45.7% (n=293) of them were stage II and 44.2% (n=283) of them were stage III. The distribution of the patients according to the stages and the differences between the stages. Localization and phase analysis.

Conclusion

According to our study, tumor localization in stage I–III patients has no effect on prognosis. In addition, although there is no statistically significant difference, tumors with MMR deficiency (dMMR) and low microsatellite inactivity (MSI-L) are more common in tumors with right colon.

TJS. 2018;34(Suppl-1):S148.

OP-266 [Colon and Rectal Surgery]. Comparison of Cleft Lift Procedure and Unilateral Fasciocutaneous V-Y Flap Technique in the Treatment of Recurrent Pilonidal Sinus Disease; Retrospective Clinical Study

Yavuz Savas Koca ^1,^✉

Objective

This study aimed to present the results of Cleft Lift procedure and V-Y flap applications in the treatment of recurrent pilonidal sinus disease.

Material and Methods

We retrospectively reviewed the data of 121 patients in whom cleft lift flap (CLF) and unilateral faciocutaneous V-Y flap (VYF) technique were applied for recurrent PSH between September 2010 and May 2016 in Süleyman Demirel University General Surgery Clinic. Seven patients whose information could not be found and 20 patients who could not come to the control examination were excluded from the study. Forty-three patients who underwent FFC and 51 patients who underwent CLF were evaluated. All patients were evaluated for their dermographic characteristics (gender, age, BMI), previous operation, duration of symptoms, perioperative complications (seroma, hematoma, wound infection, flap necrosis, wound dissection), duration of operation, duration of drain removal, duration of hospital stay and recurrence rates were examined.

Results

The duration of operation was 35.61±5.254 minutes in CLG and 57.42±7.327 minutes in VYFG (p=0.001). Wound separation was observed in 5 patients (9.8%) in CLG and in VYFG, there was no wound separation in any patient (p=0,035) From the point of view of drain removal time, 1.39±0.603 day was found in CLG and 2.79±0.638 days in VYFG (p=0,001). The average time spent in hospital was 1.75±0.523 days in CLG and 3.77±1.02 days in VFN (p=0.001). The mean follow-up period was 46 (min 12, max 72) months in CLG and 44 (min15, max72) in VFG. The number of patients with recurrence within these periods was found to be 2 (3.9%) in CLG. No recurrence was observed in VYFG (p=0.189).

Conclusion

The advantages of the Cleft method over the V-Y flap method are shorter operating time, less need for drain in patient, and shorter hospital discharge. The fact that the wound separation is more common is the disadvantages. No recurrence was observed in the V-Y flap group in terms of recurrence rates. Cleft is a method with a low recurrence rate (3.9%). Both methods are preferred methods for the treatment of recurrent pilonidal disease because of low complication and recurrence rates.

TJS. 2018;34(Suppl-1):S149.

OP-267 [Colon and Rectal Surgery]. Short Term Results of Laparoscopic Ventral Mesh Rectopexy in Rectal and Complex Pelvic Organ Prolapse; The Largest Turkish Case Series

Fatma Ayça Gültekin ^1,^✉

Objective

Laparoscopic ventral Mesh rectopexy (LVMR) has become more widely used in the treatment of pelvic floor diseases such as external rectal prolapse (ERP), high grade internal rectal prolapse (IRP) and rectocele. LVMR also allows the treatment of pelvic organ prolapse. In this study, the efficacy, safety and short term functional results of LVMR in rectal and complex pelvic organ prolapse in Turkey were examined.

Material and Methods

All patients who underwent LVMR between February 2014 and October 2017 were included in the study. Patients were evaluated preoperatively and in the postoperative 3rd month. In terms of the surgical complications and functional outcomes; fecal incontinence was evaluated with Wexner Incontinence Score (WIS) and constipation with Wexner Constipation Score (WCS).

Results

Material and Methods

Sixty-eight patients were included in the study. The patients were randomly divided into two groups (Control and Protein Support Group). Protein support group received 80 gr/day protein support for the first month after surgery. Anthropometric measurements, bioelectrical impedance analysis (BIA), SF 36 test, and ultrasound thickness measurements of gastrocnemius muscle and erector spina muscles were performed at 1 month before and after surgery. BIA and SF 36 measurements were repeated in the 3rd and 6th months.

Results

There was no difference between groups in terms of age and gender (p> 0.05). No difference was observed between the groups in terms of weight loss in the 1st, 3rd and 6th month controls (p>0.05). Fat-free body weight was significantly lower in the protein support group than in the control group (p<0.05), but there was no difference with the control group at the 6th month (p=0.3).

There was no significant difference in ultrasonographic muscle thickness measurements at baseline and at 1st month when protein support and control group were compared (p> 0.05). However; it was determined that muscle loss would decrease due to protein support. Physical role difficulty and emotional role difficulty scores were significantly higher in the protein support group at the 6th month than the control group in SF 36 subgroups (p<0.05).

Conclusion

In our study, for the first time in the literature, ultrasonography was used to determine muscle mass change in bariatic surgery patients and correlated with indirect measurements such as bioimpedance electrical analysis. 80 g/day protein support in the early period after LSG preserves muscle mass without affecting weight loss and improves quality of life in the medium term. New studies are needed on the content, amount and replacement time of the protein support product to be selected.

TJS. 2018;34(Suppl-1):S161–S162.

OP-288 [Obesity]. Pregnancy after Laparoscopic Sleeve Gastrectomy (LSG): Maternal and Fetal Outcomes of 49 Pregnant Women

Seda Sancak ^1,^✉, Özgen Çeler ¹, Elif Çırak ², Aziz Bora Karip ³, Mehmet Timuçin Aydın ³, Nuriye Esenbulut ³, Mehmet Mahir Fersahoğlu ³, Hasan Altun ^3,⁴, Kemal Memişoğlu ³

Objective

To investigate the maternal and fetal outcomes of pregnancies occur after laparoscopic sleeve gastrectomy (LSG).

Material and Methods

Patients who underwent Laparoscopic Sleeve Gastrectomy (LSG) at our center between 2012–2017 were evaluated by telephone survey. Weight and body mass index (BMI) changes, conception times, maternal and infant characteristics during the pregnancies in the postoperative period were examined. SPSS 15.0 was used for statistical analysis.

Results

The follow-up information of 592 of 700 patients who had LSG in our center between 2012 and 2017 were reached. Of these patients, 487 were female (82%). Fifty-five (11.2%) of the female patients were pregnant after LSG. Six patients could not be reached. The mean age of the patients reached 31,02 years, the total number of pregnancies after LSG was 68. Nineteen (27.9%) pregnancies resulted in abortus (one in 14 patients, 2 in 5 patients), 44 births were performed (1 in 41 patients, 2 in 3 patients) and 5 patients were still pregnant.

The number of married patients before the LSG was 39 (80%) and 26 (66%) had children. While the menstrual irregularity was 35% before LSG, all of the patients after LSG stated that their menstrual cycle was regulated. Postpartum birth rate was 65%.

While the mean time interval between LSG and conception was 22.8 months, this period was 17.85 months in abortus pregnancies (p<0.05). The mean BMI before LSG was 46.47±4.85 kg/m2. The mean BMI of the women who gave birth was calculated as 31 kg/m2 when they were pregnant and the patients received an average of 10.2 kg during pregnancy. The mean birth weight was calculated as 2934±633 gr, there was no correlation between weight gain and birth weight of the baby (p> 0.05). The risk of abortion was found to be higher in patients with diabetes or prediabetes diagnosed during bariatric surgery compared to normoglycemic patients and the birth weight of the baby was found to be lower (p<0.05).

Conclusion

Post-LSG pregnancies are better tolerated than other bariatric surgical procedures, diabetes and pregnancy after early postop period increase the risk of abortion.

TJS. 2018;34(Suppl-1):S162.

OP-289 [Obesity]. Accelerated Recovery Protocol after Single Anastomosis Gastric Bypass Surgery

Recep Aktimur ¹, Cüneyt Kırkıl ², Kadir Yıldırım ^3,^✉, Nizamettin Kutluer ⁴

Objective

Single anastomized gastric bypass (SAGB) is a procedure that is increasingly applied in bariatric surgery. The purpose of this study is; To compare the efficacy and reliability of enhanced recovery after surgery (ERAS) with traditional approach in SAGB.

Material and Methods

Data of 92 patients (group 1) followed up with traditional care and the data of 216 patients (group 2) followed up with ERAS protocol were prospectively collected. SAGB was performed by the same surgeon in all patients. Groups were compared in terms of postoperative hospital stay, surgical and recovery costs, complication rates, admission to the emergency department and re-admission.

Results

The mean hospital stay was 5 days in group 1 and 1.2±1.3 days in group 2 (p<0.001). The mean surgical and healing costs were 858.6±33.1 USD in group 1 and 625.2±289.1 USD in group 2 (p<0.001). Specific complications (mostly hemorrhage, Clavien-Dindo IIIa) occurred in 1 (1.1%) patient in group 1 and in 3 (1.4%) patient in group 2. Fifty-seven patients (61.9%) in Group 1 and 45 (20.9%) patients in the second group admitted to the ER within one month after discharge (p<0.001). There was a need for hospitalization in two patients in Group 2 (0.9%), and no re-hospitalization was required in Group 1 (p<0.001).

Conclusion

Conclusion

Knowing the degree of sarcopenia present in patients with pancreatic adenocarcinoma, predicting the postoperative complications and their effects on the survey will positively affect the clinical course of the patients.

TJS. 2018;34(Suppl-1):S165.

OP-294 [Pancreas Surgery]. Prognostic Significance of Lymph Node Metastasis and Positive Lymph Node Ratio Logarithm (LODDS) in Ampullary Adenocarcinomas

Cihan Agalar ^1,^✉, Anıl Aysal ², Tarkan Ünek ¹, Tufan Egeli ¹, Mücahit Özbilgin ¹, Nesrin Aktürk ⁴, Hüseyin Salih Semiz ³, Tuğba Ünek ³, Mesut Akarsu ⁵, Müjde Soytürk ⁵, Ozgül Sağol ², İbrahim Astarcıoğlu ¹

Objective

Introduction

Acute appendicitis (AA) is a condition that is the mostly encountered situation by emergency physicians and requires emergency surgery. In this study, a patient diagnosed with AA by using clinical and laboratory testing and ultrasound (US) and detected to have Type 3 appendix intussusception was examined in terms of diagnosis and treatment approach.

Case

A 29-year-old male patient was admitted due to severe nausea and vomiting and abdominal pain that were ongoing for 2 days. The physical examination revealed diffuse abdominal tenderness and defense and rebound in the right lower quadrant. No abnormality, except the white blood cell value of 17000/ml, was observed in his analyses. The result of ultrasonographic evaluation was reported as the appendix with increased diameter (approximately 11 mm) and increased echogenity in the surrounding mesenteric tissue. The patient was operated with the pre-diagnosis of AA. The operation was started with the McBurney incision. The appendix was observed to be inflamed. Because it was attached to the mesenterium of the ileum by curling on its own mesenterium, its mesenterium was separated so as to control the bleeding with sharp dissections. A massive structure was palpated at the junction of the appendix and the cecum. The cecum was mobilized. The massive structure was thought to be associated with the the appendix intussusception (AI). When the appendix serosa was opened and the appendix was slowly hanged, it was observed that the massive form was disappeared by filling into the appendix. The serosa was checked and the appendectomy was performed from the base of the cecum. The result of the pathological evaluation was reported as the 7,3 cm material consistent with AA, the widest of which was 1,3 cm in diameter. Its serosa was observed to be surrounded by purulent exudate and the appendix wall was bleeding in the serial sections.

Conclusion

Appendix intussusception was firstly defined in a 7-year-old boy by Mckidd during postmortem examination in 1858. The AI classification performed by Moschowitz in 1910 was modified by McSwain in 1941. In the review of Chaar et al., while only 32% of the patients were diagnosed preoperatively, 63% of these patients defined chronically increasing and decreasing abdominal pain, intermittent nausea and vomiting, and rectal bleeding from time to time. It was reported that the diagnosis was established through the examination of pathological specimen in 11% of the patients and during surgery in 57% of them. While 19% of the patients had only inflammation, 33% had endometriosis, 19% had mucocele, 11% had adenoma, 7% had carcinoid tumor, and 6% had adenocarcinoma. A wide variety of surgical procedures ranging from appendectomy to right hemicholectomy were performed on the patients.

According to the review of Chaar et al., we should reply three questions. The first one is “should simple tests be sufficient for the diagnosis of acute appendicitis?”. The second question is that “what should be considered while deciding on the margins of resection in such a case?”. The third question is that “What are the possible traps that can be encountered while planning laparoscopic appendectomy in a similar case?”. In conclusion, surprises that can be caused by an emergency situation such as AA can be the beginning of long struggles both for patient and for surgeon. It should be kept in mind that the pain in the right lower quadrant can result from other pathologies as well as appendicitis and intussusception should also be remembered among these parameters. In the suspected cases, CT should be used for confirmation and surgical therapy should be planned.

TJS. 2018;34(Suppl-1):S174–S175.

PP-0002 [Emergency Surgery and Trauma]. Grade III Duodenal Laceration Developing after Blunt Abdominal Trauma: Case Presentation

Mehmet Zeki Buldanlı ^1,^✉, Nuray Çolapkulu ², İbrahim Ali Özemir ², Oktay Yener ², Cengiz Madenci ², Özgür Ekinci ²

Introduction

Duodenal injuries are rarely seen because of their preserved location in the retroperitoneum. They generally occur after deep penetrating or force-induced blunt traumas. Isolated duodenal injuries often develop as laceration or hematoma. Therefore, they are among traumas which are sometimes difficult to diagnose and treat and have high morbidity and mortality rates. In this study, it was aimed to present a case of grade III duodenal injury developing after force-induced blunt trauma with literature.

Case

A 20-year-old male was admitted to the emergency unit due to the complaints of nausea, vomiting, and abdominal pain that occurred after he had been stuck between the truck and the wall. His physical examination revealed tenderness and defense in the whole abdominal quadrant. Free fluid was detected in the pelvis in the CT of the entire abdomen. It was decided to perform emergency laparotomy with the diagnosis of post-trauma acute abdomen. The laceration focus of the patient, who was defined to have grade III laceration in the 4th duodenal portion according to the AAST-OISC classification (American Association for the Surgery of Trauma - Organ lnjury Scaling Committee), was primarily repaired. On the postoperative 3rd day, the patient developed dyspnea and he was diagnosed with atelectasia. After his complaints completely regressed with medical treatment, he was discharged with full recovery on the postoperative 8th day.

Conclusion

In blunt traumas, duodenal injuries are sometimes diagnosed late because of the localization of the duodenum. Taking patient’s history elaborately, careful physical examination, choice of appropriate imaging technique on time, and a complete exploration in the operation are important for reducing the risks of morbidity and mortality. In the injuries of the organs with retroperitoneal localizations, such as the duodenum and pancreas, the findings of imaging techniques can be non-specific; however, we think that surgical exploration is always the first choice in cases suggesting acute abdomen according to the results of physical examination.

TJS. 2018;34(Suppl-1):S175.

PP-0003 [Emergency Surgery and Trauma]. An Injury Caused by Buckshot From a Pump Action Shotgun

Sercan Büyükakıncak ^1,^✉, Şule Esen Türkyılmaz ², Ali Tüten ³, Banu Karapolat ¹, Adnan Çalık ⁴

Introduction

Shotguns are the guns that are used in hunting and sports competitions. Because these guns are easily accessible, they can be used for the purpose of attack and suicide. Particularly in injuries caused by buckshot from shotguns, morbidity and mortality associated with organ and vascular damages can occur. These injuries are encountered in men in the third decade more frequently across the world. There is no statistical study in our country. In gunshot injuries, organ damage is seen at the rate of 90%. The small intestine, colon, and liver are the most commonly affected organs.

Case

A 32-year-old young male patient was admitted to the emergency unit due to gunshot injury. His vital signs were normal. There were entry holes of buckshot in the left lower quadrant and left iliac region. He had open dirty wound in the iliac region and comminuted fracture. No significant impairment was observed in his laboratory values. Because his vital signs were stable, contrast-enhanced abdominal tomography was performed. Air values were observed in the left paracolic area in the abdomen and an image of a metallic foreign body was viewed in the abdomen. A comminuted displaced fracture in the left iliac wing and buckshot pieces under the skin were observed. The patient was taken into operation and an approximately 1 cm perforated area was detected in the middle area of the rectum in the exploration. No contamination was seen and primary repair was carried out considering the PATI (penetrating abdominal trauma index) score. The patient was discharged without the development of any complication on the 7th day.

Conclusion

Different from other gunshot injuries, injuries caused by hunting shotguns can damage a wider area. The buckshot passing the peritoneum can lead to organ and vascular injuries. Generally, they do not have exit holes. In patients with stable general condition, tomography is useful for the detection of solid organ and retroperitoneal organ injuries. The rate of organ injuries is 95–98% in damages passing the peritoneum. Laparotomy is essential in such cases. Despite the recent developments in trauma surgery, there is no consensus on the surgical technique for colon injuries. Especially in hemodynamically stable patients with the intraoperative ATI score below 25, without peritoneal contamination, and with short duration of surgery, colostomy procedures gave its place to primary repair practices.

TJS. 2018;34(Suppl-1):S175–S176.

PP-0004 [Emergency Surgery and Trauma]. Case Presentation: Superior Mesenteric Vein Thrombosis Associated with Multiple Thrombophilic Genetic Mutations in a Young Patient

Sönmez Ocak ^1,^✉, Ömer Faruk Bük ¹, Piltan Büyükkaya ²

Mesenteric venous thromboembolism (MVTE), which is generally diagnosed late, constitues approximately 5–15% of mesenteric ischemias. The factors in its etiology include hereditary or acquired coagulation disorders, cancer, intraabdominal infections, oral contraceptive usage, and cirrhosis. A 34-year-old male patient was admitted to the emergency unit due to pain in the left upper quadrant. It was learned in his history that the pain had continued for one month but gradually increased in the last two days. No abnormality was found in his history. The physical examination revealed tenderness and defense in the left upper quadrant and epigastric region in the abdomen. There was no finding of rebound. In the laboratory analyses, the value of hemoglobin (Hb) was12,6 g/dl and the value of WBC was 9800/uL. The contrast-enhanced computed tomography of the abdomen was performed on the patient. The tomography revealed infarction areas in the subcapsular region in the lateral of the middle zone of the spleen and free fluid densities consistent with blood around the spleen. Moreover, it was observed that the diameter of the superior mesenteric vein (SMV) apparently increased and there was contamination and free fluid in the peritoneum in the left upper and middle quadrants of the abdomen. The findings were consistent with venous ischemia. Because the patient had the findings of peritoneal irritation, suspected mesenteric venous ischemia, and also rupture associated with splenic infarction, it was decided to perform laparotomy. No sign of ischemia was observed in the small intestines. The patient was performed splenectomy. The patient was discharged on the postoperative (PO) second day. On the PO 7th day, he was re-admitted to the emergency unit due to the complaints of severe abdominal pain, nausea, and vomiting and it was learned from his history that he had no complaint until the PO 6th day and his complaints began suddenly. In the abdominal examination, tenderness, defense and rebound were detected in the right lower quadrant. In his laboratory tests, the value of WBC was 34000/uL and the value of Hb was 11,1 g/dl. No abnormality was seen in his biochemical parameters. The contrast-enhanced tomography of the abdomen revealed ischemic findings in the small intestines in the right lower quadrant. The patient was urgently operated with the pre-diagnosis of mesenteric ischemia. Circulatory impairment was observed in a 60-cm segment in the proximal ileal loops. The patient was performed segmentary small bowel resection and isoperistaltic side-to-side anastomosis. Contrast-enhanced abdominal tomography was performed for control. It was observed that thrombi in the portal vein and SMV were constant, but no finding of ischemia was encountered in the intestines. A treatment regimen was initiated on the patient. Then, the patient, who tolerated the regimen, was begun oral warfarin therapy. In the control examinations in the outpatient clinic, blood sample was taken from the patient for genetic testing for hereditary thrombophilia. As a result of the genetic screening, the patient was found to have PAI SERPINE 1 homozygous 4G/4G, MTHFR homozygous 1298 CC, and factor II prothrombin 20210GA heterozygous mutations. MTHFR C667T, Factor 13 V34L, and Factor V Leiden mutation analyses were reported as normal. The patient was consulted to the department of hematology and he was recommended to continue anticoagulant therapy. Mesenteric venous thromboembolism can be seen in the young population. Because genetic factors are at the forefront in the etiology of these cases, the patients should definitely be performed genetic testing and high-risk patients should be followed closely and provided to receive lifelong anticoagulant treatment.

TJS. 2018;34(Suppl-1):S176–S177.

PP-0005 [Emergency Surgery and Trauma]. Cases of Falling Down from Height in the Province of Kars

Tülay Diken Allahverdi ¹, Ertuğrul Allahverdi ^2,^✉

Objective

Falling from height and related injuries are important public concerns and they are the cases that should be paid attention. In this study, it was aimed to review our data on patients admitted to the Emergency Unit of Kars Kafkas University due to falling from height and to present them.

Material and Methods

The study included 200 patients that were admitted to the Emergency Unit of Kafkas University Faculty of Medicine between January 2012 and July 2017. Their files were retrospectively evaluated. Patients’ demographic features, falling distance, falling type, injured organs, treatment methods, and mortality rates were recorded. Kars is a province with a population of 289.786. People in the rural areas of the city earn their lives from agriculture and livestock breeding. They do agricultural labor from May to the end of September. Therefore, the cases of falling from horses and donkeys are seen more often in summer. In the city center, the cases of falling from heights in the construction sites are more common in summer because construction sector is busier during summer. In the study, hospital admission and discharge data of patients falling from height were collected from their files. For exitus cases, the causes of deaths were learned from the autopsy reports. The following groups were included in the study: 1. Falling from saddle beasts, 2. Falling from a specific distances (such as in-house fallings and fallings from garden wall and roof ), 3. Falling from height in a construction site. The patients that had suspected death and that were referred to our hospital after being treated in another hospital or were not followed up in our hospital after the first treatment were excluded from the study.

Results

Our study included 200 patients falling from height. Of these patients, 184 were male and 16 were female, and 176 were hospitalized. Ambulatory care was planned for 24 patients after they consulted to the emergency unit. The mean age of the patients was 29+/−11.2 years. The mean height of fallings was 6+/−2 m. All the cases of fallings were accidental. The Glasgow Coma Scale score was lower than 8 in fallings from heights over 5 meters. The number of fallings from saddle beasts was 55, the number of fallings from a specific height was 62, and the number of fallings from height in construction sites was 83. Thirty-two of them were those falling from heights of 5+/−2 meters and working in construction site. These patients died due to hemorrhagic shock and multiple organ injuries. While the number of patients with extremity injury was 122, the numbers of patients with thoracic injury, intraabdominal injury, head trauma, and multiple organ injury were 16, 20, 10, and 32, respectively. After admitting the patients to the emergency unit, the indications for surgery were diagnosed according to the results of physical examination, laboratory analyses, and radiological imaging techniques. The rate of mortality was 16%. The mean duration of hospitalization was 20,2+/−14,3 days.

Conclusion

Patients falling from height should be evaluated with a multidisciplinary approach and imaging techniques should be used for determining the severity of trauma in cases. In cases of falling from height, exposure to such traumas will be decreased by taking necessary precautions and improving the socio-economical levels of families.

TJS. 2018;34(Suppl-1):S177.

PP-0006 [Emergency Surgery and Trauma]. The Role of the Parameters of RDW, NLR, and MPV in the Diagnosis of Acute Appendicitis

Sönmez Ocak ^1,^✉, Ömer Faruk Bük ¹

Acute appendicitis is the most commonly seen cause of acute abdomen and appendectomy is the most frequently performed emergency surgery. Although the rate of negative appendectomy has decreased compared to that in the past, it still remains around 5%. Complete blood count is a simple and cheap technique that is easily accessible and applicable in every centers. It has been reported in some studies that some parameters can help the diagnosis of acute appendicitis as well as elevated white blood cell count. In our study, 131 patients operated due to the pre-diagnosis of acute appendicitis were examined. Acute appendicitis was not pathologically found in 13 cases (negative appendectomy rate: 10%). Compared to the acute appendicitis group, statistically significant differences were detected between two groups in terms of the values of white blood cell count (WBC), mean platelet volume (MPV), and neutrophile/lymphocyte ratio (NLR) (p<0.001, p=0.041, and p=0.001). In the ROC analysis, the cut-off values for WBC, MPV, and NLW were 9500,8.11, and 3.285, respectively. In conclusion, with the complete blood count analysis, the values of NLR and MPV apart from WBC can be helpful in the diagnosis of acute appendicitis. We think that a new scoring system can be used with the cut-off values that would be obtained with more cases or these parameters can be integrated into the existing scoring systems.

TJS. 2018;34(Suppl-1):S177–S178.

PP-0007 [Emergency Surgery and Trauma]. A Rare Case: Splenic Injury Developing after Colonoscopy

Sercan Büyükakıncak ^1,^✉, Banu Karapolat ², Adnan Çalık ³

Introduction

Gastroscopy and colonoscopy is the most commonly used interventional procedure performed for diagnosis and treatment of gastrointestinal system diseases. Bleeding and perforation are the most frequent complications that develop after colonoscopy. One of the rarest complications is splenic injuries. The occurrence of these injuries can be associated with excessive stretching of the splenocolic ligament. A hemodynamically stable patient with grade 1, 2, and 3 injury can be applied non-operative approach under close supervision.

Case

A 53-year-old female patient was admitted to the emergency unit due to the complaint of abdominal pain. It was learned from her history that she had been performed colonoscopy in an external center 5 hours ago and her abdominal pain had increased exacerbatingly. Tenderness was detected in the left upper quadrant of the abdomen in the physical examination. Her hemoglobin value was 12 g/dl. In the abdominal ultrasonography, 73×29 mm and 35×15 mm appearances consistent with hematoma were viewed in the diaphragmatic surface of the spleen and in the lower pole, respectively. There was no free fluid and fluid collection in the abdomen. The patient, whose hemodynamic condition was stable, was performed abdominal tomography and similar findings were detected. The patient, who was found to be grade 3 according to the Abbreviated Injury Scale (AIS), was hospitalized and followed conservatively. The values of blood pressure, pulse, urine, hematocrit, and leukocyte were evaluated hourly and abdominal examination was performed frequently. After 48 hours, because the findings of examination and laboratory analysis were stable, the patient was begun oral feeding and mobilized. The patient, whose hematoma was found to be regressed in the control radiological imagings, was discharged after one week by recommending control examination.

Discussion

Colonoscopy is the golden standard method for the detection of colorectal pathologies. After colonoscopy, some complications such as bleeding (0,24–0,33%) and perforation (0,008–0,19%) can develop. The rarest complication, which is not found frequently in literature, is splenic injuries. In many studies, non-operative treatment approach has been mentioned for hemodynamically stable patients with grade 1, 2, and 3 splenic injuries. Sepsis associated with postsplenectomy and possible complications after laparotomy have been prevented. Moreover, tomography is an important technique for conservatively followed patients. Colonoscopy should be performed by experienced physicians and a persistent approach should be avoided in this procedure. We think that, regardless of how complications are corrected (surgical or medical treatment), colonoscopy should be performed by general surgeons working in cooperation with the team.

Conclusion

The main question is which treatment method can be applied to which patient. We suggest that, with suitable working conditions and adequate knowledge and skill, non-operative treatment can be used in trauma patients with stable hemodynamics and grade 1, 2, and 3 injuries.

TJS. 2018;34(Suppl-1):S178.

PP-0008 [Emergency Surgery and Trauma]. Air in the Hepatic Portal Venous System Due to Intestinal Obstruction

Mustafa Yeni ^1,^✉, Ercan Korkut ¹, Nurhak Aksungur ¹, Ufuk Memiş ¹, Furkan Ali Uygur ¹, Mesud Fakirullahoğlu ¹

Introduction

Air in the hepatic portal venous system was firstly defined in patients with mesenteric ischemia. In the following studies, it was reported to be seen also in patients with blunt abdominal traumas, intestinal obstruction, ulcerative colitis, necrotizing bowel diseases, intraabdominal abscess, gastric ulcer, gastric cancer, pseudomonas sepsis, and diverticulitis and after hemicholectomy. Mesenteric ischemia should be kept in mind in the differential diagnosis and clinical and laboratory findings should be evaluated considering that other causes can be included in the etiology.

Case

A 43-year-old male patient was admitted to the hospital due to the complaints of diffuse abdominal pain that had begun one day ago, nausea, vomiting, and inability to defecate. It was learned from his history that he had undergone appendectomy for acute appendicitis 10 years ago and operated due to incisional hernia 2 years after this surgery. In the examination, his body temperature was 36,4 °C, pulse was 96/min, respiratory rate was 20/min, and blood pressure was 138/95 mmHg. He had distension and tenderness in his abdomen, but there was no defense and rebound. The intestinal sounds were hypokinetic. In the laboratory analyses, leukocyte count was 20.260/mm3, blood glucose at admission was 256mg/dl, LDH was 195 U/L, amylase was 25 U/L, AST was 32 U/L, and ALT was 35 U/L. Other biochemical values were normal. In the direct abdominal radiography in standing position, small bowel-type air-fluid levels were observed and there was no free air in the abdomen. Abdominal computed tomography revealed diffuse air-fluid levels in the small intestines in the abdomen. Air densities demonstrating a linear extension in the portal vein and branches and in the liver parenchyma were detected. Because mesenteric ischemia could not be eliminated, the patient was taken into emergency operation. It was intraoperatively observed that his all small intestines were dilated, intestinal walls were edematous, and he had no mesenteric ischemia state. There were adhesions between the bowel loops in association with the previous operations. The patient was performed bridectomy. Prolene mesh was applied to the patient having recurrent incisional hernia. He was discharged on the postoperative 8th day.

Conclusion

For the presence of air in the hepatic portal vein, the main cause is thought to be the passage of intraluminal gas into the portal system due to mucosal damage, transmural ischemia, bowel distension, and increased intraabdominal pressure particularly in patients with mesenteric ischemia. Intestinal ischemia and necrosis were defined in 75% of patients, ulcerative colitis in 8% of patients, and intraabdominal abscess in 6%. In intestinal obstructions, air in the hepatic portal vein is a rarely encountered condition. Gas in the hepatic portal vein can be viewed through ultrasonography or computed tomography. Clinical and laboratory findings are important in the differential diagnosis and the final diagnosis can be established during surgical procedure. Therefore, it is necessary to make decision quickly and to perform early surgical procedure. In our case, while the leukocyte count above 20.000/mm3 suggested mesenteric ischemia, normal values of LDH, AST, ALT, and amylase reminded intestinal obstruction. However, the patient was urgently operated because mesenteric ischemia could not be eliminated.

TJS. 2018;34(Suppl-1):S179.

PP-0009 [Emergency Surgery and Trauma]. A Rare Acute Abdomen Case-Abdominal Cocoon Syndrome

Semra Demirli Atıcı ^1,^✉, Tayfun Kaya ¹, Yasemin Kırmızı ¹, Can Arıcan ¹, Erdal Harmanda ¹, Cengiz Aydın ¹

Abdominal cocoon, sclerosing encapsulating peritonitis (SEP), idiopathic sclerosing peritonitis, and primary sclerosing peritonitis are the definitions generally used for the same disease. SEP is a rarely seen condition characterized by the complete or partial encapsulation of the small bowel with a fibrocollagen membrane, causing some complications such as bleeding, obstruction and perforation, and generally diagnosed intraoperatively. In this case presentation, we aimed to present a patient that was urgently operated due to the findings of mechanical intestinal obstruction and intraoperatively diagnosed with abdominal cocoon.

A 46-year-old male patient was admitted to the emergency unit for the complaints of abdominal pain lasting for two days, nausea, vomiting, and inability to defecate. He had a history of previous pulmonary tuberculosis and no abnormality in the familial history. In the analyses performed at admission to the emergency unit, the value of WBC was found to be 11,400 and there was neutrophil dominance. The urea concentration was evaluated due to decreased oral intake and vomiting and it was found to be elevated (57 mg/dl). His potassium (2,81 mmol/L) and chlorine (88mmol/L) levels were detected to be decreased. The physical examination revealed tenderness and distension in the abdomen. Metalic bowel sounds were auscultated. With nasogastric decompression, an appearance consistent with intestinal content was observed. The PA lung radiography demonstrated calcifications associated with the previous Tbc in the right lung and the direct abdominal radiography in standing position revealed diffuse air-fluid levels in the planes of the small bowel.

The patient, whose physical examination and imaging was consistent with acute abdomen-mechanical intestinal obstruction, was hospitalized for emergency exploration. The patient was operated after receiving written informed consent from him pre-operatively. Following the administration of general anesthesia, a midline incision including the areas above and below the umbilicus was performed. It was observed in the exploration that the small intestines were diffusely dilated and the small intestines were completely covered with a membranous formation beginning from approximately 50-cm distance from the Trietz ligament until the terminal ileum and this membrane formed a capsulation. The capsule was dissected and the bands were separated. All small intestines were released and the operation was completed. On the postoperative 4th day, the patient defecated and the nasogastric catheter was removed. The patient was started fluid regimen on the 5th day. Because he tolerated it, it was increased. On the 6th day, intraabdominal drain was removed and the patient was discharged without any problem on the postoperative 8th day. The result of intraoperative exploration was consistent with abdominal cocoon syndrome. In the pathological evaluation of the tissue forming capsulation on the small bowel and being dissected during surgery, mature lymphocytes, plasma cells, and a few reactive mesothelial cells were observed. The results were reported as peritoneal tissues displaying fibrosis, hyalinization, and chronic non-specific inflammation. In conclusion, abdominal cocoon is a rarely encountered condition that is difficult to diagnose preoperatively. It should be considered among the differential diagnoses especially in patients admitted with the findings of mechanical bowel obstruction.

This article was presented as a poster in the 16th Colorectal Surgery Congress (May 16–20, 2017).

TJS. 2018;34(Suppl-1):S179–S180.

PP-0010 [Emergency Surgery and Trauma]. A Rare Condition Mimicking Acute Appendicitis: Cecal Diverticulitis

Semra Demirli Atıcı ^1,^✉, Tayfun Kaya ¹, Yasemin Kırmızı ¹, Cengiz Aydın ¹

The cecal diverticulum is a rarely seen lesion and clinical symptoms associated with diverticulum perforation or diverticulitis show similar features with acute appendicitis. It is difficult to differentiate it from acute appendicitis through physical examination and radiological imaging techniques are also insufficient to provide data for elimination. Therefore, patients are generally diagnosed intraoperatively. In this case report, we present a patient that was taken into operation for the pre-diagnosis of acute appendicitis and intraoperatively detected to have perforation of cecal diverticulum.

A 25-year-old female patient was admitted to the emergency unit due to the complaints of nausea, vomiting, loss of appetite, and right lower quadrant pain going on for one day. In the analyses, the value of WBC was found to be 14,700 and there was neutrophile dominance. In the abdominal ultrasonography performed in emergency conditions, the appendix vermiformis was observed to be 12 mm at its widest point, its lumen was obliterated, and the wall was thick. There was a finding of diffuse inflammation in the neighbor mesenterium and the inflammation appeared as surrounded by the mesenterium and bowel loops (plastron?). The patient was hospitalized for operation with the pre-diagnosis of acute appendicitis. She was operated after receiving written informed consent. In the exploration performed with McBurney incision following the administration of general anesthesia, the cecum was observed to be surrounded by the omentum. After the dissection, a 1-cm diverticular perforation was found in the cecum. The cecum was applied primary suture after the excision of the diverticular structure. Then, the appendix was observed to be retrocecal and subserosal and the appendectomy was performed. The patient, who was able to pass gas on the postoperative 3rd day, was started oral regimen, she tolerated it, and oral intake was increased. On the postoperative 5th day, stool discharge occurred. Abdominal drain was removed on the postoperative 6th day and the patient was discharged without any problem.

In conclusion, it is difficult to diagnose cecum diverticulum, which is a rare lesion, preoperatively because its symptoms, findings, and imagings mimic acute appendicitis. If its diagnosis is overlooked, complications with high mortality can develop. For this reason, cecum diverticulum and secondary complications should be considered in the differential diagnoses in patients consulting to the emergency unit with pain in the right lower quadrant.

This paper was presented as a poster in the 16th Colorectal Surgery Congress (May 16–20, 2017).

TJS. 2018;34(Suppl-1):S180.

PP-0011 [Emergency Surgery and Trauma]. A Case with the Coexistence of Acute Pancreatitis and Acute Appendicitis

İbrahim Kılınç ^1,^✉, Serap Ulusoy ¹, Mehmet Özer ¹, Abdussamed Yalçın ², Ali Coşkun ², Mehmet Kılıç ²

Introduction

In patients admitted due to the complaint of abdominal pain, many conditions such as acute pancreatitis, appendicitis, perforation, and urogenital system pathologies should be remembered. More than one pathology can coexist in some patients.

Case

A 42-year-old male patient was admitted to the emergency unit due to the complaints of abdominal pain radiating to the back for one week, nausea, and vomiting. In the evaluations, his vital signs were stable. In the physical examination, while tenderness and defense were detected in the right and left upper quadrants in the abdomen, the lower quadrants were normal. The value of WBC was 9400, amylase was 980, and lipase was 1200. In the ultrasonographic examination, the gallbladder was observed to be normal. The abdominal tomography revealed the appendix to be normal. However, the pancreas was reported to be edematous and to have pancreatitis. The patient was hospitalized for the treatment of acute pancreatitis. Because his physical examination findings were not regressed on the 8th day of hospitalization, he was performed control tomography and it was seen that pancreatitis continued and the appendix was also edematous. In laparotomy, it was observed that the appendix was perforated, the small bowel loops were severely dilated, and there was malnutrition in the 30-cm ileum loop. The appendectomy was carried out. The Bogota-bag procedure was applied in order to follow malnutrition. On the postoperative 3rd day, exploration was performed again. It was observed that the nutrition of the small bowel loop was improved and the abdomen was closed. The patient, who developed ileus in the follow-ups, was applied parenteral feeding for 6 days. His amylase and lipase values returned to normal. Ileus condition healed on the 7th day. The patient without any active complaint was discharged on the 10th day with some recommendations.

Conclusion

It should be kept in mind that other intraabdominal pathologies can develop in patients that are followed for acute pancreatitis, but show no clinical recovery.

TJS. 2018;34(Suppl-1):S180–S181.

PP-0012 [Emergency Surgery and Trauma]. Early Intervention to Invagination in a Patient Diagnosed with Peutz-Jeghers Syndrome

Deniz Tazeoğlu ^1,^✉, Canberk Toy ¹, Cüneyt Akyüz ¹, Nilay Tuğba Uzunay ¹, Fazıl Sağlam ¹

Case

A 23-year-old male patient, who had been diagnosed with Peutz-Jeghers syndrome for about 8 years and followed up, was admitted to the emergency unit due to the complaint of abdominal pain that had started a day before and increased in the last 4 hours. In his physical examination, distension and tenderness were observed in the abdomen, but no sign of acute abdomen was found. Because of the presence of Peutz-Jeghers syndrome and abdominal pain, intestinal obstruction and invagination were firstly considered in the differential diagnosis. In the direct abdominal radiography in standing position, small bowel planes were observed. A finding defining nested intestines (target sign) was revealed in the abdominal ultrasonography. In the laparotomy, invagination was observed in 3-cm jejunal loop at the distance of 20 cm from the Trietz. It was released in the invaginated loop. There was edema but no sign of ischemia. No additional pathology was observed in the abdomen. The patient was discharged with full recovery on the postoperative 4th day.

Conclusion

Peutz-Jeghers syndrome (PJS) is an autosomal dominant inherited pathology characterized by hamartomatous polyps and pigmented mucocutaneous lesions in the gastrointestinal system, particularly in the small bowel, which is a rare cause of jejunal invagination. Although the onset of the disease is generally known to be at the ages of 20s-30s, it is stated to vary depending on the type of genetic mutation.

In patients with PJS, multiple surgical procedures and repeating complications can cause short bowel syndrome and intestinal adhesions. Therefore, treatment methods require being minimally invasive. Surgical and endoscopic techniques should be preferred as complementary methods.

TJS. 2018;34(Suppl-1):S181.

PP-0013 [Emergency Surgery and Trauma]. A Rarely Seen Acute Mechanical Intestinal Obstruction Case: Colonic Endometriosis

Mehmet Zeki Buldanlı ^1,^✉, İbrahim Ali Özemir ², Oktay Yener ², Yasemin Dölek ³

Objective

Endometriosis is a disease seen in women at reproductive age and characterized by the growth of the endometrial tissue outside the uterus. Colonic endometriosis can present with the complaints of menstrual cycle-associated pelvic pain, dyspareunia, tenesmus, and painful defecation or it can rarely cause acute mechanical intestinal obstruction. Its gastrointestinal localization was reported at the rate of 3–37% in literature and 7–23% of these cases were stated to have clinical features of acute mechanical intestinal obstruction. In literature, there are a few cases of mechanical obstruction associated with sigmoid endometriosis mimicking colon malignancy. In this study, it was aimed to present a patient detected to have acute mechanical intestinal obstruction developing secondary to colonic endometriosis with literature.

Case

A 40-year-old female patient was admitted to the emergency unit for the complaints of diffuse abdominal pain, distension, nausea, vomiting, and inability to defecate. Laboratory analyses demonstrated the value of leukocytosis as 15.100/μL. The intravenous contrast-enhanced abdominal tomography revealed air-fluid levels in the small bowel loops and severe distension in all colonic loops from the sigmoid colon. In the patient planned to be operated, it was observed in the exploration that the sigmoid colon was attached to the uterus as a mass and formed a gato. The adhesions were separated and the resection and Hartmann procedure were applied to the sigmoid colon segment in the appearance of a mass. Pathological examination revealed fibrosis areas in the serosal fat tissue involving the submucosa, muscularis propria, serosal endometrial gland and stroma areas under intact colon mucosa and locally hemosiderin-loaded macrophages. The pathological diagnosis was established as endometrosis.

Conclusion

Endometriosis is a gynecologic disease that can affect all organs, particularly ovarium, and its gastrointestinal localization should be kept in mind in the etiology of AMIO, especially in female patients in reproductive period, and the related symptoms should be questioned.

TJS. 2018;34(Suppl-1):S181–S182.

PP-0014 [Emergency Surgery and Trauma]. Morgagni Hernia in Adults: Case Report with the Review of Literature

Ahmet Karayiğit ^1,^✉, Veysel Cem Özcan ¹, Mahmut Onur Kültüroğlu ¹, Niyazi Karaman ¹

Introduction

Congenital diaphragmatic hernias are rarely seen in adults. However, inability to diagnoze or late diagnosis can cause important morbidities. Morgagni hernia (MH) is located in the anterior mediastinum due to the retrosternal localization of the Morgagni foramen, which is defined as an anterior diaphragmatic defect. Most of patients are asymptomatic. MHs in adults are associated with obesity, trauma, or increased intraabdominal pressure.

Case

A 60-year-old female patient was admitted to the emergency unit due to the complaints of abdominal pain, abdominal swelling, nausea, vomiting, and inability to defecate lasting for 3 days. In the physical examination, the bowel sounds were hypoactive and there was distension in the abdomen. Defense and rebound were detected particularly in the epigastrium. The ampulla was empty in the rectal examination. In the complete blood analysis, leukocyte count was 17.300 and CRP value was 198. In the radiological evaluation, air-fluid levels were observed in the lower zone of the right lung in the postero-anterior lung graph. In CT, bowel loop compressing on the right lung was viewed in the diaphragm sections. The patient was taken into emergency operation. In the laparotomy, it was observed that the transverse colon and omentum were herniated into the chest from the defect below the xiphoid process in the right side and the colon was partially incarcerated. These structures in the thorax were reduced into the abdomen. The intestinal circulation was observed to return to normal. The hernia sac in the approximately 3-cm defect was excised. This defect in the diaphragm was repaired by using non-absorbable suture material, without mesh. The patient was discharged with full recovery on the postoperative 5th day.

Conclusion

In many cases, it has been reported that symptoms are unclear and most of patients are asymptomatic except unapparent epigastric disorders. Respiratory distress, repeating lung infections, and peritonitis picture associated with incarceration can occur in some patients. The risk of complications including gastric volvulus and colon obstruction is quite high. The treatment of MH is performed with surgical techniques. There are different approaches to surgery. Both transthoracic and transabdominal approaches have been defined. In literature, laparoscopic repairs of MH were also defined. Primary closure is generally sufficient for a small defect, but closure with a mesh can be required in the presence of a larger defect.

TJS. 2018;34(Suppl-1):S182.

PP-0015 [Emergency Surgery and Trauma]. Acute Gastric Volvulus with Bochdalek Hernia: A Rarely Case of Acute Abdomen

Ahmet Karayiğit ^1,^✉, Mahmut Onur Kültüroğlu ¹, Serdar Sarıdemir ¹, Osman Uyar ², Bülent Aksel ¹

Introduction

Gastric volvulus is seen in all age groups, but generally in the elderly population. It is a rare condition that can be life-threatening. Although it occurs as acute, chronic, and acute in chronic base, its chronic form is more frequently seen. The Bochdalek hernias are congenital defects developing in the posterior part of the diaphragm at the levels of 10th and 11th ribs. They are generally rarely encountered in adults. Most of Bochdalek hernias are asymptomatic and they are detected incidentally.

Case

A 29-year-old male patient was admitted to the emergency unit for the complaints of abdominal pain and bloating, nausea, and vomiting that lasted for more than 2 days. The physical examination revealed distension and pain in the epigastric region. It was observed that the patient vomited wastes of foods without bile. The value of WBC was increased to 17.000. In the posterior-anterior lung radiography, there was an appearance of soft tissue pushing the lung tissue upward in the left thoracic cavity. The direct abdominal radiography in standing position revealed an appearance with increased diameter and fullness of fluid in the epigastric region. The patient was performed thoracoabdominal CT. In the thoracic CT, the stomach with increased distension was viewed in the thoracic cavity. In the upper abdominal CT, the stomach was observed to be severely expanded and to be full of fluid. The patient was reported to have Bochdalek hernia according to the tomography evaluation. He was urgently operated with open surgical technique. It was observed that he had Bochdalek hernia and organoaxial gastric volvulus. The patient, who was detected to have partial necrosis, was performed resection and diaphragm repair with mesh. The patient was discharged with full recovery on the postoperative 7th day.

Conclusion

Delayed diagnosis of acute gastric volvulus can cause ischemia, necrosis, and perforation. These cases can also manifest with gastrointestinal bleeding and septic shock. Mortality can reach to 50% in the cases of gastric volvulus developing necrosis and perforation. Gastric volvulus can be detorsionated through endoscopy or it can be successfully treated with open or laparoscopic surgery.

TJS. 2018;34(Suppl-1):S183.

PP-0016 [Emergency Surgery and Trauma]. Acute Mesenteric Ischemia: Our Experiences and Prediction of Additional Resection Need According to the Values of Leukocyte and Lactate in the Second Examination

Ali Emre Naycı ^1,^✉, Soykan Arıkan ¹, Önder Akkuş ¹, Feyzullah Ersöz ¹, Serkan Sarı ¹, Mehmet Baki Doğan ¹, Coşkun Çakır ¹

Objective

Acute mesenteric ischemia (AMI) is still a vascular emergency condition with high mortality and morbidity at present. Despite difficulties in its diagnosis and treatment, this disease is partially successfully dealt with clinical suspect and intervention on time. In this study, 44 patients admitted to the Emergency Unit of İstanbul Education and Research Hospital were evaluated retrospectively.

Material and Methods

Forty four patients diagnosed with AMI were examined retrospectively.

Results

A total of 44 patients, including 24 female and 20 male individuals, were evaluated. the mean age was found to be 69 years. Of these patients, 28 were performed second-look (SL). Fifteen of these 28 patients was performed additional resection. In the patients undergoing SL, no statistically significant difference was detected between the groups undergoing and not undergoing additional resection in terms of preoperative and postoperative leukocyte values (p>0.05). In the group not undergoing additional resection, the postoperative leukocyte value was not significantly different than the preoperative value (p>0.05). In the group undergoing additional resection, the postoperative leukocyte value displayed a significant increase compared to the preoperative value (p<0.05).

Conclusion

The second look in the cases of mesenteric ischemia is a method that is used at the 48th hour. If the increase in the leukocyte and lactate values of patient continues after the first operation, the second look may not be left to be done at the 48th hour for reducing the amount of resection.

TJS. 2018;34(Suppl-1):S183–S184.

Omental infarction is a pathology that occurs due to the rotation of the omentum along its long axis, with unknown primary etiology. It is considered to develop secondary to underlying vascular pathologies, hernias, and hypercoagulopathy. Omental infarction manifests with abdominal pain and nausea, vomiting, and fever can accompany it. In our case, the patient had abdominal pain but no nausea, vomiting, and fever. Omental infarction can mimic acute abdomen with its symptoms in the physical examination. It is diagnosed through CT and USG. In USG, incompressible, heterogeneous, oval, large hyperechoic solid mass lesion at the most sensitive point of the probe is typical. In CT, the appearance of hyperdense ring (ring sign) formed by visceral peritoneum thickened around the mass is typical. In our case, the patient was diagnosed with omental infarction through CT. Because necrosis, abscess, and sepsis can develop after infarction, laparotomy is mostly planned for patients diagnosed with omental infarction and omental portion resection is performed. However, some clinicians have claimed in their clinical case series that this pathology can be resolved by applying conservative treatment. In our study, we found that the picture of omental infarction clinically disappeared with conservative treatment in a patient diagnosed with omental infarction.

Conclusion

Omental infarction is a rare pathology that cases the picture of acute abdomen and there is no consensus on its treatment in literature.

TJS. 2018;34(Suppl-1):S185–S186.

PP-0020 [Emergency Surgery and Trauma]. A Rare Cause of Acute Abdomen: Appendiceal Neuroma

Çağrı Akalın ^1,^✉

Introduction

Acute appendicitis is a clinical picture that includes causes leading to obstruction in the appendix lumen and requiring surgery. In recent years, there have been some studies demonstrating that this picture can occur due to the hyperplasia of neuroendocrine cells in the stroma of the appendix. In this study, we aimed to present our cases undergoing appendectomy due to the pre-diagnosis of appendicitis, which is a rare cause of acute abdomen, and histopathologically diagnosed with appendiceal neuroma.

Case-1

A 24-year-old male patient was admitted to the emergency unit for the complaint of abdominal pain for one day. The physical examination revealed tenderness and defense in the right lower quadrant of the abdomen. In the laboratory analyses, white blood cell count was 13000/mm3 and CRP was 3,2 mg/L. In the ultrasonography of the whole abdomen, increased echo consistent with inflammation was observed in the mesenterium in the right lower quadrant. There was approximately 11 mm thickening and echo loss in the 43-cm segment in the middle of the appendix and an increase in the wall and surrounding vascularity. The mentioned area was incompressible (acute app?). Moreover, several hypoechoic lesions consistent with LAP, the largest of which was 5×5 mm, were detected in the inflamed mesenteric fatty tissue. The patient having the symptoms of acute abdomen was taken into operation with the pre-diagnosis of acute appendicitis. In the examination, the appendix was inflamed and edematous and the patient was performed appendectomy. The patient was discharged with full recovery on the postoperative 1st day. The result of pathological evaluation was reported as appendiceal neuroma.

Case-2

A 35-year-old female patient consulted to the emergency unit due to abdominal pain going on for 2 days. Her physical examination demonstrated tenderness, defense, and rebound in the right lower quadrant of the abdomen. In the laboratory analysis of the patient, white blood cell count was found to be 13900/mm3 and C-reactive protein (CRP) was 19,1 mg/L. No pathology was detected in the computed tomography of the whole abdomen. The patient with the findings of acute abdomen was taken into operation with the pre-diagnosis of acute appendicitis. The appendix was observed to be inflamed and severely edematous. She was performed appendectomy. She was discharged with full recovery on the postoperative 1st day. The result of pathological evaluation was reported as appendiceal neuroma.

Case-3

A 54-year-old female patient was admitted to the emergency unit for the complaints of one-day abdominal pain and loss of appetite. The physical examination revealed tenderness and defense in the right lower quadrant of the abdomen. In her laboratory analysis, white blood cell count was detected to be 16700/mm3 and CRP was 7,6 mg/L. In the ultrasonography of the whole abdomen, a suspicious dilated tubular structure, the largest point of which was 10 mm, was found in the right lower quadrant (acute app?). The patient was operated with the pre-diagnosis of acute appendicitis. There was phlegmon in the appendix and apendectomy was performed. The patient was discharged with full recovery on the postoperative 1st day. The result of pathological evaluation was reported as appendiceal neuroma.

Conclusion

Stromal origin neuroendocrin cells included in the tissue of the appendix increase in number and they obliterate the lumen of the appendix and cause acute appendicitis. The treatment of appendiceal neuroma, which is a rarely seen condition causing acute abdomen, is performed with appendectomy, which is a procedure applied in acute appendicitis. Its final diagnosis is established through histopathological examination and no additional treatment apart from appendectomy is required.

TJS. 2018;34(Suppl-1):S186.

PP-0021 [Emergency Surgery and Trauma]. Strategy for Approaching to Liver Traumas: An Analysis of 86 Cases

Feyyaz Güngör ^1,^✉, Araz Babayev ¹, Emine Merve Horoz ², Turan Acar ¹, Hilmi Güngör ¹, Kemal Erdinç Kamer ¹, Murat Kemal Atahan ¹, Osman Nuri Dilek ¹

The liver is the most commonly injured organ in blunt abdominal traumas and the second most commonly injured organ in penetrating abdominal traumas. The management of liver injuries requiring surgical intervention is challenging even for experienced surgeons because of the complex structure of the liver. In this study, treatment approaches applied in patients with liver trauma were examined.

In this study, the data and results of 86 patients admitted to our hospital for liver trauma between 01.01.2012 and 30.12.2017 were examined. According to them, 67 of the patients (77,9%) were male and 19 (22,09%) were female. Of the patients whose mean age was 34,03 (15–102) years, 49 (56,97) had penetrating trauma and 37 (43,03) had blunt trauma. 39 (45,34%) of these patients were treated non-operatively and an operation was needed in 47 patients (54,65%). When the patients were evaluated according to the organ injury scale, the distributions of liver injuries (according to the AAST criteria) were grade-I in 10 patients, grade-II in 37 patients, grade-III in 23 patients, grade-IV in 8 patients, grade-V in 6 patients, and grade-VI in 2 patients. The grade distributions of non-operatively followed patients were grade-I in 7 patients, grade-II in 19 patients, grade-III in 12 patients, grade-IV in 1 patient, and grade-V in 1 patient. The transfusion of blood products was performed in 54 (61,62%) of the cases. The distributions of surgical techniques in cases requiring an surgical intervention were manual compression in 11 cases, electrocauterization in 3 cases, electrocauterization and omentoplasty in 1 case, electrocauterization and primary suturation in 16 cases, electrocauterization and haemostatic agent in 4 cases, and packing in 12 cases. In the patients requiring surgical intervention, the morbidity rate was 12,7% (6 patients) and the mortality rate was 8,5% (4 patients).

Bleeding spontaneously stops in 50–70% of patients with liver trauma. The follow-up of patients, whose hemodynamic state is stable after liver trauma, with non-operative methods is important because of morbidity and mortality rates caused by early intervention. An operation was not performed in 95,1% of our patients followed by a conservative approach. In hemodynamically unstable patients, taking bleeding under control temporarily with damage control techniques should be kept in mind as an important life-saving choice and the primary procedures in such patients should be for hemostasis and stabilization.

TJS. 2018;34(Suppl-1):S186–S187.

PP-0022 [Emergency Surgery and Trauma]. Perforation of Hepatic Hydatid Cyst without the Occurrence of Anaphylaxis

Mehmet Torun ^1,^✉, İsmail Ege Subaşı ¹

A 70-year-old male patient was admitted to our emergency unit due to the complaint of abdominal pain developing after falling from height. In his medical history, HT and DM were found, but he had no other comorbid disease. In the examination performed in the emergency unit, diffuse tenderness, defense, and diffuse distension in the abdomen were detected. However, no rebound was observed. In the first analyses, the value of WBC was 12,2, HCT was 39,8, Hb was 12,4, PLT was 210, EOS was 8,83, CRP was 16,3, and INR was 1,84. The contrast agent was given intravenously and abdominal CT was performed. It revealed an appearance of perforated hydatid cyst reaching to the diameter of 80 mm and diffuse fluid in the abdomen. The findings of abdominal examination and general condition of the patient was evaluated and he was taken into operation for treatment.

The preoperative vital signs of the patient were as follows: TA: 110/70, pulse: 86/min, saturation: 98%, and body temperature: 37,7C. The patient was operated. The abdomen was entered with supraumbilical and subumbilical midline incisions. An approximately 1200 cc amount of free fluid was observed and it was aspirated. In the exploration, a 5×6 cm hydatid cyst with a space of 2 cm was detected in the 7th segment of the liver. Then, in the continuation of the exploration, a second hydatid cyst that completely covered the 4th segment and could not be detected in preoperative imagings was found. Both cysts were duly applied cystitomy+omentoplasty. After the operation, the findings of abdominal examination regressed. The values of CRP, leukocyst, and eosinophil were decreased. Because of serous fluids in the drains, the drains were removed. The patient, whose general condition was stable and oral intake returned to normal, was discharged with 800 mg/day albendazole.

TJS. 2018;34(Suppl-1):S187.

PP-0023 [Emergency Surgery and Trauma]. A Rare Complication of Anticoagulant Treatment: Intramural Hematoma of the Small Intestine

Turan Acar ¹, Nihan Acar ¹, Feyyaz Güngör ^1,^✉, Kemal Erdinç Kamer ¹, Şebnem Karasu ², Serkan Karaıslı ¹, Osman Nuri Dilek ¹

Non-traumatic intramural hematomas of the small intestine rarely occur in association with anticoagulant therapy. In this study, it was aimed to explain the algorithm of our clinical approach to non-traumatic intramural hematomas of the small intestine associated with excessive anticoagulation and to present long-term outcomes of hospitalized patients.

Medical recordings of patients with spontaneous intramural hematoma of the small intestine were evaluated retrospectively and 16 patients were included in this study. Of these patients, 10 were female and 6 were male. All patients used oral anticoagulants for various cardiovascular and cerebral comorbidities. Their mean age was 77.5±8.4 years (range: 65–95). The common complaints at admission were abdominal pain, vomiting, and weight loss. Ten patients (62.5%) had anemia and 15 patients (93.7%) had leukocytosis. And, increased level of c-reactive protein was observed in all patients. With abdominal computed tomography, all patients were diagnosed with intramural hematoma of the small intestine. Fourteen patients (87.5%) were treated with conservative treatment. Two patients (12.5%) were required operative interventions because their clinical course did not improve. The mean length of hospitalization was 10.25±3.6 days (range: 3–17). Mortality occurred in 2 patients (12.5%).

In patients having abdominal complaints and elevated anticoagulant level, intramural hematoma of the small intestine should be kept in mind. If possible, abdominal computed tomography should be performed in these patients. Accurate and on-time diagnosis provides patients to be treated non-operatively and successfully.

TJS. 2018;34(Suppl-1):S187–S188.

PP-0024 [Emergency Surgery and Trauma]. Perforation of jejunal diverticulum: A rare cause of acute abdomen

Yiğit Düzköylü ^1,^✉, Esin Erkan Şair ¹, Erdal Birol Bostancı ¹

Introduction

Jejunal diverticulosis is a quite rare condition and it defines the acquired herniation of small intestinal mucosa areas from the weak segments of the muscularis mucosa layer of the bowel. In examinations with contrast agent, it is viewed at the rate of 2% and at the mesenteric margin. Although it may cause non-specific symptoms such as abdominal disturbance and pain, patients can stay asymptomatic during their lives. The perforation of diverticulum is rarer and seen especially in the elderly patients. It can lead to the symptoms of acute abdomen and it is diagnosed with contrast-enhanced evaluations and sometimes with peroperative procedures. In this study, it was aimed to present a patient admitted to the emergency unit for the symptoms of acute abdomen with her preoperative and postoperative findings.

Case

A 62-year-old female patient was admitted to the emergency unit for the complaint of abdominal pain continuing for the last 16 hours. In her laboratory analysis, the value of CRP was 215 and the value of white blood cell count was 14.000. She had no comorbid disease except peptic ulceration. The abdominal CT revealed 2×2 cm perforation area in the proximal jejunal region and free fluid in the abdomen. Following the preoperative preparation, the patient was taken into emergency surgery. In the peroperative examination, 2×2 cm perforated jejunal diverticulum was observed in the 10 cm distal part of the Treitz ligament. Segmental resection and double-layer end-to-end anastomosis were performed. No postoperative complication was observed and the patient was discharged on the 7th day.

Conclusion

Acute abdomen associated with perforated jejunal diverticulum is a rare surgical emergency. Although jejunal diverticulosis can be asymptomatic during lifetime, it can be highly morbid in the occurrence of perforation. As in our case, it is generally encountered in the elderly population. Most of time, segmental resection involving damaged intestinal area and primary anastomosis are curative. Although this condition is rarely seen, the perforation of small intestine diverticulum should be kept in mind particularly in the elderly patients having acute abdomen with chronic dyspeptic complaints.

TJS. 2018;34(Suppl-1):S188.

PP-0025 [Emergency Surgery and Trauma]. A Rare Cause of Acute Abdomen: Bowel Obstruction Associated with Acute Appendicitis

Feyyaz Güngör ^1,^✉, Coşkun Onak ¹, Halis Bağ ¹, Hüdai Genç ¹

Mechanical bowel obstruction is a cause of diffuse acute abdomen it is resulted from many factors. Acute appendicitis accompanied by paralytic ileus is well-known; however, the case of acute appendicitis with mechanical ileus is very rare and this condition is defined as isolated cases in literature. In this study, two patients admitted to the emergency unit due to abdominal pain and operated with the diagnosis of acute appendicitis-associated ileus were presented with literature.

The first case was a 36-year-old male patient and had the complaints of abdominal swelling, pain, nausea, vomiting, and inability to defecate for 3 days. In the physical examination, the abdomen was distended and tenderness, defense, and rebound were detected in the lower quadrants. The result of rectal examination was normal and approximately 200 cc ileal content was observed in the inserted nasogastric catheter. According to the laboratory analysis, he had leukocytosis (14.000), but no other pathological value. In the direct abdominal radiography in standing position, there was air-fluid level in the small intestine loops. In the abdominal computed tomography (CT) with intravenous opaque agent, which was performed due to undefined clinical findings, a dilatation reaching to 42 mm in the ileal loops was observed and it was evaluated to be consistent with ileus. The patient was operated with the diagnosis of ileus. In the exploration, it was observed that the appendix was inflamed and it was adherent to the bowel loop in the 30 cm proximal region from the ileocecal valve. It was dilated in the proximal region of the small intestine and there was no other pathology. The patient was performed appendectomy and he was discharged without any complication on the postoperative 4th day.

The second case was a 57-year-old male patient and he stated that he had abdominal pain, which had started around the umbilicus one week ago and then located in the right lower quadrant. He also had the complaints of vomiting and abdominal swelling with pain, and inability to defecate for 2 days. The physical examination demonstrated metallic bowel sounds in the lower quadrants and positive defense and rebound. Approximately 300 cc ileal fluid was observed in the inserted nasogastric catheter. Rectal examination revealed no pathology. The computed tomography was performed because of the presence of air-fluid levels in the small intestine loops observed the direct abdominal radiography in standing position and unclear clinical picture. The CT evaluation revealed findings consistent with acute appendicitis with the wall thickness of 18 mm in the medial region of the cecum and dilatation and retention in the distal ileum. In the exploration, the appendix was observed to be acute and inflamed and attached to the small intestine in the 60 cm proximal region from the ileocecal valve. No other pathology was detected. The patient was performed appendectomy and he was discharged without any complication on the postoperative 2nd day.

Mechanical intestinal obstruction is a diffuse acute abdomen resulted from many causes and it requires emergency intervention. Acute appendicitis can be accompanied by bowel distension at various degrees. In general, this distension is a result of bowel paralysis. Moreover, appendix inflammation can rarely cause mechanical intestinal obstruction directly. It is a pre-diagnosis that should definitely be kept in mind in patients admitted for the clinical picture of ileus.

TJS. 2018;34(Suppl-1):S189.

PP-0026 [Emergency Surgery and Trauma]. Presentation of Two Cases Having Liver and Spleen Laceration after the Insertion of Pleurocan and Tube Thoracostomy

Şevket Barış Morkavuk ^1,^✉, Serap Ulusoy ¹, Saim Duman ¹, Ersin Gürkan Dumlu ¹, Ali Coşkun ¹, Abdussamed Yalçın ¹, Mehmet Kılıç ¹

Introduction

A chest tube provides the drainage of the pleural space out of the thorax with the help of a closed drainage catheter through the one-way system. Based on this logic, tube thoracostomy and pleurocan, which is a smaller surgical intervention, are used. These are among the most commonly used surgical procedures in the practice of chest surgery. Although they are safe and easily applicable, they have complications that may result in morbidity and mortality. In this study, it was aimed to present two cases having liver and spleen lacerations after the insertion of pleurocan with literature.

Case-1

A 23-year-old female patient was brought to the emergency unit due to extravehicular traffic accident. It was learned from the anamnesis that she had blunt thoracic trauma due to being stuck between the wall and a tractor about one hour ago. In the physical examination, bruise and lacerations were observed on the skin at the level of 10–12th ribs. The patient having normotensive and tachycardic course had superficial but tachypneic respiration. In the blood gas evaluation of the patient, whose hemoglobin value was 9.8 gr/dl, O2 saturation value was found to be 87%. The patient, whose PA radiography demonstrated pneumothorax in the right lung, was inserted tube thoracostomy by a thoracic surgeon. Because the patient had a fast decrease in Ta values after the procedure and Hgb value in the follow-up was 6.7 g/dl, abdominal CT was performed. It was observed in CT that tube thoracostomy had intraperitoneal localization, caused a full-thickness laceration at the 7th segment of the liver, and located in the thorax by perforating the intraabdominal diaphragm. The patient was taken into emergency surgery. Thoracic tube was removed and the laceration observed in the liver was performed primary repair. Intraabdominal diaphragm was applied full-thickness repair. The thoracic tube was inserted again and the operation was ended.

Case-2

A 67-year-old patient that was operated due to the diagnosis of sigmoid colon cancer was inserted pleurocan by a thoracic surgeon due to the observation of left massive pleural effusion on the postoperative 5th day. After this procedure, because of the suspicious trace of pleurocan catheter in the control PA radiography, the patient was performed abdominal CT. In CT, it was observed that the catheter caused laceration in the superior segment of the spleen and drained the thorax by perforating the diaphragm from here. After removing the catheter, pleurocan was repeated from upper level. The patient was followed up because the vital signs were stable and Hgb levels did not decrease. Since no intraabdominal massive fluid was observed in the control abdominal USG and laboratory parameters were stable, the patient was followed non-invasively and discharged with recommendations after the removal of the catheter on the postoperative 10th day.

Conclusion

Closed chest drainage catheters are used in pneumothorax, hemothorax, pleural effusion, empyema, cheilothorax, and surgical procedures in which the thoracic cavity is opened. Although the ideal entry point of tube thoracostomy differs depending on the clinics, the area defined as ‘safe triangle’ behind the pectoralis major muscle, where 3rd and 5th intercostal spaces intersect with the midaxillary line, is mostly preferred. Intraparenchymal, mediastinal, and abdominal tube insertion can lead to some complications such as bleeding, nerve damage, and infection. After the procedure, PA radiography for checking the location and thoracic and abdominal CT in suspected cases are recommended to be performed. The tube can be removed 24 hours after the discontinuation of air leakage, after total expansion of the lungs in the radiography, and after reduction of daily drainage below 100–200 ml.

TJS. 2018;34(Suppl-1):S189–S190.

PP-0027 [Emergency Surgery and Trauma]. A Rarely Seen Foreign Body (Eggplant) Perforation in the Rectum: Case Report

Şevket Barış Morkavuk ^1,^✉, Mehmet Özer ¹, İbrahim Kılınç ¹, Abdussamed Yalçın ¹, Ali Coşkun ¹, Mehmet Kılıç ¹

Introduction

Most of foreign bodies in the rectum are sharp or blunt objects pushed into the rectum from the anus. At a lower rate, foreign bodies are swallowed and they progress along the gastrointestinal system but stuck in the rectum. While foreign bodies stuck in the rectum after oral intake are mostly encountered in people with low intellectual level, mentally disabled and elderly people, thieves, and smugglers, objects pushed from the anus are generally seen as sexual stimuli in middle-aged men. Patients are generally admitted to the emergency unit due to bleeding and pain in the anus. The diagnosis is generally established after taking anamnesis and performing detailed examination. In this study, we aimed to present a patient who consulted to the emergency unit with pain and bleeding in the anus and whose examinations revealed intraabdominal perforation and a foreign body in the rectum with literature.

Case

A 45-year-old male patient was admitted to the emergency unit due to the complaints of severe abdominal pain and bleeding after defecation. In the physical examination of the patient, no pathology was detected with the inspection of the anal canal. Hematochezia was found in the digital rectal examination. In the abdominal examination, diffuse tenderness, defense, and rebound were positive in all quadrants of the abdomen, more apparently in the lower quadrants. In the laboratory analysis, the value of WBC was 18900 K/ul and Hgb was at normal interval. In the direct abdominal radiography in standing position, right sub-diaphragmatic free air and an appearance consistent with a foreign body extending to the symphysis pubis in the rectum were observed and it was learned from the anamnesis that the patient penetrated an eggplant into the rectum for sexual gratification. The patient was performed laparotomy based on these findings. In the exploration, an approximately 3 cm full-thickness rectal laceration on the pelvic reflexion and a foreign body (eggplant) were observed. The perforated area was enlarged and the foreign body was removed out of the abdomen. The focus of the perforation was applied primary suturation and the patient was performed protective loop ileostomy. No additional pathology was detected in the follow-up of the patient and he was discharged after scheduling an appointment for the closure of loop ileostomy on a day after 2 months.

Conclusion

Rectal injuries are examined under two main groups as intraperitoneal and extraperitoneal injuries. Most of injuries occur in association with blunt and penetrating injuries. Penetrating injuries are mostly encountered in middle-aged homosexual men. Rectal injuries are classified as stage I (hematoma or partial laceration), stage II (laceration less than 50%), stage III (laceration more than 50%), stage IV (full-thickness laceration), and stage V (the presence of devascularized segment). Because adequate anamnesis cannot be taken from patients, the establishment of diagnosis is generally delayed. In the view of a foreign body silhouette in the pelvis in the direct abdominal radiography in standing position, rectal foreign body should be suspected. In cases consulting in early period and not having findings of perforation, if the foreign body is under the rectosigmoid junction, it can be tried to be removed from the anus in the sims or lithotomy position after sedation analgesia. The lesions in more proximal regions should be removed with colonoscopy. Patients whose foreign bodies cannot be removed in 30 minutes or who have the findings of perforation should be performed laparotomy, the foreign body should be pushed into the rectum and then removed from the anus or it should be removed from the perforation area in the abdomen.

TJS. 2018;34(Suppl-1):S190.

PP-0028 [Emergency Surgery and Trauma]. Isolated Ovarian Injury Caused by Penetrating Stab Wound

Elif Çolak ^1,^✉

A 58-year-old male patient was admitted to the emergency unit due to abdominal pain that had started around the umbilicus two days ago and radiated to the right lower quadrant. No abnormality was found in the medical history of the patient. He had no loss of appetite, nausea, vomiting, dysuria, loss of weight, night sweating, diarrhea, and constipation. He had minimal tenderness in the abdomen and defense in the right lower quadrant. He had no fever. His hemodynamics was stable. In the Laboratory analysis, the value of leukocyte was 15.600/mm³, hemoglobin was 14,2 gr/ml, and platelet was 126.000/ml. No abnormality was observed in the direct abdominal radiography in standing position and AC radiography. The ultrasonographic evaluation revealed a suspicion of plastron appendicitis. The CT revealed thickness in the terminal ileal loops, submucosal edema, partial luminal obliteration, a linear lesion suggesting a foreign body in the lumen, and fluid in the anterolateral region of the cecum. With the diagnosis of perforation associated with a foreign body, the abdomen was opened with subumbilical median incision. Microperforation was detected in a mid-jejunal 5-cm edematous segment. There was edema and inflammation in the terminal ileum. Fluid secondary to inflammation was observed around the cecum. The enterotomy was performed for the 3–4 cm solid and fixed foreign body detected in the terminal ileum through palpation. It was found that the foreign body causing the perforation and inflammation was an olive leaf. The enterotomy site and minimally perforated mid-jejunal area were performed primary double-thickness repair procedure. No other pathology was observed in the exploration. No postoperative complication developed and the patient was discharged without any problem.

Discussion

Although patients generally heal without any problem in the rarely seen cases of swallowing a foreign body, mortalities have been reported. The outcomes can differ depending on the type of swallowed foreign body, pathologies of the patient, and the timing of the intervention. In literature, foreign bodies such as toothpick, fishbone, chicken or cow bone, and false teeth have been reported. Its clinical findings vary from non-specific abdominal pain to the clinical picture of acute abdomen. The most frightening complications are bleeding and perforation. The region where perforation is mostly observed is the terminal ileum. The development of peritoneal irritation findings following the stage of intraluminal injury occurring until the occurrence of the symptoms explains why appendicitis is suspected in perforations appearing after swallowing foreign bodies. The occurrence of perforation mostly in the terminal ileum is also a factor suggesting acute appendicitis. In our case, subdiaphragmatic free air was not observed in plain radiography in the preoperative period. In literature, the frequency of free air has been reported to be about 16%. In the postoperative inquiry of our case, it was learned that the patient was a farmer and they prepared their meals in the field. According to the probable scenario, he swallowed dried olive leaf while eating food.

Conclusion

In conclusion, swallowed foreign bodies can lead to peritoneal irritation and thus acute appendicitis-like clinical pictures. To provide clinically accurate solutions can be possible only with complete anamnesis, careful examination, and proper imaging techniques.

TJS. 2018;34(Suppl-1):S193.

PP-0032 [Emergency Surgery and Trauma]. Kidney Preserving Surgery in a Pediatric Case with Grade 5 Kidney Laceration

Yücel Yüksel ^1,^✉, Mehmet Sarıer ², İbrahim Duman ², Selim Demirezen ³, Harun Süslü ⁴, Erdal Kukul ²

Introduction

While renal traumas constitute 1–10% of all traumas, they constitute 50% of urogenital system traumas. Renal trauma is divided into two groups as blunt and penetrating traumas. Blunt trauma occurs due to vehicle accidents and fallings. Penetrating trauma occurs due to gunshot injuries and sharp object injuries. While conservative treatment is applied in hemodynamically stable patients with grade I, II, and III injuries, an operation can be required in grade IV and V cases with impaired hemodynamics. Nephrectomy is usually carried out in Grade 5 cases.

Case

An 8-year-old male patient was admitted to the hospital with the complaints of weakness and abdominal pain due to falling from 80 cm-height on his right lumbar region. His blood pressure was 85–42 mm/Hg and pulse was 123/min. The physical examination revealed diffuse tenderness and rebound in the abdomen. In the tomography, grade 5 laceration was detected in the right kidney. He was operated and grade 5 laceration dividing the right kidney into two pieces (as 60% and 40% of the kidney) was detected. It was found that the renal artery and vein were separated into two branches in the hilus and the artery and vein going into the lower and upper poles were intact. Arterial and venous circulation of both pieces were normal. Firstly, renal pelvis and collecting system were repaired and suture was applied over the DJS of the ruptured renal pelvis with 6-0 PDS, and renal pelvis was combined. The kidney parenchyma was repaired over pledgit with 1-0 PDS. The operation was terminated after performing omentopexy on the kidney. Postoperative vascular circulation of the kidney was followed through Doppler USG. The blood supply was reported to be normal. DJS was removed on the 34th day of the kidney repair. In the postoperative 6th month, DMSA and DTPA scintigraphies were performed. The GFR functions of the kidneys were 52 ml/min in the right kidney and 64 ml/min in the left kidney. In the DMSA scintigraphy, split renal function was reported as 44.8% on the right side and 55.2% on the left side.

Conclusion

As in all traumas, the approach in renal traumas is to reduce mortality and morbidity and to preserve the organ. In appropriate cases with grade 5 kidney traumas, renography can be performed.

TJS. 2018;34(Suppl-1):S193–S194.

PP-0033 [Emergency Surgery and Trauma]. Tuba uterina in strangulated femoral hernia sac in a pregnant patient

Deniz Tazeoğlu ^1,^✉, Seyda Kadir Meke ¹, Bakhtiyar Chakhalov ¹, Cüneyt Akyüz ¹, Mukaddes Demiray ¹

Case

A female patient with 10-month pregnancy was admitted to the emergency unit for the complaints of swelling and pain in the inguinal region. No acute abdomen was observed in the physical examination; however, tenderness was found in the bilateral lower quadrants and strangulated femoral hernia was detected on the right side. In the superficial ultrasonography, a tubular structure was observed in the femoral canal. The hernia sac was firstly opened in the operation and edematous and congested tuba uterina was observed in it. Tuba uterina was kept in warm physiological saline solution. When its color and circulation returned to normal, it was pushed into the abdomen. Femoral hernia was repaired. The preoperative and postoperative opinions of the gynecology and obstetrics department were asked and fetal well-being was evaluated. The patient was discharged with full recovery on the postoperative 2nd day.

Conclusion

The incidence of femoral hernia is approximately between 2% and 8% and it occurs in women at a 4–5 times higher rate than men. While it is more commonly seen between the ages of 40 and 70 years, its occurrence is very rare in young people. Although femoral hernia is less common than inguinal hernia, it generally occurs as strangulated and therefore, it can lead to morbidity and mortality. In literature, a case of pregnant patient with tuba uterina in strangulated femoral hernia sac was not found. We wanted to present our case because it was a rare condition and it would be instructive.

TJS. 2018;34(Suppl-1):S194.

PP-0034 [Emergency Surgery and Trauma]. Development of Abscess Associated with Perforated Appendix in Incarcerated Inguinal Hernia: Delayed Amyand Hernia

Mehmet Kulus ^1,^✉, Mehmet Abdussamet Bozkurt ¹, Savaş Bayrak ¹, Mehmet Emin Güneş ¹

Amyand hernia is a condition in which there is appendicitis in the hernia sac. In this case report, we wanted to present a 36-yearold male patient who was admitted with the findings of incarcerated inguinal hernia and accompanying sepsis one week after being followed for abdominal pain.

Considering right incarcerated inguinal hernia, the patient was planned to be operated. When hernia sac was opened, 500 pc purulent matter and perforated appendicitis were observed. Because of purulent fluid coming out from the abdomen, laparotomy was performed and intraabdominal abscess was drained. Appendectomy was performed and inguinal hernia repair was carried out.

The patient was discharged with full recovery on the postoperative 3rd day.

Amyand hernia is an entity that should be remembered in incarcerated inguinal hernia.

TJS. 2018;34(Suppl-1):S194.

PP-0035 [Emergency Surgery and Trauma]. Our Experience on Solid Organ Injury in Abdominal Traumas

Ebral Yiğit ¹, Edip Erdal Yılmaz ¹, Rıdvan Yavuz ¹, Serdar Gümüş ¹, Bahri Çakabay ^1,^✉, Yusuf Yağmur ¹

Objective

In general surgery, patients admitted to the emergency unit due to injuries associated with traumas constitute an important majority of emergency patients. In this study, it was aimed to analyze the results of follow-up and treatment approach applied on patients with injuries associated with abdominal traumas retrospectively.

Material and Methods

Thirty-five patients consulting to the emergency unit of our hospital due to abdominal trauma between August 2016 and February 2017 were evaluated retrospectively.

Results

Of the patients, 28.5% were admitted for gunshot injury, 20% for traffic accident (in-vehicle traffic accident), 40% for penetrating stab wound, and 3.5% for falling from height. Of the patients with abdominal trauma, stomach injury was observed in 2 patients, small bowel injury in 7 patients, large intestine injury in 4 patients, rectal injury in 1 patient, spleen injury in 8 patients, liver injury in 9 patients, kidney injury in 4 patients, bladder injury in 1 patient, thoracic injury in 9 patients, and extremity trauma in 10 patients. Thirteen patients were clinically followed up. One patient was inserted thoracic tube. One patient was performed primary repair of the stomach. One patient was performed primary repair of the stomach+primary repair of the liver. One patient underwent primary repair of the liver. Primary repair +thoracic tube drainage was applied in one patient. Two patients were performed small bowel resection+anastomosis procedure. In one patient, small bowel resection+anastomosis+tube drainage procedure was performed. One patient underwent small bowel resection+nastomosis+primary repair of the colon+loop ileostomy. Primary repair of the aort+primary repair of the small bowel+colon resection+anastomosis was carried out in one patient. The Whipple operation+right nephrectomy was performed in one patient and splenectomy+left nephrectomy in one patient. Splenectomy+thoracic tube drainage was applied in one patient, primary repair of diaphragm in one patient, small bowel resection+ end ileostomy in one patient, small and large bowel resection+end-to-end anastomosis in on epatient, and small bowel resection+anastomosis+primary repair of the colon+loop ileostomy in one patient. Four patients underwent laparotomy. No mortality occurred.

Conclusion

Multiple organ injuries can develop after abdominal trauma. While evaluating patients, a multidisciplinary approach should be followed and solid organ injury should always be kept in mind.

TJS. 2018;34(Suppl-1):S195.

PP-0036 [Emergency Surgery and Trauma]. The Evaluation of Histopathological Results of Patients Undergoing Appendectomy

Rıdvan Barkın Kabalar ^1,^✉, Semra Tutcu Şahin ¹

Objective

Appendectomy is one of the most commonly performed operations in the clinics of general surgery. Although patients are discharged with clinically well-being after operation, its histopathological outcomes can be different from that of acute appendicitis. In this study, it was aimed to examine the histopathological results of our patients who were performed appendectomy.

Material and Methods

The files of 655 patients undergoing appendectomy in the Clinic of General Surgery in Celal Bayar University Hospital between 2008 and 2017 were evaluated retrospectively.

Results

Of the patients, 260 (39,7%) were female and 395 (60,3%) were male. Their mean age was 34,5 (14–94) years. Appendectomy was performed in 641 of the patients (97,9%), right hemicholectomy and ileotransversostomy in 10 patients (%1,5), partial right colon resection and end ileostomy in one patient (0,2%), and abscess drainage in 3 patients (0,5%). During operation, 547 patients (83,5%) were diagnosed with acute appendicitis, 90 (13,7%) with perforated appendicits, 9 (1,4%) with plastron appendicits, 6 (0,9%) with appendix tumor, 1 (0,2%) with pseudomyxoma peritoni, 1 (0,2%) with appendiceal mucocele, and 1 (0,2%) with perforated appendicitis and cecal mass. Three patients could not be performed appendectomy. The operation was ended with abscess drainage.

In the patients undergoing appendectomy, histopathologically normal appendix was detected in 34 (5,2%) patients. According to the pathological reports, 533 (81,7%) acute appendicitis, 66 (10,1%) perforated appendicitis, 14 (2,1%) appendix tumor, 2 (0,3%) plastron appendicitis, 1 (0,2%) endometriosis of the appendix, and 2 (0,3%) mucocele cases were found. A total of 14 appendix tumors were histopathologically classified as 5 (0,8%) neuroendocrine tumors, 4 (0,6%) mucinous neoplasms, 2 (0,3%) adenocarcinomas, 2 (0,3%) sessile serrated adenomas, and 1 (0,2%) carcinoid tumors.

Conclusion

Even though acute appendicitis is considered as preoperative and peroperative diagnoses, all appendectomy materials should be sent for routine histopathological evaluation. The possibility of non-acute appendicitis diagnoses and the necessity of pathological reports should be explained to patients. Each surgeon should follow the pathological results of appendectomy materials and contact with patient in the presence of non-appendicitis pathological findings for planning additional treatments.

Diaphragm rupture is rarely seen. It occurs in about 3% of all abdominal injuries. It usually develops secondary to blunt or penetrating traumas. Diaphragm ruptures caused by stab wounds may not be detected early. Over time, herniations may occur secondary to intraabdominal pressure. In this study, a case of descending colon perforation due to chronic diaphragmatic rupture secondary to trauma was presented.

Case

Our patient, who was admitted due to the complaints of abdominal pain, bloating, and inability to defecate, had a history of penetrating stab wound on the left side of the abdomen 4 years ago. In the physical examination, the patient had tenderness in the abdomen but no evidence of acute abdomen. The rectum was detected to be empty in the digital examination of the rectum. In laboratory analyses, the values of hemogram and biochemistry were normal. The value of CRP was detected as 16.6 mg/L. Air-fluid levels at the colonic level were detected in direct abdominal x-ray. In CT, wall thickening at sigmoid colon level, dilated colon loop at the proximal area, and diaphragmatic hernia were observed. Colonoscopy was planned for suspected malignancy in the sigmoid colon. The patient, who had a perforation area at the splenic flexure level in the colonoscopy, was taken into emergency operation. In the exploration, splenic flexure and proximal descending colon were found to be herniated into the diaphragm. The column was removed from the diaphragm. The perforated area was observed at the descending colon level. The thorax was aspirated. There was no stool contamination. The diaphragm was primarily repaired. Resection decision was taken because of the presence of ischemia in the colon. Approximately 10 cm descending colon resection and anastomosis were performed. Thoracic tube was applied and the operation was terminated. The vital signs of the patient were stable during postoperative follow-ups. The patient was discharged on the 7th day when the oral intake was opened and the patient had no additional complaints.

Conclusion

Penetrating diaphragmatic injuries develop after stab wounds or gunshot injuries at the level of the lower thorax and upper abdomen. If it is noticed early, it needs to be repaired. Chronic diaphragm rupture usually does not present with symptoms. In the long term, it may cause thoracic herniation of the intraabdominal organs and associated serious complications such as obstruction and perforation. The diagnosis is usually made through thoracoscopy, laparoscopy, or laparotomy after injury. The diagnosis of chronic diaphragm ruptures is difficult. If it causes herniation, it can be detected through imaging techniques such as CT. Surgical repair is necessary when diagnosed.

In conclusion, herniation associated with chronic diaphragm rupture should be kept in mind if patients with the findings of obstruction have a history of a penetrating thoracic or abdominal trauma.

TJS. 2018;34(Suppl-1):S197–S198.

PP-0041 [Emergency Surgery and Trauma]. The Effect of Mean Platelet Volume and Neutrophile/Lymphocyte Ratio on the Prognosis and Severity of the Disease in Acute Appendicitis Cases

Eyüp Murat Yılmaz ^1,^✉, K Varlık Erel ¹

Objective

Acute appendicitis is one of the most common causes of abdominal pain. In this study, it was aimed to investigate the effect of mean platelet volume (MPV) and neutrophile/lymphocyte (N/L) ratio on the severity of the disease.

Material and Methods

A total of 113 patients undergoing appendectomy in Adnan Menderes University, Faculty of Medicine, Department of General Surgery between December 2014 and September 2016 were included in the study. Considering the values of MPV and N/L ratio, the correlation between histopathological values and macroscopic findings was evaluated.

Results

A total of 113 patients were included. While perforation was not detected in 91 (80,5%) cases, it was found in 22 (19,5%) cases. The histopathological findings were interpreted as acute appendicitis in 99 (87,6%) patients, lymphoidhyperplasia in 7(6,2%) patients, and phlegmonous appendicitis in 7 (6,2%) patients. No statistically significant difference was found between the MPV and N/L values and macroscopic and histopathological values.

Conclusion

While N/L ratio is thought to be important for determining the severity of acute appendicitis, the parameter of MPV is not considered to have a such importance.

TJS. 2018;34(Suppl-1):S198.

PP-0042 [Emergency Surgery and Trauma]. Is There Seasonal Variation in the Incidence of Acute Appendicitis?

Metin Yalaza ¹, Sadettin Er ^1,^✉, Özgür Akgül ¹, Birkan Birben ¹, Betül Keskinkılıç Yağız ¹, Sabri Özden ¹, İsa Sözen ¹, Arif Zeki Akat ¹

Objective

Many studies conducted in recent years have shown that acute medical diseases do not occur randomly in time, but they develop at specific times of a day and in specific months of the year at higher rates. The aim of this study was to investigate the observable possibility of seasonal variation in the onset of acute appendicitis (AA).

Material and Methods

A total of 686 patients operated due to the pre-diagnosis of AA in Ankara Numune Education and Research Hospital in 2015 were considered for the study, but 651 of them who were histopathologically confirmed to have AA were analyzed. The patients were divided into sub-groups according to their genders, ages, and time of surgery. By using t-test for statistical analyses, the relationship between the seasons and the incidence of acute appendicitis was investigated.

Results

Of the patients followed and treated for the pre-diagnosis of AA in 2015, 56% were male and 44% were female. The rate of AA was higher in men than in women by 12%. The number of patients whose pre-diagnosis of AA was confirmed by the result of pathological evaluation was 651. This demonstrates that 95% of patients hospitalized and operated due to the pre-diagnosis of AA are those with AA. According to the analyses of data, AA is 12% more common in men than in women. In the classification of 651 cases (15–83 years old) into successive groups involving 6 years, the number of AA patients at the age range of 22–28 years was the highest and this rate constituted 27.9% of the total number. This rate gradually decreased in the groups at the ages of ≥22 years and decreases to 0.6% for the age of 78 years and above. The number of AA cases was 123 (18.9%) in winter, 179 in spring (27.5%), 187 (28.7%) in summer, and 162 (24.9%) in autumn. In spring, the number of AA patients increased approximately by 9% compared to winter. In summer, its incidence increased approximately by 1% compared to spring. Acute appendicitis cases were observed to be more common in summer but less common in winter. Considering the value of p=0.001 (<0.05), a statistically significant difference was found in the number of patients with AA among the seasons. When the operations performed at the same period were classified according to the days of a week, it was found that these operations were mostly carried out on Thursdays, at the rate of 16.4%. Moreover, the numbers of operations on Fridays and Sundays was higher than on the other days.

Conclusion

Our data support some studies showing that the incidence of acute appendicitis is low in winter and it increases in summer. Although some authors have suggested that this can be associated with seasonal viral, bacterial, and parasitary infections, the causes of this phenomenon are still unclear.

TJS. 2018;34(Suppl-1):S199.

PP-0043 [Emergency Surgery and Trauma]. The Importance of the Differentiation of Intraabdominal Free Air in the Presence of Chilaiditi’s Syndrome

Introduction

Nephritic and perinephric abscesses are one of the major clinical problems encountered in hospitalized patients with the incidence of 1–10 per 10000 and its incidence in men and women is approximately the same. These abscesses, which are generally confined within the Gerota’s fascia and treated with conservative methods such as antibiotic therapy and percutaneous drainage according to their diameters, can lead to flank, scrotal, subphrenic abscesses and occasionally colonic fistulas. Our case is one of rare cases because perinephric abscess crosses the Gerota’s fascia and opens into the abdomen, which causes secondary peritonitis.

Case

Material and Methods

Retrospective evaluation of the records of the patients who were examined in the emergency unit between January 2015 and December 2017 and requested to be consulted to the Department of General Surgery and retrospective analysis of the admission type, following procedures, and their results.

Results

The number of patients who were consulted to the Department of General Surgery by the emergency outpatient clinics and services was 44114. The mean number of consultations per month was 1225,4±49,5 in 36 months and the mean number of operations per month was 117,1±3,1. In 1033 (2,3%) of these patients with indications, emergency endoscopy was performed in the first 12 hours of admission and 4217 (9,5%) were operated after the evaluation. Of the patients taken into operation, while 3935 (93.3%) were operated due to acute surgical abdomen, 223 patients (5.2%) underwent surgery due to trauma. Thirty-three patients (0.7%) were operated for gastrointestinal system bleeding continuing after the first intervention. On the other hand, 26 patients (0.6%) were operated due to necrotizing fasciitis. While the most common reason for operation was acute appendicitis for patients with acute surgical abdomen (n=2353; 55.7%), it was penetrating stab wounds for patients with trauma (n=111; 2,6%). The rate of laparoscopic surgery in appendicitis cases was 95.8% (n=2255). During this period, 385 patients were operated for acute cholecystitis. The number of cases undergoing laparoscopic procedure was 376 (97.6%). In patients who underwent cholecystectomy, it was not switched to open surgery, partial cholecystectomy was performed in 5 cases (1.3%). In cases of peptic ulcer perforation, the operations of 100 patients (55.6%) were completed laparoscopically. In diagnostic laparoscopies performed for left thoracoabdominal injuries in trauma cases, diaphragmatic injuries were also detected in 24 patients (n=47). In 17 (70.8%) of these patients, in whom no other intraabdominal pathology requiring to switch to open surgery was detected, laparoscopic repair of the diaphragm was performed. 3793 (89.9%) of 4217 surgeries were performed by the resident doctors under the supervision of a specialist physician.

Conclusion

In our clinic, which is one of several hospitals with the highest number of General Surgery consultations and surgeries per month in İstanbul, laparoscopy facilities are used at advanced levels in emergency surgical interventions and resident training is in first place under all conditions.

TJS. 2018;34(Suppl-1):S209–S210.

PP-0059 [Emergency Surgery and Trauma]. The Use of Hem-o-Lok Clip and Intracorporeal Suture in Laparoscopic Appendectomy

Semra Demirli Atıcı ^1,^✉, Halit Batuhan Demir ¹, Emran Kuzey Avcı ¹, Can Arıcan ¹, Murat Akalın ¹, Bülent Çalık ¹, Gökhan Akbulut ¹

Objective

In patients presenting with the complaint of abdominal pain to the emergency unit, acute appendicitis is the most common abdominal pathology requiring urgent surgical intervention. The standard surgical treatment is open appendectomy. However, with developing technology at present, laparoscopic appendectomy has advantages such as shorter hospitalization time, less pain, early return to work, and better cosmetic results as well as disadvantages such as higher cost, longer operation time, and higher rate of intraabdominal abscess development, compared to open appendectomy. With the spread of laparoscopic appendectomy in the treatment of acute appendicitis; it is still unclear which of the techniques is the most appropriate intervention for the closure of the appendectomy stump. At present, various surgical techniques such as the use of stapler, hem-o-lok clip, titanium clip, and ligature, use of bipolar cautery, pushing the knot made externally into the abdomen, and lasso technique are frequently used. In this study, we evaluated the demographic characteristics of the cases undergoing laparoscopic appendectomy due to the diagnosis of acute appendicitis at Tepecik Education and Research Hospital Department of General Surgery between 2017 and 2018, the techniques of hem-o-lok clip and intracorporeal knotting in terms of the duration of operation and postoperative complications and also the superiority of these methods to each other.

Material and Methods

The patients who was hospitalized and performed laparoscopic appendectomy in the General Surgery Department of Tepecik Training and Research Hospital between 2017 and 2018 due to the diagnosis of acute appendicitis were evaluated retrospectively. The study included 129 patients. Gender of the patients, techniques used during operation, duration of operation, duration of hospitalization, and postoperative complication rates were evaluated.

Results

Between the years of 2017 and 2018, 129 patients were operated laparoscopically. The study included 129 patients. Of them, 74 (57.4%) were female and 55 (42.6%) were male. In 10 patients (7.75%) (6 males, 4 females), laparoscopy was switched to open surgery because of technical insufficiency and patients’ inability to tolerate increased intraabdominal pressure. The age range was 17–73 years and the mean age was 35.8 years. Six patients were over 60 years of age and they were postoperatively followed up in the surgical intensive care unit for at least one day due to their comorbid diseases. Knotting was used in all patients whose operation was switched from laparoscopic to open appendectomy and hem-o-lok or knotting was used in patients whose operations ended laparoscopically. In two patients who underwent laparoscopic appendectomy, postoperative intraabdominal abscess and trocar-site hernia developed as morbidity (1.55%). Intraabdominal abscess developed in one patient performed intracorporeal knotting and incarcerated hernia developed in the subumbilical trocar-site in a patient for whom clip was used. Clip was used in 70 patients (54.27%) and intracorporeal silk suture was used in 59 patients (45.73%). The mean duration of operation was 81.25 min and this time was 75.6 minutes in the patients for whom clip was used. The mean duration of postoperative hospitalization was 1.95 days, which was found to be 1,89 days for patients applied clipping and 2,05 days for patients applied intracorporeal knotting.

Conclusion

In laparoscopic appendectomy, the durations of operation and hospitalization are longer in patients for whom clips are used than in those for whom intracorporeal knotting is used.

TJS. 2018;34(Suppl-1):S210.

PP-0060 [Emergency Surgery and Trauma]. The Results of Incomplete Early Intervention After Corrosive Substance Intake

Bahri Özer ^1,^✉, Semih Yaman ¹, Mustafa Şit ¹, Oğuz Çatal ¹, Elif Yalçın ¹, Muhammet Fatih Keyif ¹, Selçuk Köksal ¹, Mehmet Hayri Erkol ¹

The intake of a corrosive substance causes rapid, progressive, and severe burns in the upper gastrointestinal system. This clinical picture is called corrosive esophagitis. If the acute phase of the injury is overcome, esophageal stricture or malignancy may develop during the healing process. The concentration and pH of the caustic substance, the amount received, and the duration of contact with the mucosa are important in corrosive esophagitis. A 33-year-old male patient diagnosed with bipolar disorder had been suspected of suicide attempt by drinking hydrochloric acid and he had been taken to the emergency unit of an external center by his family with a complaint of abdominal pain. Emergency intervention had been made and the gastric lavage and activated charcoal had been administered. There was not enough information about the examination performed by general surgery at the external center, and the patient, who had been discharged after the process without hospitalizaiton, had had mental fog and syncope at home after one hour. He was re-admitted to the emergency unit. Emergency surgery was planned with the suspicion of intestinal perforation, but because there was no empty bed in the intensive care unit, he was referred to our hospital. The patient who was referred to our department was taken into emergency operation and performed laparotomy. All intraabdominal organs were observed to be necrotized. The patient was applied total gastrectomy, total pancreatectomy, total small intestine resection, subtotal large intestine resection, and splenectomy and packing was performed. The patient died due to multiorgan failure on the postoperative 2nd day. In cases of corrosive substance ingestion, endoscopic evaluation should be performed within the first 24 hours. If there is haemorrhage, erosion, pale-atrophic mucosa, and necrosis in the stomach mucosa in the endoscopic findings, the patient should be followed closely for perforation. In this regard, complications can be avoided and mortality rates can be reduced.

TJS. 2018;34(Suppl-1):S210–S211.

PP-0061 [Emergency Surgery and Trauma]. Acute Appendicitis in the Elderly Patients: Evaluation of the Diagnostic Values of Alvarado Score and Computed Tomography

Selçuk Kaya ¹, Ömer Faruk İnanç ^1,^✉, Önder Altın ¹, Ahmet Şeker ¹, Yunus Emre Altuntaş ¹

Objective

Acute appendicitis is one of the most common causes of acute abdomen in emergency surgery clinics. While acute appendicitis occurs primarily in young people with a life-time risk of 7%, 5–10% of cases are the elderly patients. Forty-eight operated patients aged ≥70 years were retrospectively evaluated in order to assess the reliability of computed tomography (CT) and the Alvarado score in the diagnosis of acute appendicitis.

Material and Method

Forty-eight patients aged ≥70 years, who were operated with the prediagnosis of acute appendicitis and whose histopathological diagnosis was reported as acute appendicitis between January 2016 and January 2018, were retrospectively evaluated. In addition to the demographic data of the patients, the diagnostic values of the Alvarado score and CT in the normal population were compared with the results of the patients who were operated in our clinic. We assessed whether the diagnoses of leukocytosis, pain in the right lower quadrant, fever, pain radiation, loss of appetite, vomiting, rebound, tenderness, and shift of neutrophil count to the left in the Alvarado score and the findings of the computerized tomography were consistent with postoperative histopathological diagnoses.

Results

Of the patients histopathologically diagnozed with acute appendicitis in our clinic, 60.4% were male and 39.6% were female and the mean age was 76.7±5.8 years. In the Alvarado scores, pain localization had the lowest diagnostic value with the rate of 56.3%, the diagnostic value of the shift of the neutrophil count to the left was the highest with the rate of 93.8%. When the Alvarado scores of >7 were considered as suspicious for the diagnosis of acute appendicitis, the diagnostic value for the score range of 1–6 was 23%, this value was 85.4% in the score range of 7–10. This rate in CT was 91.6%.

Conclusion

The incidence of appendix perforation is 17–40%. In elderly patients, this rate can reach up to 70%. Therefore, it is important to diagnose acute appendicitis in elderly patients. The Alavarado scoring and CT are benefited in the establishment of its diagnosis. When the diagnostic value of Alvarado score is examined, diagnostic power of scoring differs in studies in literature. However, the values of >7 in the scoring system increase the sensitivity in the diagnosis. While the diagnostic power in normal population was reported to be 30% for the scores of 1–4 and 66% for the scores of 5–6 in the study of Alvarado et al., it was 24.6% for the scores of <7 in our study. This rate was 93% for the score of 7 and above in the study of Alvarado et al., but 85.4% in our study. CT is often used as an auxiliary diagnostic technique in the diagnosis of acute appendicitis. In the recent studies, the sensitivity and specificity of CT scans are reported as 87–100% and 83–98%, respectively. The sensitivity in our study was 93.8%. In our study, it was determined that Alvarado scoring in elderly patients with suspected acute appendicitis had lower diagnostic power than the normal population, and that CT was valuable in terms of both differential diagnosis and sensitivity. However, there is a need for further studies including more extensive series to support our findings.

TJS. 2018;34(Suppl-1):S211.

PP-0062 [Emergency Surgery and Trauma]. Meckel’s Diverticulum Perforation Associated with Strangulated Inguinal Hernia (Littre’s Hernia): A Rare Case

Mehmet Üstün ^1,^✉, Batuhan Halit Demir ¹, Cengiz Aydın ¹

Meckel’s diverticulum, which is a remnant of the omphalomesenteric canal, is the most frequent congenital malformation of the gastrointestinal tract. It can rarely be seen in any hernia sac and this condition is defined as the Littre’s hernia. A 59-year-old male patient with Meckel’s diverticulum perforation associated with strangulated inguinal Littre’s hernia was successfully treated with diverticulectomy with linear GIA stapler and and graft-free hernia repair. Littre’s hernia may also be present in the cases of abdominal wall hernias requiring urgent surgical intervention due to incarceration. For this reason, it is important to have knowledge about treatment management.

TJS. 2018;34(Suppl-1):S211–S212.

PP-0063 [Emergency Surgery and Trauma]. The First Consultation in the Emergency Unit for Acute Right Lower Abdominal Pain in Women in the Reproductive Age: General Surgeon or Gynecologist?

Hamit Sinan Hatipoglu ^1,^✉, Filiz Hatipoğlu ²

Objective

The suspect of acute appendicitis is the most frequently consulted acute abdomen disease in the emergency units and can cause serious surgical morbidity and even mortality due to complications that may develop in association with delayed diagnosis and/or delayed surgical intervention. The referrals of patients to the departments of gynecology and obstetrics or general surgery by the emergency physicians after admission to the emergency service due to the sudden onset of pain in the right lower quadrant particularly in women at reproductive age can sometimes lead to unwanted delays and serious complications. In this study, we wanted to draw a route guide on which units the first consultation should be done after the first physical examination and laboratory analysis in the emergency service and which clinical data should be used for this decision.

Material and Methods

Retrospective data on physical examination and laboratory findings of 335 reproductive women who were admitted to the emergency unit and then consulted to the general surgery with the pre-diagnosis of acute appendicitis and finally operated by a general surgeon and/or gynecologist between April 2009 and December 2017 were evaluated with pathology results and surgical findings.

Results

The mean age of the patients was 24.6±4.5 years (range 13–45 years). Acute appendicitis was present in 263 (78.5%), perforated appendicitis in 31 (9.3%), and gynecological organ pathology in 41 (12.2%) patients. Of the cases with gynecologic organ pathologies, 25 had ovarian cyst rupture (7.5%), 12 had corpus hemorrhagicum cyst rupture (3.6%), and 4 had adnexal torsion (1.1%). In the differential diagnosis between acute abdomen patients with appendicitis and gynecologic organ pathologies, hypotension (100/60 mmHg and below), tachycardia (100/min and above), high fever (38C and above), defense, Rovsing’s sing, and increased leukocyte counts were found to be statistically significant.

Conclusion

In women at reproductive age, acute gynecological organ pathologies may resemble the clinical picture of acute appendicitis. Especially after the first examination and analyses performed in the emergency departments, it is very important to focus on the differential diagnosis and to refer to the correct surgical unit. The presence of hypotension and tachycardia in patients with gynecologic organ pathology and high fever, defense, Rovsing’s sign, and increased leukocyte counts in patients with appendicitis were detected to be statistically significant.

TJS. 2018;34(Suppl-1):S212.

PP-0064 [Emergency Surgery and Trauma]. Frequency of Tumors in the Appendix Specimens of 3754 Patients Applied Laparoscopic Appendectomy Due to the Diagnosis of Acute Appendicitis

Ahmet Çakmak ^1,^✉, Aziz Bora Karip ¹, Hüseyin Çiyiltepe ¹, Nuriye Esen Bulut ¹, Mehmet Mahir Fersahoğlu ¹, Ender Onur ¹, Kemal Memişoğlu ¹

Objective

In the pathological examination of appendectomies, the incidence of tumors is reported 1%. In this study, the pathology results of patients who underwent laparoscopic appendectomy with the diagnosis of acute appendicitis in our hospital were retrospectively investigated and the pathologic diagnoses and clinical features of patients detected to have a tumor were tried to be revealed.

Material and Methods

The reports of appendiceal pathology specimens performed in our hospital between January 2008 and December 2017 were examined through hospital information system. 4186 pathology reports were reached. While 3754 cases undergoing laparoscopic appendectomy with the diagnosis of acute appendicitis were included in the study, the cases undergoing open appendectomy, having preoperative suspicion of tumor, or undergoing elective appendectomy were excluded from the study. Demographic characteristics and tumor types of the patients were examined.

Results

Of 3754 patients, 2388 were male (63%) and 1366 were female (37%). Their mean age was 33,42 years. Of 18 (0,5%) patients whose pathological evaluation revealed tumor, 13 were male (72,2%) and 5 were female (27,8%) and their mean age was 37,6 years. The pathology results of these 18 cases were carcinoid tumor in 7 patients, mucocele in 6 patients, adenocarcinoma in 1 patient, mucinous cystadenoma in 1 patient, malignant epithelial tumor invasion in 1 patient, B-cell lymphoma in 1 patient, and Hodgkin’s lymphoma in 1 patient.

Two of seven patients with carcinoid tumors are still being followed by our clinic. In the remaining 5 patients, information on follow-up could not be obtained. The patients with mucocele and mucinous cystadenomas were evaluated for once in the outpatient clinic postoperatively. Right hemicolectomy was applied to the patient with adenocarcinoma and no additional feature was detected in the pathology of colon resection. In the patient with malignant epithelial tumor invasion, screening was performed and additional focus could not be detected. The patient having B-cell lymphoma was performed endoscopic examination due to severe abdominal pain and lymphoma was detected in the gastric biopsies, and the patient was given hematologic treatment. No record of control examination in the outpatient clinic was found for the patient with the diagnosis of Hodgkin’s lymphoma. It was stated that the patient could not be reached with the contact information written on the file and this incident was reported to the hospital administration.

Conclusion

In our study, the incidence of tumor was detected to be 0.5% in patients undergoing laparoscopic appendectomy due to the diagnosis of acute appendicitis. Informing patients about the importance of following pathology results after discharge and keeping accurate contact information in the hospital information processing system are important in terms of patient follow-up, treatment, and medicolegal aspect.

TJS. 2018;34(Suppl-1):S213.

PP-0065 [Emergency Surgery and Trauma]. A Rare Cause of Massive Gastrointestinal Bleeding: Henoch-Schönlein Purpura

Erdem Durum ¹, Aziz Bora Karip ¹, Ahmet Yalın İşcan ¹, Ahmet Çakmak ^1,^✉, Ali Cihan Bilgili ¹, Ender Onur ¹, Kemal Memişoğlu ¹

Introduction

Henoch-Schonlein Purpura (HSP) is a vasculitis mediated by IgA immune complex. It is usually seen in children and young adults, but rarely in advanced age. Cases of gastrointestinal bleeding have been reported in the literature. While the patients with digestive system involvement presents with abdominal pain, vomiting, and melena, the findings of imaging techniques are characterized by multifocal mucosal thickening, the presence of skip areas, and mesenteric edema. In this case report, an advanced-aged patient with massive gastrointestinal bleeding due to the digestive system involvement of HSP was presented.

Case

Material and Methods

The files of patients who underwent appendectomy in our hospital due to the pre-diagnosis of acute appendicitis between January 2014 and July 2017 were retrospectively reviewed. Demographic data of the patients, laboratory findings, operative data, emergency services, and hospital invoice costs for surgery and hospitalization were examined. Open and laparoscopic techniques were compared in terms of cost.

Results

Appendectomy was performed in 282 patients (54.6% male) with a median age of 33 (18–85) years. A total of 248 (87.9%) patients were operated with open technique and 34 (12.1%) patients were operated with laparoscopic technique. The median length of operation was 60 (20–215) minutes and the median duration of hospitalization was 2 (0–20) days. Complications developed in 10 (3.5%) patients during their hospitalizations. While the median expense of the operating room was 247.49 (102,72–1242,97) TL, the median total invoice cost was 741.49 (457,67-3886) TL. In only 4 cases, it was seen that the hospitalization invoice did not exceed the repayment amount. In the laparoscopic group, operating room costs (292,48 vs. 244,66 TL, p=0.0069) and total invoice cost (964,46 vs. 707,62 TL, p<0.001) were found to be significantly higher than the open surgery group.

Conclusion

In the present repayment system, appendectomy surgery is not cost effective in an institutional sense. Because it is impossible not to operate patients admitted to the emergency department with acute appendicitis, the higher preference of the open technique can help the institutions to lose less money.

It is difficult to establish preoperative diagnosis in De Garengeot hernias. It has been reported that the appendix can be incarcerated in such hernias, but the signs of typical appendicitis are not observed due to the localization of the inflammation in the femoral canal. In patients admitted due to abdominal pain, the physical examination result that is inconsistent with acute appendicitis and the finding of positive inflammation in the right lower quadrant and femoral canal in imaging methods should suggest De Garengeot hernia.

TJS. 2018;34(Suppl-1):S220.

PP-0078 [Emergency Surgery and Trauma]. Is Peritoneal Closure Necessary in Open Appendectomy? A Prospective Randomized Study

Hüseyin Kazim Bektaşoğlu ¹, Samet Yığman ^1,^✉, Erkan Yardımcı ¹, Enver Kunduz ¹, Fatma Ümit Malya ¹

Objective

Appendectomy is the standard treatment for acute appendicitis. Although laparoscopic appendectomy has gained popularity in recent years, open appendectomy is still the most preferred method. While laparoscopic appendectomy incisions are closed, the separate closure of the peritoneum is usually not paid attention and the closure of the peritoneum during open appendectomy is often dependent on the surgeon’s preference. The purpose of this study is to assess the effect of the closure of the peritoneum while closing the appendectomy incision on patients’ postoperative complications, pain, and quality of life.

Material and Methods

This study was planned as single-center, prospective, randomized, and double-blind. The study population consisted of patients aged between 18 and 65 years, who were admitted to the emergency unit and performed open appendectomy with the diagnosis of acute appendicitis between June 2016 and December 2016. The criteria for exclusion were determined as the presence of intraabdominal abscess in preoperative imaging, intraabdominal observation of local or diffuse purulent fluid, pregnancy, story of malignancy, chronic liver disease, chronic renal failure, diabetes, the presence of a known psychiatric or mental disturbance, and refusal of the patient to participate in the study. The patients were randomized during the closure of appendectomy incision and they were put into two groups according to whether the peritoneum was closed or not. The patients’ demographic data, duration of operation, duration of hospitalizaiton, visual pain scores on the postoperative 1^st day (0–10), evalaution of the quality of life through the EuroQol-5D-5L test on the postoperative 10^th day, surgical site infections developing during the postoperative 30 days, wound dehiscence, bowel obstruction, and mortality were recorded.

Results

Our experience and researches show that intraabdominal washing with antioxidant-enriched ozone solution during laparoscopic appendectomies result in a decrease in early and late postoperative complications to a very low level compared to the appendectomies performed by the conventional method.

TJS. 2018;34(Suppl-1):S224–S225.

PP-0085 [Emergency Surgery and Trauma]. Case of Multiple Small Bowel Perforation in a Patient Receiving Treatment for Neuro-Behçet’s Disease

Arif Burak Çekiç ¹, Mehmet Uluşahin ^1,^✉, Reyyan Yıldırım ¹, Mehmet Arif Usta ¹, Serdar Türkyılmaz ¹

Introduction

Behçet’s disease is a systemic and chronic disease characterized by inflammation. Behçet’s disease is also known to cause gastrointestinal system (GIS) involvement. In GIS, the most commonly affected organ is the mouth and then the ileocecal region. In this article, the case of multiple terminal ileum perforation detected in a patient with known diagnosis of Behçet’s disease will be presented.

Case

A 39 year-old male patient with Behcet’s disease was consulted to our department with severe abdominal pain while he was being treated due to the diagnosis of neuro-Behçet’s disease in the neurology department. It was learned that his pain was present for 2 days and gradually increased. The patient also had simultaneous dental abscess and antibiotic therapy was started in this regard. It was learned that he was receiving colchicine treatment for Behçet’s disease in neurology department and steroid therapy was not initiated because of the development of abdominal pain. It was learned from his anamnesis that the diagnosis of Behçet’s disease was established 6 years ago. He did not have any comorbid disease except Behçet’s disease and he had no history of a previous operation. However, he had a history of azathioprine usage until 1 year ago, but had not received any treatment for 1 year. Diffuse tenderness and defense were detected in the abdominal examination. In the laboratory analysis, leukocyte was 16300/ul, neutrophil percentage was 87, and CRP was 17 mg/dl. Other parameters were within normal intervals. The direct abdominal radiography in standing position demonstrated subdiaphragmatic free air. Abdominal computed tomography (CT) taken in emergency conditions revealed free air values in the perihepatic region and between the intestinal loops. Emergency operation was recommended to the patient. There was diffuse purulent fluid in the laparotomy performed with midline incision. 4–5 perforation areas smaller than 1 cm were observed in the 10–15 cm area starting from the distance of 5 cm to the cecum in the terminal ileum. After segmental small bowel and colon resections were performed, ileocolic anastomosis was performed. In the postoperative period, the patient had no problem except superficial wound infection and was discharged on the 10th day. His follow-ups in the outpatient clinics for Behçet’s disease are continued by the related departments.

Conclusion

Behçet’s disease is a systemic inflammatory disease that can involve many systems. Although the most commonly affected organs in GIS are the mouth and ileocecal region, involvement can be detected anywhere. A large number of Behçet’s patients with multiple perforations in the terminal ileum are available in the literature. It is usually characterized by ischemia, infarction, and subsequently perforation resulted from clinical vascular involvement. Obliteration in the vascular structures and neutrophil infiltration in the affected intestine are detected in its pathology. As anastomosis can be done after resection, operation can be ended with ileostomy according to the degree of peritonitis and ileostomy can be closed electively. In the case of patients with Behçet’s disease, perforation should be kept in mind in the presence of abdominal pain and the necessary tests should be done immediately. It should be remembered that peritonitis and sepsis can seriously be life-threatening in case of delay.

TJS. 2018;34(Suppl-1):S225.

PP-0086 [Emergency Surgery and Trauma]. Inguinal Hernia Sac and Small Intestine Mesenteric Injury Associated with Penetrating Trauma

Murat Şen ^1,^✉, Özgen Işık ¹, Ersin Öztürk ¹

Introduction

Although inguinal hernias are encountered as the most common type of hernia, traumatic injuries of hernia sacs are rarely seen. In the literature, the most common cause of injuries in hernia sacs reaching the scrotum is demonstrated to be gunshot injuries and then penetrating stab wounds. In this study, we will share our experience on a patient who had a scrotal hernia and found to have segmental intestinal ischemia associated with an injury in the meso of the small bowel after opening of the hernia sac following a traumatic injury.

Case

A 57-year-old male patient with a history of right scrotal hernia for approximately 10 years was admitted to the emergency service due to the opening of the scrotal hernia after an occupational accident that happened while working with a power tool known as a hand grinder on October 2017. The patient whose the approximately 100-cm bowel loop was observed outside the abdomen and who also had meso injury was taken into an emergency surgery. The herniated intestines were got into the abdomen with subumbilical median laparotomy. It was observed that the circulation of 10-cm bowel loop was impaired in association with the mesenteric injury and a resection anastomosis was performed in this region. Then, the hernia sac was isolated with the right inguinal incision and reduced. It was ligated and removed. In the patient with normal cord elements and testis circulation, hernia repair was carried out by using the Shouldice technique without application of graft and VAC dressing was applied to the wound. After 3 days, the wound of the patient was clean and the skin was sutured. The patient was discharged on the 6th postoperative day.

Conclusion

In traumatic hernia sac injuries, it should be kept in mind that bowel loops and mesenteric tissues in the sac can also be injured and surgical exploration should be done carefully. Since sacs in traumatic cases are generally unclean, hernia repair techniques performed without grafting can be preferred.

TJS. 2018;34(Suppl-1):S225–S226.

PP-0087 [Emergency Surgery and Trauma]. Our Medical and Surgical Treatment Experience on Patients Admitted to the Emergency Unit with the Clinical Picture of Ileus

Akın Çalışır ¹, Halil Kirazlı ^1,^✉, Enes Şahin ¹, Mustafa Şahin ¹

Objective

Ileus is the condition in which the movement of the intestinal content towards the distal part slows down or completely stops due to any reason. The most common cause of ileus is adhesions associated with previous operation. In this study, we aimed to present the etiology and treatment plannings of patients hospitalized due to ileus.

Material and Methods

Patients hospitalized with the diagnosis of ileus in the emergency unit of Selçuk University Medical Faculty Hospital between January 2011 and December 2017 were examined retrospectively.

Results

A total of 739 patients with the diagnosis of ileus were referred to our department from the emergency unit. Of these patients, 58.4% were male and 41.6% were female. The mean age of the patients was calculated as 62.3 years. It was found that 453 of the patients received medical treatment and 286 of the patients received surgical treatment. Of the patients treated with medical treatment, 82 were re-hospitalized, but no surgical treatment was required during the hospitalization of these patients. Among the patients undergoing surgical treatment, 33.5% had bride ileus not giving a response to medical treatment, 26.5% had strangulated or incarcerated hernia (incisional, umbilical, and inguinal), 25.1% had newly diagnosed colon-rectum cancer, 10.1% could not be performed colonoscopic reduction due to sigmoid volvulus, and 4.8% developed ileus due to other causes (bezoar, gallstone ileus, internal herniation, etc.). There were a total of 549 patients who were hospitalized due to Bride ileus. It was observed that 72% of these patients developed ileus within approximately 11.2 months after the first surgeon. Of these patients, 17.9% (96) were treated surgically. Of the patients, 37.5% (36) were opened ileostomy, 9.3% (9) were applied colostomy, and 53.2% (51) were performed bridectomy. In 26 patients, primary repair was applied due to intraoperative bowel injury. Wound site infection and intraabdominal abscess occurred in 37 and 3 cases, respectively. In patients who were not operated due to bride ileus and applied medical therapy, symptomatic and radiological healing was observed on the 3rd day on average, oral feeding was started, and the patients were discharged on the 4th day. however, the patients administered surgical treatment for bride ileus were discharged on the 13th day on average.

Conclusion

20–25% of patients who are admitted to the emergency unit with acute abdomen are those having bowel obstruction. The most common cause of intestinal obstructions is ileus associated with adhesions. Most of small intestine obstructions are due to adhesions and most of colon obstructions are due to tumors. There is no clear algorithm for the time of surgery to be performed in patients followed due to bride ileus. when to undergo surgery for the disease followed by Bride ileus. In its approach, the decision of surgery is made based on the evaluation of patient-specific findings and clinical experience. Elderly patients and those having undergone major abdominal surgery may sometimes be admitted with ileus symptoms under the influence of immobilization. In the follow-ups of these patients, medical approaches can be kept in the foreground to avoid exposing them to an additional surgical load. In addition, intraoperative or postoperative complications and some conditions such as opening ostomy prolongs the duration of hospitalization and affect the life standards of the patient. Therefore, we believe that primarily medical treatment should be tried in patients with bride ileus, but the necessary surgical treatment should not be delayed.

TJS. 2018;34(Suppl-1):S226–S227.

PP-0088 [Emergency Surgery and Trauma]. A Rare Acute Abdomen Case of an Advanced-Aged Patient: Isolated Cecal Necrosis

Ali Osman Akten ^1,^✉, Özgür Akgül ²

Introduction

Acute colonic ischemia is often seen in the elderly population. It usually develops in association with atherosclerosis and low blood flow. In rarely encountered cecal ischemia, the clinical signs mimic acute appendicitis and concomitant cardiac insufficiency and renal failure can cause the disease to display a poor prognosis. In this case report, a case of isolated cecal necrosis detected in an elderly patient who was urgently operated due to acute abdomen.

Case

A 74-year-old female patient was admitted to the emergency unit with the complaints of diffuse abdominal pain, loss of inappetite, and nausea that continued for about 12 hours. The patient did not have any abnormality except the history of hypertension and previous cholecystectomy. In the physical examination, defense and rebound were revealed in the right lower quadrant of the abdomen. Her blood pressure was 150/95. In the laboratory analysis, the value of WBC was 21,3×103/ul, neutrophil was 17,7×103/ul, CRP was 123 mg/l, Hgb was 11,5 g/dl, total bilirubin was 2.4 mg/dl, and direct bilirubin was 0,74 mg/dl. No air-fluid level and free air was observed in the direct abdominal abdominal radiography. Abdominal ultrasonography revealed edematous cecal wall, inflamed paracecal fatty tissue, and appendix with normal diameter. Tubo-ovarian pathology was not detected. Minimal pericecal free fluid was observed. In abdominal CT, there were localized increase and edema in the cecal wall and multiple pericecal lymph nodes. The thickness of the appendix wall was normal. Anti-hypertensive medical treatment was recommended in the preoperative cardiology consultation. Emergency laparotomy was performed because of acute abdomen (the pre-diagnosis of perforated appendicitis). Right hemicolectomy and ileotransversostomy were performed in the patient who was found to have isolated cecal necrosis. The patient who did not develop postoperative complication was discharged on the 6th day with recommendations. The pathological result of the patient was reported as ischemic colitis and reactive lymph nodes.

Conclusion

Ischemic colitis is the most common form of gastrointestinal ischemias. Isolated cecal necrosis, which is very rare among non-occlusive ischemic colitis cases, may be due to the atherosclerotic or thromboembolic occlusion of the cecal artery, or it may present as non-occlusive cecal necrosis associated with open cardiac surgery, chronic heart disease, and hemodialysis. Isolated cecal necrosis is a rare cause of surgical acute abdomen. In the literature, there are a few case reports. Isolated cecal necrosis mimics acute appendicitis clinically. Emergency surgery is required in cases with clinically and radiologically suspected cecal necrosis. While most surgeons recommend right hemicolectomy and anastomosis, there are also those recommending right hemicolectomy-ileostomy or partial cecal resection. It is difficult to diagnose it early because of its non-specific clinical, radiological, and laboratory findings. In the literature, mortality increases up to 70% in cases not intervened within the first 24 hours and early surgical intervention is of great importance. Although there were no comorbidities that would suggest an isolated cecal necrosis in the differential diagnosis in our case, early surgical intervention provided a significant advantage of survival for the patient. In conclusion, isolated cecal necrosis is a rare cause of acute abdomen that should be kept in mind in the presence of pain localized in the right lower quadrant especially in the elderly patients.

TJS. 2018;34(Suppl-1):S227.

PP-0089 [Emergency Surgery and Trauma]. A Rare Cause of Hemorrhagic Shock: Spontaneous Hepatocellular Carcinoma Rupture

Hüseyin Kılavuz ^1,^✉, Sefa Özyazıcı ¹, Ümit Turan ¹

Hepatocellular carcinoma (HCC) is the most common primary malignant tumor of the liver. Intraperitoneal hemorrhage after the spontaneous rupture of HCC is a complication that can be mortal. Surgical intervention and arterial embolization are among the main treatment options. In our case, the male patient who was admitted to the emergency unit with abdominal pain, distension, and hemodynamic shock was planned to be performed urgent exploration because his abdominal tomography revealed free fluid consistent with hemorrhage. In the intraoperative exploration, intraabdominal hemorrhage and a 4×3 cm hemorrhagic ruptured mass in the second segment of the left lobe of the liver were observed. After lateral segment resection of the left lobe was performed under emergency conditions, a drain was inserted into the abdomen and the operation was terminated without any complication.

The histopathological diagnosis of the patient, who was discharged after the treatment in postoperative period, was reported as “hepatocellular carcinoma”. It should be kept in mind that lesions that may be spontaneously ruptured in the liver may be encountered in the cases taken into operation under emergency conditions with the findings of intraabdominal hemorrhage. As in this case, it is life-saving to perform an effective and rapid intervention to the urgent hemorrhagic liver masses.

TJS. 2018;34(Suppl-1):S227–S228.

PP-0090 [Emergency Surgery and Trauma]. De Garengeot Hernia: Case Report

Berkay Küçük ¹, Alper Doğu ¹, Hilal Özer ¹, Alper Güven ^1,^✉

Introduction

The presence of appendix vermiformis in the femoral hernia sac is a rare condition and it is called De Garengeot Hernia. There is no standard approach to its preoperative diagnosis and operation because it is rarely seen. In this study, a patient who consulted with De Garengeot Hernia and the applied treatment are presented.

Case

A 59-year-old male patient admitted to the emergency room with the complaints of swelling and pain in the right groin for 24 hours was found to have irreducible hernia in the right femoral region. It was learned from his anamnesis that he did not have nausea and vomiting and he was able to defecate. There was no abnormality in the laboratory analysis except for the white blood cell count of 11000/mm3. When the area was entered with the right inguinal incision and the femoral hernia sac was opened, incarceration and gangrenous appendix were observed. Because the root of the appendix could not be reached from the femoral canal, the fascia transversalis was opened and the proximal area of the femoral hernia was reached. The femoral ring was expanded and backward reduction was performed on the sac with its contents. The cecum was reached through the hernia sac and appendectomy was applied. The hernia sac was ligated from the neck region and its excess part was excised. The defect was repaired with the McVay technique. The patient was discharged on the 3rd day after the operation without any problems. The result of pathological evaluation was reported as acute appendicitis.

Conclusion

The presence of appendix vermiformis in the femoral hernia sac constitutes 1% of cases and acute, gangrenous, or perforated appendicitis is found in 0.5%. Since this condition is very rare, a common surgical attitude has not occurred. To perform appendectomy and femoral hernia repair is definitive. We think that patchless repair should be preferred because of the wound site infection rate approaching 29% in De Garengeot hernias.

TJS. 2018;34(Suppl-1):S228.

PP-0091 [Emergency Surgery and Trauma]. A Case of Small Bowel Perforation in a Patient with the Diagnosis of Tuberculosis

Reyyan Yıldırım ^1,^✉, Arif Burak Çekiç ¹, Mehmet Uluşahin ¹, Muhammed Selim Bodur ¹, Serdar Türkyılmaz ¹

Introduction

Tuberculosis is a major health problem with a historical background, which is common in our country. This disease, which is characterized by caseating granulomas, is most commonly seen in the lungs, but can sometimes display multisystemic involvement.

Case

A 44-year-old male patient, who was followed up with the diagnosis of HIV in the Department of Infectious Diseases, was consulted to our department due to severe abdominal pain. It was learned that the patient had been diagnozed with HIV about 4 years ago, he did not receive the initiated treatment for a while, and he had been hospitalized in the Clinic of Infectious Diseases with the complaints of fatigue, weight loss, and loss of appetite. The patient’s HIV treatment was restarted during his hospitalization. Because there were findings consistent with miliary tuberculosis and the tuberculin skin test (PPD) was measured as 15 mm in the thoracic computed tomography (CT) taken for opportunistic infection scanning, treatment was begun. A few days later, the patient was assessed in our department because of severe abdominal pain. It was learned that the patient’s pain was severe for a day. In the physical examination, diffuse tenderness and defense were detected in the abdomen. No pathological findings were found in laboratory analysis. Free air was observed under each diaphragm on the patient’s direct abdominal radiography in standing position. In the abdominal CT, wall thickness and dilatation in the small intestine segments and free fluid and pneumoperitoneum between the bowel loops in the abdomen were reported. Emergency surgery was recommended to the patient based on current findings. In laparotomy, an approximately 4 cm perforation with ischemic wound lips and non-smooth margins was found at the 20 cm distance to the ileocecal valve in the ileum and diffuse fluid was detected in the abdomen. The patient was applied segmental small bowel resection and anastomosis. In the postoperative period, broad-spectrum antibiotherapy was added to the treatment because the inside of the abdomen was dirty. The result of pathological evaluation was reported as necrotizing granulomatous inflammation consistent with tuberculosis. The patient was given antituberculosis therapy for about 2 years because the results of thoracic CT and the pathology of small intestine resection were consistent with tuberculosis. Due to the HIV positivity, his follow-ups are being continued in the Department of Infectious Diseases.

Conclusion

The gastrointestinal system (GIS) tuberculosis is a clinical picture that is still quite common although its rate has decreased compared to the previous years. It can accompany to pulmonary tuberculosis or its isolated form can be encountered. With a large majority, it affects the ileocecal region and the jejunum. It usually occurs as ulcerative or hypertrophic lesions. It can be a condition that can be encountered at every age and most of the cases have symptoms such as abdominal pain, nausea, vomiting, fever, and fatigue. Sometimes, an palpable mass may develop in the right lower quadrant. The final diagnosis of GIS tuberculosis can be established by the demonstration of the bacterium resistant to acid, its growth in the culture, or PCR. In the presence of a suspicion in patients with a known diagnosis of primary tuberculosis, treatment can be started. GIS tuberculosis can cause complications such as bleeding, perforation, and obstruction. Emergency surgical intervention can be needed in the occurrence of complications, particularly perforation, and it should not be forgotten that the morbidity and mortality rates can be high in these patients.

TJS. 2018;34(Suppl-1):S228–S229.

PP-0092 [Emergency Surgery and Trauma]. Case Presentation: Adult Hirschsprung’s Disease Presenting with Perforation

Leyla Zeynep Tigrel ^1,^✉, Gamze Çıtlak ¹, Akın Ünal ¹, Yunus Anacur ¹

Introduction

Adult Hirschsprung’s disease (HD) is a commonly misdiagnosed and rare cause of constipation. The total absence of intramural ganglion cells in the submucosal (Meissner) and myenteric (Auerbach) nerve plexuses of the affected intestinal segment is the primary pathology in HD. 95% of HD cases are diagnosed before the age of 5 years. Although colon perforation mostly occurs with tumor, diverticulitis or traumatic causes in adult patients, a 38-year-old Hirschsprung patient undergoing an emergency surgery due to perforation is presented in this study.

Case

A 38-year-old male patient was admitted to the emergency unit due to severe abdominal pain going on for 2 days. In the anamnesis of the patient, it was learned that he had the complaint of constipation gradually increasing in years, he had consulted to health centers for this condition, he had weight loss for the last 6 months, and his abdominal swelling increased gradually and started to prevent the daily activities of the patient. His abdominal examination revealed severe distension. In the laboratory analysis of the patient, the value of leukocyte was 12.03×10 3uL and C-reactive protein value was 16.5 mg/l. In the abdominal computed tomography, there was an apparent gas-stool distension in the all colon loops and it was measured as 112 mm at the widest point. At the rectum-sigmoid colon level, the wall was thick and the colon wall was slightly thinner at the transverse colon level. There was a small amount of free fluid and massive extraluminal air in the abdomen. The patient, who was radiologically diagnozed with perforation, was taken into emergency operation. In the exploration, 100ml of intraabdominal purulent fluid was detected. The diameter of the rectum and sigmoid colon were approximately 20 cm and a 3-mm perforation area was observed in the anterior area of the sigmoid colon. Minimal dilatation was seen in the ascending colon, transverse colon, and descending colon. The colon between the ascending colon distal and the rectosigmoid junction was resected and the Hartman procedure was performed. Because 150 ml purulent fluid was seen in the abdominal drain on the postoperative 3rd day, oral iv rectal contrast-enhanced abdominal CT was performed and it revealed no contrast-media leakage outside the lumen. Therefore, it was decided to administer conservative follow-up. On the postoperative 5th day, the decision of emergency operation was taken because of the presence of fecaloid discharge from the patient’s incision. A 3-cm opening in the stapler line at the distal area of the rectum closed in operation and intraabdominal purulent fluid were detected. The opening was repaired and the abdomen was cleaned. After completing the treatment of the wound site infection in the median incision, the patient was discharged on the 23rd day after the first operation. After the discharge, biopsy was taken through rectoscopy from the rectum wall. The patient is biopsied from the rectum wall by rectoscopy after discharge. In the pathologic examination, microscopic inflammation rich in eosinophils was observed and ganglion cells and peripheral nerve bundles were not seen in the submucosa.

Conclusion

In this case having long-term constipation, which was not investigated adequately, it was observed that morbidity increased in the postoperative period. Rare diseases such as HD should not be overlooked for adult patients admitted to health institutions due to constipation. The potential causes of constipation should be actively investigated through methods such as endoscopy and rectal biopsy, and the signs of disease should not be overshadowed with symptomatic treatments without revealing its etiology.

TJS. 2018;34(Suppl-1):S229–S230.

PP-0093 [Emergency Surgery and Trauma]. Accuracy Rate of Tomography Results Evaluated with the Method of Service Purchase in Cases of Acute Appendicitis

TJS. 2018;34(Suppl-1):S231.

PP-0096 [Emergency Surgery and Trauma]. Case Report: Acute Appendicitis in a Patient with Situs Inversus

Akın Çalışır ¹, Enes Şahin ¹, Halil Kirazlı ^1,^✉, Fahrettin Acar ¹, Mustafa Şahin ¹

Introduction

Acute appendicitis is one of the most common gastrointestinal emergencies. Its diagnosis is established with the help of clinical symptoms and imaging techniques. Clinical findings may not be at the expected level due to the localization of the appendix, which may lead to delayed diagnosis of acute appendicitis. The appendix can have retrocecal, pelvic, subcecal, preileal, postileal, subhepatic, mid-inguinal, and rarely left-sided localization. Left-sided appendix can be due to two types of congenital anomalies, situs inversus totalis and intestinal malrotation. Situs inversus totalis is a rare congenital anomaly with an incidence of 0.01%, characterized by complete transposition of the thoracic and abdominal organs. The etiology of this anomaly is unknown, but it is assumed that an autosomal recessive defect is predisposing in the long arm of the 14th chromosome. People with the anomaly of situs inversus totalis usually live a normal life without being aware of their condition until they are incidentally diagnosed during an imaging technique performed for an emergency surgical situation. The differential diagnosis in these patients is very difficult because of the unusual findings of physical examination.

Case

A 26-year-old male patient was admitted to the emergency room with a complaint of diffuse abdominal pain in the region of umbilicus that had started few hours ago. In the emergency service, laboratory tests were performed and the patient was considered to have no acute situation. Upon that, he was given medical treatment and discharged. When the complaints of the patient were not resolved and the pain moved to the left lower quadrant, he was re-admitted to the emergency unit. In the physical examination of the patient who was consulted to our department, severe tenderness, defense, and rebound were detected in the left lower quadrant. His WBC value was 12.8 K/ul. Because the PA chest X-ray demonstrated dextrocardia, abdominal CT was performed with the pre-diagnosis of situs inversus totalis and acute appendicitis. It was observed in the imaging that the patient had situs inversus totalis anomaly and the appendix was hyperemic and edematous, and its environment was contaminated. The appendectomy procedure was performed by entering the abdomen with Elliot’s incision on the left side.

Conclusion

In the differential diagnosis of abdominal pain in the left lower quadrant, diverticulitis, renal colic, ovarian cyst rupture, Meckel’s diverticulitis, incarceration, or strangulated inguinal hernia, psoas abscess, and rarely acute appendicitis due to left-sided appendix should be taken into consideration. In the literature, the incidence of acute appendicitis with situs inversus totalis is specified to be between 0.016% and 0.024%. The diagnosis of thyroid inversus totalis can be easily made by examinations such as PA chest X-ray, ultrasonography, and computed tomography. In this case, we established the diagnosis through PA chest X-ray and abdominal CT. In these patients, surgical interventions to be performed after the diagnosis of situs inversus totalis do not differ provided that they should be performed from the reverse side.

If the findings of physical examination are consistent with acute abdomen in patients admitted due to left lower quadrant pain, left-sided acute appendicitis should definitely be considered. This will avoid potential delays in diagnosis and possible morbidity and mortality.

TJS. 2018;34(Suppl-1):S232.

PP-0097 [Emergency Surgery and Trauma]. The Use of a Thermal Camera in the Diagnosis of Acute Appendicitis, which is the First in Literature

Hamit Sinan Hatipoğlu ^1,^✉

Objective

Acute appendicitis is the most frequently consulted acute abdominal disease in emergency departments and it may cause serious surgical morbidity and even mortality due to complications that may develop intra-operatively and post-operatively in diagnostic and/or surgical interventional delays. Currently, there are real effective diagnostic tools for the diagnosis of acute appendicitis, and the diagnosis of appendicitis is based on clinical examination, laboratory findings, and abdominal ultrasonography. In addition, scoring systems, abdominal x-rays, computed tomography, magnetic resonance imaging, and diagnostic laparoscopy are also used for diagnosis. In this study, it was aimed to determine whether thermal camera is a good new diagnostic tool for acute appendicitis with the detection of minimal temperature changes on the skin surface in the reflected abdominal region, which may be due to intraabdominal inflammation in acute appendicitis, by thermal imaging.

Material and Methods

After approval by the Clinical Studies Ethics Committee, prospective data and thermal imaging camera records including surgical and pathological findings of 51 consecutive patients with the diagnosis of acute undergoing appendectomy due to the diagnosis of acute appendicitis by the same general surgeon between January 2013 and January 2015 were obtained. In addition to the findings obtained in the initial examination at the emergency unit, simultaneous body temperature, preoperative thermal camera views, peroperative findings of the abdominal skin surface, and pathological findings of the appendiceal tissue were also evaluated. Hand-held infrared thermal imaging cameras were used for measurements.

Results

The mean age of the patients was 27.4±7.5 years (18–55) and 30 of them were male. While 12 of the patients had the highest temperature measured on the epigastric area, 17 had in the umbilical area. Epigastric and umbilical areas constituted 56.9% of patients. The lowest temperature measurement on the anterior wall of the abdomen was observed in the hypogastric region in 15 patients and in the right inguinal region in 10 patients, and the rate of the patients in these two areas was 49%.

Conclusion

This work is the first literature study on infrared thermal camera imaging used as a new diagnostic tool in the diagnosis of acute appendicitis. When the results of the study are taken into account, the thermal imaging camera used in this study is far from being a new diagnostic tool for acute appendicitis and it may be suitable for the determination of superficial inflammation, but not for deep inflammation. Because of the insufficiency of infrared thermal camera imaging for evaluating the body in depth, its usefulness for acute intraabdominal inflammation is limited. These methods may be promising for the future if temperature changes in deep tissues are visualized as a result of developing technology.

TJS. 2018;34(Suppl-1):S232–S233.

PP-0098 [Emergency Surgery and Trauma]. Renal Artery Thrombosis and Hypercoagulability Developing after a Blunt Trauma: Case Report

Barış Özkara ^1,^✉, Ayşe Arduçoğlu Merter ¹, Burhan Mayir ¹, Osman Zekai Öner ¹, Mehmet Tahir Oruç ¹

Introduction

Renal Artery Thrombosis (RAT) is a rare condition that can cause renal parenchymal loss. It frequently develops secondary to heart valve diseases and heart rhythm disorder. It can also be seen after trauma. It is a rare condition the diagnosis of which is often overlooked because of nonspecific findings. In this report, a case of renal artery thrombosis detected after a traffic accident was presented.

Case

A 31-year-old male patient was admitted to the emergency room with the complaint of abdominal pain within 1–2 hours after trauma. The general condition of the patient evaluated in the emergency department was good, he was conscious and cooperative. His vital signs were normal. The physical examination revealed no additional finding other than right hypochondriac and right lumbar tenderness. There was no feature on his history. In the laboratory analysis, HGB was 15.2, WBC was 12.8, BUN was 15, CR was 1.2, and LDH was 904 and other routine values were usual. In the complete urinary analysis, hemoglobinuria (+++), proteinuria (+), and 51 erythrocytes were present. The results of coagulation tests were normal. Abdominal CT revelaed thrombus material in the right renal artery. Perfusion was not observed in the right renal parenchyma. The appearance of the thrombus material at the proximal area of the celiac truncus, allowing passage to the distal part, was observed. Considering the present findings, the patient was started low-molecular-weight heparin treatment. In the clinical follow-up, no invasive intervention was required for the patient because his vital signs were stable and his pain regressed. The patient was consulted to the department of genetics for his susceptibility to hypercoagulopathy. The coexistence of PAI-1 4G/4G allelic structure and MTHFR A1298C heterozygous structure were detected in laboratory tests. This polymorphism was thought to be responsible for right renal artery thrombosis. In the control Doppler USG, no thrombus in the celiac truncus lumen was observed. The patient without additional pathology in the follow-ups was discharged with oral anticoagulant therapy. At the fifth month of his follow-up, the patient is taking oral anticoagulant and continues the control examinations in the outpatient clinic of hematology.

Conclusion

RAT is rarely seen important clinical condition, the diagnosis of which can be delayed due to its non-specific clinical and laboratory findings and therefore, can result in renal parenchymal loss. Trauma is rarely the cause of this condition. Its clinical presentation and laboratory findings can be nonspecific. The most important biochemical parameter showing renal infarction is not specific but increase in LDH level. The diagnosis is established with renal angiography or contrast-enhanced abdominal CT. The primary treatment for renal artery thrombosis is anticoagulant therapy. Treatment options other than anticoagulant therapy include percutaneous transcatheter aspiration, embolectomy, and nephrectomy. The use of surgical treatments is currently limited because they cause high morbidity and they provide limited preservation of the renal tissue. Therefore, conservative treatments should be considered instead of surgical treatment. These patients should also be carefully evaluated in terms of hereditary factors causing hypercoagulopathy. Although trauma is a rare cause in the etiology, it is important to keep the renal artery thrombosis in mind in the differential diagnosis of patients who present with abdominal pain after trauma.

TJS. 2018;34(Suppl-1):S233.

PP-0099 [Emergency Surgery and Trauma]. A Rare Cause of Ileus: Isolated Cecal Necrosis

Melih Can Gül ^1,^✉, Bekir Sarıcık ¹, Ömer Rıdvan Tarhan ¹, Ayfer Şen ¹

Introduction

Isolated cecal necrosis (ICN) is a condition that is rarely seen in the elderly people. It can be confused with acute appendicitis and other causes of acute abdomen particularly in elderly patients. It is extremely difficult to diagnoze ICN in the preoperative period. Delayed diagnosis and treatment may cause sepsis and death due to necrosis developing as a result of progress in intestinal ischemia. In this study, it was aimed to present a patient who was operated for the pre-diagnosis of ileus and diagnozed with acute partial cecal necrosis in the light of current literature.

Case

A 74-year-old male patient was admitted to the emergency unit with the complaints of abdominal pain that started 36 hours ago and gradually increased, loss of appetite, nausea, and vomiting. The patient had a history of chronic artery disease (CAD), chronic obstructive pulmonary disease (COPD), and chronic renal failure (CRF) for 5 years and he was using aspirin, isosorbide dinitrate, and salbutamol. In the abdominal examination of the patient, distension, tenderness, defense, and rebound were detected in all quadrants. The leukocyte count of the patient was 13,800/mm3. The hemoglobin value was 6.9 gr/dl, creatinine was 3,27 mg/dl, CRP was 193 mg/l, and other results were normal. The abdominal x-ray of the patient showed multiple air fluid levels in the small intestine. The patient’s oral intake was stopped and a nasogastric catheter was placed. Fluid including small intestine content was observed. The patient underwent an emergency operation with the pre-diagnosis of ileus. In the exploration performed with supra and subumbilical incision, it was observed that the small intestine loops were dilated and three isolated ileal loops were adhered on the cecal wall in the right lower quadrant of the abdomen. After the adhesions were separated with sharp and blunt dissections, the appendix was in normal appearance. Necrosis was seen in an approximately 5 cm segment on the anterior wall of the cecum. There was no tumoral mass. It was observed that there was an abscess on the necrotic area secondary to serosal fat necrosis, and the omentum and related ileal loops adhered to the cecal wall and caused dilatation in its proximal region. The patient was performed right hemicholectomy. Although the patient did not have any intra-abdominal complications during intensive care follow-ups in the postoperative period, he died on the postoperative 11th day because of acute renal failure and cardiac arrhythmia developing on the ground of CRF. In the pathological evaluation, transmural infarction, fibrin thrombi in small veins, and fat necrosis in the serosa were reported.

Conclusion

The etiology of isolated partial cecal necrosis is not fully understood, but it is a rare cause of acute abdomen reported to develop in those with atherosclerotic heart disease or in association with hypotension attacks seen after hemodialysis. It is difficult to diagnose it preoperatively. In the tomography of the abdomen, thinning of cecal wall and isolated pneumatosis coli can be seen. However, our patient could not be performed intravenous contrast-enhanced tomography due to the presence of acute renal failure. Since the findings of the patient were consistent with ileus, emergency laparotomy decision was taken. The treatment of partial cecal necrosis is surgical. Depending on the size of the cecal necrosis and the presence of peritonitis findings, partial resection of the affected cecal area, segmental colon resection, or right hemicolectomy may be performed. Most authors claim that right hemicolectomy should be reliably chosen because a partial resection of cecum is risky. In our case, the patient underwent right hemicolectomy.

TJS. 2018;34(Suppl-1):S234.

PP-0100 [Emergency Surgery and Trauma]. A Rare Cause of Mechanical Bowel Obstruction: Endometriosis

Yusuf Emre Aytin ^1,^✉, Ahmet Orhan Sunar ¹, Eyüp Kahya ¹, İbrahim Ethem Cakcak ¹, Serhat Oğuz ¹

Introduction

Endometriosis is the condition in which the endometrial tissue is outside the uterine cavity. It is commonly observed in women at reproductive age. Ectopic endometrial foci are most commonly seen in the ovaries but rarely in the intestinal organs. Intestinal endometriosis can be localized in the ileocecal region, even if it is frequently seen in rectosigmoid and rectovaginal septum. In this article, we wanted to describe the surgical approach in two cases developing mechanical bowel obstruction due to intestinal endometriosis.

Case 1

A 21-year-old female patient admitted to the emergency unit with abdominal pain, nausea and vomiting stated that her menstrual period started 3 days ago and her abdominal pain increased gradually. Her abdominal examination revealed distension and defense in all quadrants. The drainage of intestinal content was performed on the patient inserted a nasogastric catheter. The patient with elevated CRP and leucocytosis had a large number of small intestinal air fluid levels in the abdominal radiography. Emergency exploration decision was made upon the increased wall thickness obstructing the passage of the terminal ileum in abdominal tomography. Endometriosis foci causing adhesion on the ileum were observed at the 20 cm proximal regio of the ileocecal valve and small intestinal resection and anastomosis were applied to the pathological area. The patient was uneventfully discharged on the postoperative 6th day. The pathological result was reported as foci of endometriosis.

Case 2

In the abdominal examination of a 33-year-old female patient who was admitted to the emergency unit due to the complaints of abdominal pain, nausea and vomiting in the menstruation period, distension was detected. A nasogastric catheter was inserted and intestinal drainage was performed. There was diffuse small intestinal air fluid levels in the abdominal radiography of the patient having leucocytosis. The patient underwent an emergency operation because of massive lesion that did not allow passage in the cecum. In the exploration, the endometrial foci and adhesions occluding the cecum and terminal ileum were observed. The patient was performed ileotransversostomy after ileocecal resection. The patient was uneventfully discharged on the 7th postoperative day. The result of pathological evaluation was reported as endometriosis foci.

Conclusion

Symptoms seen in intestinal endometriosis may be pelvic pain particularly increasing in the menstrual period, constipation, or recurrent diarrhea. Hormonal therapy has no corrective effect on mechanical obstruction symptoms. Resection of the affected intestinal segment and anastomosis are the best accepted approaches in patients with intestinal endometriosis. In these two cases, bowel obstruction was present and surgical treatment was performed.

Intestinal endometriosis is rare but may cause mechanical bowel obstruction. For this reason, it should be remembered in the presence of mechanical intestinal obstruction findings especially in women of reproductive age and it should not be forgotten that surgery is the first choice in its treatment.

TJS. 2018;34(Suppl-1):S234–S235.

PP-0101 [Emergency Surgery and Trauma]. Indication for Emergency in Diaphragmatic Hernias; Incarceration

Yusuf Emre Aytin ^1,^✉, Ahmet Orhan Sunar ¹, Eyüp Kahya ¹, İbrahim Ethem Cakcak ¹, Tamer Sağıroğlu ¹

Introduction

The congenital diaphragmatic hernia is a congenital disorder with high mortality and characterized by the protrusion of abdominal organs from the posterolateral defect in the diaphragm into the thoracic cavity. The most common type of congenital diaphragmatic hernias is the Bochdalek Hernia, which accounts for 85–90% of cases. Most cases become symptomatic after birth and are diagnosed at this time. In rare cases, there are cases of Bochdalek Hernia who are asymptomatic until the adulthood. In this article, we aimed to present a 71-year-old patient who was urgently operated due to Bochdalek hernia in our clinic.

Case

A 71-year-old male patient presented with sudden onset abdominal pain, vomiting and respiratory distress. The patient had epigastric tenderness in the abdominal examination, and the nasogastric tube that was inserted in the emergency service had gastric contents without bile. In the blood analysis, the value of leukocyte was 19000/uL and crp was 18.2mg/dl. In the evaluation of thoracoabdominal tomography taken by considering acute abdomen, she was reported to have Bochdalek hernia and the corpus of the stomach and omental tissue was herniated and incarcerated. The patient was taken into emergency operation and the exploration revealed a 7×5 cm Bochdalek hernia and the omental tissue and stomach corpus were herniated from this area. The herniated omental tissue and stomach corpus were taken into the abdomen. Because the herniated omental tissue was necrotic, omentectomy was performed. Resection was not applied since the blood supply to the stomach was normal. The repair of the diaphragm was properly carried out. The operation was terminated by putting dual patch on the repaired area.

Conclusion

Although congenital diaphragmatic hernias are frequently diagnosed during the neonatal period, its incidence in adults has been reported to be 0.17% in a study. In cases with the sudden onset of respiratory distress, abdominal pain and signs of obstruction in the gastrointestinal system, Bochdalek hernia should not be forgotten and emergency surgical treatment should be planned because the risk of complication risk is high in large hernias including abdominal organs.

TJS. 2018;34(Suppl-1):S235.

PP-0102 [Emergency Surgery and Trauma]. A Rare Case: Isolated Superior Mesenteric Venous Injury Due to a Blunt Abdominal Injury

Mehmet Kubat ^1,^✉, İsmail Pınar ²

Introduction

As a result of blunt and penetrating abdominal trauma, primarily solitary and luminal organs are injured. Intraabdominal vascular injuries due to blunt abdominal traumas are rarely seen. It is very difficult to visualize the superior mesenteric venous (SMV) and portal venous injuries in emergency conditions.

Case

A 62-year-old male patient was admitted to emergency service with blunt abdominal trauma due to low-speed in-vehicle traffic accident. In the ultrasonography performed under urgent conditions, the presence of diffuse fluid in the abdomen and suspected liver injury were reported. The patient was performed emergency laparotomy and an approximately 6 cm injury in the inferior part of the transverse colon mesentery and in the mesenteric root of the small intestine and a hematoma around it were detected. Also venous hemorrhage was seen. Under the splenic vein junction on the SMV, there was an avulsion tear and defect of about 15 mm in length, which was thought to be associated with the traction of the lateral branches. End-side vessel anastomosis and primary repair were performed with 5/0 prolene sutures. In the postoperative period, the patient was followed up in intensive care unit for 2 days and oral ingestion with liquid foods was started after 2 days. CT angiography and Doppler ultrasonography were used to follow the SMV and portal vein flows. The patient was discharged on the postoperative 12th day with appropriate anticoagulant therapy. No pathology was observed in SMV and portal vein during the 6-month follow-up.

Isolated SMV injury due to blunt abdominal trauma has rarely been reported. Treatment options for SMV injuries are controversial. At least 5 treatment modalities including ligation, lateral repair, end-to-end anastomosis, and autologous and prosthetic grafts have been described. Simple ligation should be preferred in patients with unstable condition and/or multiple injuries due to possible venous congestion and similar complications. Although the preference of venous repair methods in mesenteric venous injuries is technically more difficult, it will be anatomically and functionally more accurate. Patients with irrepressible small bowel edema due to the development of thrombosis in the collaterals and SMV after venous ligation have been reported and it has been observed that the return of the gastrointestinal system to its normal functions can require more time and can also cause the development of ischemia. In another respect, patients with thrombosis and small bowel necrosis developing after SMV resection and end-to-end anastomosis have also been reported. Although we did not encounter a similar condition in our patient, we were aware of that we should not overlook a similar complication.

Conclusion

SMV injuries after blunt abdominal trauma have high mortality due to difficult diagnosis and difficulty in the isolation of the injured structures although they are quite rare. Ligation is a preferable method in patients who can not achieve hemodynamic stability; however, collateral development’s being time-consuming and the occurrence of small bowel edema and congestion are important handicaps. We believe that the use of vascular repair techniques by experienced surgeons in hemodynamically stable patients is important for the continuity of anatomical and functional integrity.

TJS. 2018;34(Suppl-1):S235–S236.

PP-0104 [Emergency Surgery and Trauma]. Mesenteric Torsion Associated with Mesenteric Cyst

Ersan Semerci ^1,^✉, Sadık Emre Direk ¹, Abdullah Serin ¹

Introduction

To present a case report on the treatment of the acute abdomen picture caused by rarely seen mesenteric cyst and mesenteric torsion with laparoscopic surgery, case report.

Case

Material and Methods

Of 33 patients treated for NF in the department of general surgery in our hospital between the years of 2011 and 2016, 30 patients whose data were fully obtained were included in the study. Patients’ ages, comorbid diseases, duration of hospitalization, duration of stay in the intensive care unit, and recent conditions were recorded. Statistical analyses were performed by using SPSS 20 software.

Results

The mean age of the patients was 57.5 (20–81) years. The ratio of male to female was 17/13. NF occurred in association with perianal abscess in 14 patients, pilonidal sinus abscess in 3 patients, elective surgery in 10 patients, and emergency surgery in 3 patients. Of the patients, 50% had diabetes mellitus. Tissue culture was positive in only 12 (40%) patients. The most commonly growing microorganisms were E. coli, Acinetobacter spp, and P. aeroginosa. The mean LRINEC score was 8.5±2.8. There was a significant correlation between patient age and LRINEC Score (p=0.018, R=0.43). Although the patients with high LRINEC scores had longer duration of hospitalization, it was not statistical significant. The LRINEC scores of patients requiring intensive care were significantly higher than those who did not require intensive care (p=0.01). Although the duration of hospitalization was longer in the patients with high Wang & Wong stage, it was not at the level of statistical significance. It was found that patients with high Wang & Wong stage were hospitalized in the intensive care unit for a significantly longer time (p=0.037). Mortality was seen in five patients (16.7%). When factors such as LRINEC Score, Wang & Wong stage, age, gender, and the presence of comorbidity, which could affect the survival, were analyzed, it was seen that only advanced age was significantly related to survival.

Conclusion

NF is more common in middle aged and male patiets, and our findings are compatible with literature. In the literature, there are publications showing a negative correlation between LRINEC score and survival. In our study, a relationship between the LRINEC scores and survival was not detected, but patients with high LRINEC scores were found to have longer hospitalization in hospital and in intensive care unit. There was no significant relationship between survival and Wang & Wong stage, but it was found that advanced-stage patients were hospitalized in the hospital and intensive care unit for a longer time. In univariate and multivariate analyses, the only factor that significantly affected survival was advanced age.

TJS. 2018;34(Suppl-1):S238.

PP-0108 [Emergency Surgery and Trauma]. A Rare Complication after Appendectomy: Stump Appendicitis

Sinan Sayır ^1,^✉, Semih Sağlık ², Seval Taşpınar ³

Introduction

Acute appendicitis is at the top of the causes of surgical acute abdomen. Wound site infection, intra-abdominal abscess, peritonitis, sepsis, ileus and rarely seen stump appendicitis are among the complications of appendectomy. Stump appendicitis is a picture characterized by the inflammation of the remnant appendix tissue in cases where appendectomy is performed incompletely. It was first described by Dr Rose in 1945. While the incidence of acute appendicitis in the normal population has been reported to be 7%, the incidence of stump appendicitis has been reported to be 1/50000.

Case

Our patient was a 35-year-old male patient. He was admitted to the emergency unit due to the complaints of abdominal pain, nausea, vomiting, and loss of appetite that started 36 hours ago. The temperature on admission was 37.5°C, and there was a right Mc Burney incision scar associated with appendectomy performed 4 years ago. The patient had tenderness, rebound and defense in the right lower quadrant. In the laboratory analysis, the white blood cell count was 16000/mm³. Abdominal computed tomography revealed a blunt ending tubular intestinal segment with a diameter of 14 mm in the right lower quadrant, contamination of the surrounding tissue, and an abscess with a diameter of 26×20 mm. An operation was planned with the diagnosis of stump appendicitis. The operation was started as laparoscopic, but switched to open surgery due to past surgery-related adhesions. Peri-appendicular abscess drainage was performed. An inflamed and perforated 4 cm appendix tissue was detected at the distal area of the cecum. The appendix was isolated until the cecal junction and appendectomy was carried out. On the postoperative 3rd day, the drain of the patient was removed. He was discharged on the 5th day with full recovery.

Conclusion

Stump appendicitis is a rare complication that increases morbidity due to delayed diagnosis. As appendectomy, stump appendicitis also displays the clinical picture of acute abdomen. In our case, the findings of clinical and physical examination were consistent with acute abdomen. From radiological methods, CT is an important imaging technique in diagnosing stump appendicitis. In CT, findings such as increased diameter of stump appendicitis, increased density in surrounding tissues, free fluid around the cecum, and abscesses can be seen. In our case, stump appendicitis and abscess around it were observed. In the cases of stump appendicitis, the time of discharge is longer than in the normal appendicitis cases because of the complications that may accompany. There were abscesses and perforation in our case and he was discharged on the postoperative 6th day. Leaving a stump longer than 5 mm in appendectomy may cause obstruction and inflammation by forming a reservoir for the fecaloid. In our present case, the stump length was 4 cm and there was fecaloid. Stump appendicitis may occur due to subserosal or retrocecal anatomic variations of the appendix, intense inflammation, and inexperience of the surgeon. Despite the history of appendectomy, the diagnosis of stump appendicitis should be considered in patients admitted with the clinic of acute appendicitis such as right lower quadrant pain and peritonitis signs. Early diagnosis and treatment of stump appendicitis are important to reduce possible complications and morbidity.

TJS. 2018;34(Suppl-1):S238–S239.

PP-0109 [Emergency Surgery and Trauma]. Incidentally Detected Tumors of the Appendix

Danial Khabbazazar ^1,^✉, Erdinç Kamer ¹, Turan Acar ¹, Gülden Ballı ¹, Emine Özlem Gür ¹, Haldun Kar ¹, Ercüment Tarcan ¹, Mehmet Hacıyanlı ¹

Objective

Tumors of the appendix are usually asymptomatic and incidentally detected during appendectomy or other abdominal operations. Less than 3% of patients undergoing appendectomy have a primary appendiceal tumor. In this study, we aimed to discuss the characteristics of 5 patients who were operated due to acute appendicitis and incidentally found to have a tumor of the appendix in our clinic with literature.

Material and Methods

In the study, 585 patients who underwent laparoscopic and open appendectomy with the pre-diagnosis of acute appendicitis in the General Surgery Department of İzmir Katip Çelebi University, Atatürk Training and Research Hospital between 01.01.2016 and 31.12.2017 were investigated. Five patients whose pathological evaluation was reported as appendix tumor was included in the study. Patients’ demographic characteristics, histopathologies, clinical findings, surgical findings, and follow-ups were retrospectively analyzed.

Results

Of 5 patients, 3 were female and 2 were male, and their mean age was 50 years. Clinical findings of all patients were found to be consistent with acute abdomen. There were leukocytosis in four cases and leukopenia in one case. The CRP value was high in all cases. In three cases, USG was reported as acute appendicitis and three cases were performed computerized tomography for diagnostic purpose. After physical examination, laboratory analyses, and imaging techniques, they were taken into operation due to the pre-diagnosis of acute appendicitis. All patients had open appendectomy. During the operation, appendectomy was performed in 4 patients and appendectomy and cecum wedge resection were performed in one patient. In the histopathological evaluation, pathological evaluation was reported as well-differentiated neuroendocrine in 2 patients and as low-grade appendiceal mucinous neoplasm in 3 patients. Right hemicolectomy was performed in 2 patients in their follow-ups. The 90-year-old patient died independently of the disease three months after the operation.

Conclusion

TJS. 2018;34(Suppl-1):S242.

PP-0115 [Emergency Surgery and Trauma]. A Case of ‘Wandering Spleen’ Presenting with the Clinical Picture of Acute Abdomen

Harun Sır ^1,^✉, Selim Güleç ¹, Ali Kemal Taşkın ¹, Deniz Necdet Tihan ¹

Spleen stabilization is achieved by splenophrenic, splenocolic, gastrosplenic, splenorenal, and colicophrenic ligaments. In conditions causing loosened ligament, such as developmental anomalies in these ligaments or collagen tissue diseases, the spleen can localize in any place in the intraabdominal cavity, except its usual location at the left upper quadrant, and it can even localize in the pelvis with the influence of gravity. Although this extremely rare condition is usually asymptomatic, it sometimes present with findings such as mechanical intestinal obstruction associated with an abdominal mass and compression or with the severe picture of acute abdomen associated with splenic ischemia due to splenic artery and/or vein torsion. In this study, the clinical course of a 29-year-old female patient who was admitted to our clinic with diffuse abdominal pain, had a palpable mass in the lower abdominal quadrant in the physical examination, and had a torsion of “wandering spleen” in the imaging techniques was examined. The decision of laparotomy was made and the patient was performed emergency splenectomy. She was discharged without any problems on the postoperative 4^th day and no medical problem was detected in the 3^rd month of follow-ups at the outpatient clinic. In the literature, the incidence of splenic torsion secondary to “wandering spleen”is around 0.2%. Although “wandering spleen”, which is especially common in young women, is rarely encountered in current clinical practice, this condition should be kept in mind when general surgeons evaluate the cases of acute abdomen because it may lead to a clinical picture requiring emergency surgical approach.

TJS. 2018;34(Suppl-1):S242–S243.

PP-0116 [Emergency Surgery and Trauma]. Our Case with Intraperitoneal Rupture of Hydatid Cyst: Evaluation of 12 Cases

Ozan Okyay ^1,^✉, Necat Almali ¹

Objective

Hydatid cyst is often a parasitic infestation caused by E. granulosus. Hydatidosis is endemic in the Mediterranean region, including Turkey. In humans, it can be seen in the liver at the rate of 50–75%, in the lungs at the rate of 25%, and in different organs at the rate of 5%. Patients with hydatidosis are asymptomatic until complications occur. One of the most common complications is the spontaneous or traumatic intraperitoneal rupture of the cyst. Intraperitoneal perforation of the cyst can occur in a variety of forms, ranging from mild abdominal pain to anaphylaxis and sudden death. Of hepatic hydatid cysts, 1.7–8.6% are manifested by intraperitoneal perforation. Its treatment is emergency surgery.

Material and Methods

Twelve patients who were urgently operated due to intraperitoneal rupture in our clinic between October 2012 and October 2017 were examined retrospectively.

Results

In the same period, 106 patients underwent elective hydatid cyst surgery. Our perforation rate was 10.1%. The proportions of female (6) and male (6) were equal for the cases that were operated due to intraperitoneal rupture. The mean age was

39.8 (16–79) years. All patients had peritoneal irritation findings. One patient had a history of previous PAIR. Only one of the patients described a trauma story and spontaneous perforation was present in 11 patients. Ruptured cysts were seen in the right lobe in 9 patients and in the left lobe in 3 patients. The patients, except two patients with a previous diagnosis of liver hydatid cyst, were hospitalized in our hospital after admission to the emergency unit. Blood tests (whole blood count, blood group, routine biochemistry), PAAC graph, abdominal USG and computerized tomography were used for preoperative evaluation. PAAC graph and abdominal USG were used as standard in all patients. Four patients underwent computerized tomography. In USG imaging, intrabdominal free fluid was detected in all patients. CT images showed multiple cysts in the liver and abdomen and intraabdominal free fluid. In all of the 12 patients with perforated hepatic hydatid cysts, the circumference of hydatid cyst was surrounded by pads impregnated with 3% hypertonic saline solution to prevent the spread of parasite into the abdomen during the removal of the cyst. The open bile ducts on the internal surface were sutured with non-absorbable sutures. The abdominal cavity was irrigated with 3% hypertonic saline to prevent peritoneal spread. Subsequently, partial pericystectomy (pp) and drainage, pp and omentoplasty, or laparoscopic pp were performed.

Conclusion

Although the perforation of the hydatid cysts into the peritoneal cavity is rare, it can cause some difficulties for surgeons. This pathology should be included in the differential diagnosis of acute abdomen in endemic regions. In patients diagnosed with intraperitoneal hydatid cyst rupture, emergency medical treatment should be initiated against allergic and anaphylactic reactions and urgent surgery should be done without delay. The aim of surgical treatment is to prevent complications, to remove local disease, and to reduce the morbidity, mortality, and recurrence rates to the lowest level.

TJS. 2018;34(Suppl-1):S243–S244.

PP-0117 [Emergency Surgery and Trauma]. Our One-Year Fecal Diversion Results in the Treatment of Perineal Necrotizing Fasciitis (Fournier’s gangrene)

Zeynep Gül Demircioğlu ^1,^✉, Ozan Çalışkan ¹, Mahmut Kaan Demircioğlu ¹, Onur Güven ¹, Mehmet Köstek ¹, Mehmet Mihmanlı ¹, Mehmet Uludağ ¹

Objective

Perineal Necrotizing Fasciitis (Fournier) is a severe and life-threatening polymicrobial infection of the perineal and perianal region. Even in today’s treatment conditions, it has a high mortality and decreases quality of life. Therefore, the administration of the most aggressive treatment in the appropriate patient group at the accurate time provides a positive contribution to the course of the disease and reduction of the cost. In this study, we aimed to share the results of 8 patients treated for Fournier’s gangrene (FG) at our clinic in 2017.

Material and Methods

The data of 8 patients admitted to our emergency service in 2017 and diagnosed with FG were retrospectively evaluated. Patients’ demographic characteristics, comorbid diseases, durations of hospitalization, the application of fecal diversion, and the number of surgical debridement after fecal diversion were compared.

Results

Of 8 patients with the diagnosis of FG, who were admitted to our emergency service in one year, 4 (50%) were female and 4 (50%) were female. The mean age was 58.78 (42–83) years. The majority of patients (87.5%) had diabetes as a comorbid disease and the others (12.5%) had coronary artery disease and hypertension. Although the lesions had perianal localization in all patients, concurrent scrotal involvement was observed in 1 patient (12.5%). Three patients (37.5%) had skin defects larger than 75 cm2 in the perianal region after the first debridement. Loop colostomy was performed as fecal diversion in 5 patients (62.5%), including these 3 patients. The average debridement number was 6.12 (1–20). In patients treated with fecal diversion, the inhibition of stool contamination was observed to have positive contribution to decreasing the number of surgical debridements. The duration of hospitalization was longer in patients undergoing fecal diversion for reducing the length of hospital stay, reducing the number of surgical debridements, and controlling polymicrobial infection than in those not undergoing it. Because these patients had larger lesions localized close to the perianal region, which were difficult surgical injuries. Vacuum wound dressing systems were used in 4 patients (50%) to aid in surgical debridement. Vacuum dressing systems were used in only 4 (80%) of 5 patients undergoing fecal diversion. One patient died on the 54th day of hospitalization. Mortality was seen as 12.5% in this series. The other 7 patients were discharged on average 18.85 days (6–35 days).

Conclusion

FG is a serious polymicrobial infection with high mortality rates even with current treatment modalities. These patients usually have comorbidities, the most commonly diabetes. The cutaneous involvement is just the tip of the iceberg and surgical debridement should be enlarged until perfused live tissue is seen. In 8 FG patients who were admitted to our hospital in one year, we prevented stool contamination as soon as possible in patients requiring fecal diversion, and we concentrated on surgical debridement. There is a need for larger series of studies with more patients.

TJS. 2018;34(Suppl-1):S244.

PP-0118 [Emergency Surgery and Trauma]. An Unusual Cause of Ileus: Giant Metastatic Ovarian Mass

Oğuz Hançerlioğulları ^1,^✉, Şahin Kaymak ¹, Rahman Şenocak ¹, Mehmet Fatih Can ¹

Introduction

Adhesions that appear as a cause of ileus are seen in most of patients following major abdominal surgery. Most of the small bowel obstructions are due to adhesions and 80% of the adhesions are associated with previous operations. Moreover, adhesions can occur due to the masses outside the gastrointestinal system (ovarian adenocarcinoma; ovarian fibroma, endometriosis). In this study, we aimed to present a patient operated for ileus associated with giant ovarian metastasis of colon cancer.

Case

A 67-year-old female patient was admitted to our clinic with the complaints of nausea, vomiting, abdominal distention, excessive fatigue, and inability to defecate. Her medical history included left hemicolectomy due to colon cancer. In her physical examination, her abdomen was very tense and distended. The patient was taken into emergency surgery with the pre-diagnosis of ileus. An approximately 15 cm bilateral ovarian mass obstructing the ileum was observed in the patient. The mass was removed by performing bilateral salpingo-oophorectomy without perforation.

The patient’s condition dramatically improved in the postoperative period and she was discharged on the 5th day. The result of histopathological examination was reported as metastatic adenocarcinoma.

Conclusion

It should be kept in mind that the adhesions developing in the evaluation of patients admitted due to ileus can also be associated with masses originating from the regions outside the gastrointestinal system. It should be noted that the patient may need to be evaluated systemically.

TJS. 2018;34(Suppl-1):S244–S245.

PP-0119 [Emergency Surgery and Trauma]. The Effectiveness of QUICKSOFA and SIRS in Patients with Major Burn

İsa Sözen ^1,^✉, Sadettin Er ¹, Mesut Tez ¹, Ahmet Çınar Yastı ¹

Objective

In burn patients, there is no risk determinant for a mortality rate that has already been agreed upon. In our study, the efficacy of the SIRS (Systemic Inflammatory Response Syndrome) and QUICKSOFA (Quick Sepsis Related Organ Failure Assessment) evaluations, which are among commonly used parameters in clinical practice, in burn patients was investigated

Material and Methods

Of the patients hospitalized in our clinic in 2017, 44 patients who were accepted as major considering burn percentage and depth as criteria were included in the study. In this retrospective study, 12 (27.3%) patients were found to have mortal course. The QUICKSOFA values were calculated by using Glaskow coma score, respiratory rate and systolic blood pressure data on patients’ files and SIRS values were calculated by using white blood cell count, respiratory rate or PCO2, temperature, and heart rate. The patients receiving 2 out of 3 values for QUICKSOFA and those receiving 2 out of 4 values for SIRS were considered positive. The results were analyzed for significance by using the Chi-square test. The value of p <0.05 was considered as statistically significant.

Results

In 12 (66.7%) of 18 patients with positive QUICKSOFA and mortality risk, mortality occurred (p<0.001). Mortality was observed in 12 (52.2%) of 23 patients with positive SIRS (p<0.001). For both tests, the patients with negative mortality risk did not display a mortal course. In five patients, both tests provided the result of high risk for these patients although they did not have mortality.

Conclusion

In trauma patients, risk scoring for mortality is important for detecting patients who need to be paid more attention. It is especially important in the case of massive injuries. In our study, it was observed that false positive rate was lower in the patients applied QUICKSOFA than those applied SIRS. Patients who need to be referred to reference centers can be distinguished by applying QUICKSOFA in massive injuries. There is a need for further extensive multicentre studies to determine the specificity and sensitivity of these tests.

TJS. 2018;34(Suppl-1):S245.

PP-0120 [Emergency Surgery and Trauma]. A Rare Foreign Body in the Stomach: Case Report

Yasin Kara ^1,^✉, Yahya Kemal Çalışkan ¹, Musa Diri ¹, Mustafa Uygar Kalaycı ¹

Introduction

Foreign body swallowing is a condition that is frequently encountered in children. Less frequently, it is seen in the adult age, chronic alcoholics, epileptic or psychiatric patients, and in those with mental retardation. It has been emphasized in the literature that 75.6% of the foreign bodies are spontaneously removed, 19.5% are removed with endoscopic method, and 4.8% are performed surgical intervention. In this case report, we aimed to emphasize the importance of remembering ingestion of foreign bodies in patients with mental retardation or psychiatric illness, who are admitted to outpatient clinics for abdominal pain.

Case

A 52-year-old male patient followed up by the department of psychiatry for schizophrenia was admitted to the emergency unit due to the complaints of bloody vomiting and abdominal pain. There was no abnormality in her familial history. In the evaluation of his vital signs taken in the emergency unit, blood pressure was 120/70, pulse was 80, body temperature was 37.3. The physical examination revealed tenderness in the epigastrium, but no evidence of defense and rebound in the abdomen. The intestinal sounds were normoactive and there was spontaneous gas-stool discharge. In the laboratory analysis, the value of leukocyte was 11.300 g/dl, hct was 29.74, hb was 10.19 g/dl, and MCV was 89.30, and he had mild anemia. No abnormality was detected in his biochemical values. In the direct abdominal radiography in standing position, which was performed in the emergency unit, there was an image consistent with radiopaque foreign body in the stomach and several foreign bodies were observed at the level of the small intestine and colon. During the gastroscopy, a large number of coins, metal cutlery handles, and screws were observed in the corpus. Decision of an operation was made for the patient. With gastrotomy, 95 metal foreign bodies were removed. The opened stomach was closed over double layers. On the postoperative 7th day, the patient was consulted to the psychiatry and he was discharged without any complication. In the control direct abdominal radiography in standing position, which was performed in the 2nd month, there was no foreign body in the stomach, small intestine and colon.

Conclusion

Foreign body swallowing is more common in children, but can be seen in adults with mental retardation and psychiatric disorders, and it should be remembered in these patients with abdominal pain. Foreign bodies do not have a unique symptom and physical examination finding. Direct radiographs can be used to obtain information about the number of radiopaque foreign bodies, their shapes, and their locations in the gastrointestinal system. Approaches in the treatment of swallowed gastrointestinal bodies are endoscopy, observation, and surgery. In the presence of peritoneal irritation findings, laparotomy should be performed when the foreign body remains in the same localization for 48–72 hours. In cases such as obstruction and perforation, surgery may be needed.

TJS. 2018;34(Suppl-1):S245–S246.

PP-0121 [Emergency Surgery and Trauma]. Spontaneous Rupture of Splenic Artery Aneurysm in Pregnancy

Yasin Kara ^1,^✉, Zeynep Betül Özkök ¹, Mustafa Uygar Kalaycı ¹

Introduction

The most common type of visceral artery aneurysms is splenic artery aneurysms with the rate of 66%. Although no specific cause is known, the etiologic factors found to be responsible include atherosclerosis, focal arterial inflammation, pancreatitis, hypersplenism, portal hypertension, trauma, hormonal and hemodynamic changes due to pregnancy, liver transplantation, and splenomegaly. Spontaneous rupture of the splenic artery aneurysm (SAA) has mostly been seen in women with pregnancy and reported to have mortality of 70%. In this study, we aimed to present a 33-week pregnant patient who was admitted to the emergency unit with the complaint of undefined abdominal pain and who died due to arrest associated with hypovolemic shock in her follow-up.

Case

A 32-year-old, 33-week pregnant woman was admitted to the emergency obstetric polyclinic with the complaint of abdominal pain ongoing for 3 days and darkening color of urine. In the examination, emergency gynecopathology was not considered and she was directed to the emergency adult polyclinic. No abnormality was detected in the whole abdominal ultrasound. In the laboratory analysis, the value of leukocyte was 41000, hct was 29, and hb was 11. Because the patient was pregnant, abdominal tomography was not requested. In the control analysis of the patient who developed sudden hypotension while undergoing the examination and treatment in the emergency unit, the value of hct was evaluated as 15 and hb as 3.7. In the bedside ultrasonography, abdominal diffuse free fluid was detected and she was taken into laparotomy due to the pre-diagnosis of intraabdominal bleeding by the team from the departments of general surgery and gynecology and obstetrics. In the exploration, 3,000 cc of intraabdominal hemorrhagic fluid was aspirated, the uterus and adnexal structures were observed to be natural, and the liver and spleen were healthy. However, there was bleeding leaking from a 5×3 cm palpable mass adjacent to the spleen into the splenic hilus. The gastrocolic ligament was opened and the rupture of pulsatile aneurysm was observed in the 1/3 distal area of the splenic artery. After the patient was performed splenectomy and aneurysm resection, and also massive blood transfusion, she was taken into postoperative intensive care follow-up. During this period, the patient developed the picture of DIC and cardiac arrest. She did not respond to resuscitation and she died. The pathological evaluation of the specimen was reported as arterial aneurysm.

Conclusion

Splenic artery aneurysm can very rarely expand and rupture during pregnancy. In patients with ruptured SAA, cardiac arrest is inevitable as well as hypotension, tachycardia, and hemodynamic collapse. Clinical suspicion, early diagnosis, and preoperative resuscitation are the key elements of treatment together with early surgical intervention.

TJS. 2018;34(Suppl-1):S246.

PP-0122 [Emergency Surgery and Trauma]. A Rare Cause of Acute Abdomen: Omental Infarct: Case Report

Yasin Kara ^1,^✉, Önder Özer ¹, Mustafa Uygar Kalaycı ¹

Introduction

Omental infarct is a rare cause of acute abdomen, occurring with impaired blood supply by torsion, thrombosis or vasculitis of the omental vessels, or obstruction of the omental venous return. In the literature, less than 100 cases, most of whom were adult men, have been reported. Depending on the location of the infarcted omental tissue, it may be confused with acute abdomen causes such as appendicitis, cholecystitis, diverticulitis, and peptic ulcer perforation. In this study, we present a a patient operated for acute abdomen and diagnosed with omentum infarction.

Case

A 38-year-old male patient was admitted to the emergency unit with pain in the right upper abdominal pain ongoing for two days. In the physical examination, there was tenderness with palpation, defense, and rebound in the right upper quadrant of the abdomen. Laboratory tests revealed the value of leukocytosis as 10500/mm3 and CRP as 25 and other parameters were within normal interval. No abnormality was detected in the ultrasound, but inflammation, edema, and increased thickness were observed in the omental tissue in the right upper quadrant in the whole abdominal CT and it was reported as omental infarct. Diagnostic laparoscopy was planned for the patient. The appendix and gallbladder were observed to be natural. There was erythema and edema in a 7×6 cm omental segment in the right upper quadrant and partial omentectomy was performed with ligature. The patient’s postoperative abdominal findings were regressed and he was discharged on the 2nd day with full recovery. The pathology of the partial omentum material was reported as omental infarct.

Conclusion

PP-0126 [Emergency Surgery and Trauma]. A Rare Complication of Perianal Abscess Mimicking Acute Abdomen

Fatih Akgündüz ^1,^✉, Süleyman Çetinkünar ¹, Ali Kaan Şanal ¹, Hakan Karataş ¹

Perianal abscess is a condition that is seen more frequently in males, recurs at the rate of 10–15%, develops perianal fistula at the rate of 15–40% later, and requires to be operated. Its etiology includes foreign bodies, trauma, inflammatory bowel diseases, radiation exposure, hematological pathologies, obesity, diabetes mellitus, malignancy, and immune deficiencies. Anatomically, it is classified as perianal (40%), ischiorectal (25%), intersphincteric, and supralevator. Clinically, it can present with pain, redness, local temperature increase, discharge, fluctuating mass, and perianal discomfort. Although its diagnosis is usually established clinically, anoscopy, MR, CT, and ERUS can be helpful. As the differential diagnosis, Bartholin’s abscess, retrorectal abscess, hidradenitis suppurativa, inflammatory bowel diseases, and malignancy should be eliminated. Its treatment is surgery. Our case was a 47-year-old male patient who was admitted to an external center due to anal pain ongoing for 3 days. Post-op antibiotherapy was applied to the patient who underwent drainage under local anesthesia with diagnosis of perianal abscess. On the postoperative 2nd day, he developed abdominal pain and he was referred to our clinic. He had no history of a comorbid disease and previous surgery. In the emergency unit, his complete blood analysis and routine biochemistry were analyzed. His value of WBC was 22000, CRP was 18, and other parameters were normal.

In the physical examination, there was defense, rebound, and tenderness in the right upper and lower quadrants. The abdominal CT showed an abscess pouch starting from the lateral part of the rectum and extending from the posterior of the rectus fascia to the right subcostal area. After making a decision of surgery, the patient was taken into an operation. Following adequate drainage in the perianal region, the abscess in the posterior of the right rectus was drained with one right subcostal incision and one right lower quadrant incision. The patient was applied post-operative VAC therapy and discharged on the postoperative 10th day.

TJS. 2018;34(Suppl-1):S249.

PP-0127 [Emergency Surgery and Trauma]. The Importance of The Location of Ostomy and Experience in Gunshot Injuries: A Case Report

Şahin Kaymak ^1,^✉, Aytekin Ünlü ¹, Mustafa Tahir Özer ¹

Introduction

Gunshot injuries (GI) are the type of injuries that are still important due to the current situation of our country. Success in the treatment of gunshot injuries is directly proportional to the experience of the surgeon. In this study, we wanted to share our experience on an GI case that was referred to our clinic after the first intervention.

Case

A 30-year-old male patient was operated for GI in an external center. He had a bullet entry hole from the superior of the left gluteal region, but no exit hole. In the exploration, left colon injury, multiple injuries in the small bowel (7–8 injuries), left retroperitoneal injury, and non-displaced fracture in the left iliac bone were observed. The patient was performed left colon resection + end colostomy + multiple primary repairs of the small bowel + left retroperitoneal bleeding inspection operation and referred to our clinic on the second postoperative day. When the patient arrived, he had an area of hyperemia and induration extending from the left lower quadrant to the left anterior wall of the abdomen. The patient was followed for necrotizing fasciitis and the diagnosis was avoided because clinical picture of the patient was not completely defined. During the patient’s follow-up, gradually elevating WBC (18000, followed by 30,000) and fever (38.8 degrees) were observed from the postoperative 7th day, relaparotomy was planned for the patient. In the relaparatomy, it was seen that primary repair had been performed on 7–8 injuries between the 50th and 70th centimeters from the Treitz ligament in the first operation and there were 2 leakages, one of which was at the repair site in the most distant area and which did not caused contamination in the abdomen. Diffuse necrosis area was detected in the retroperitoneal region, the left inguinal region, the muscles of the left abdominal wall and the subcutaneous area. After extensive debridement, it was observed that the area of the anterior abdominal wall, from which the colostomy was removed, was also affected. The patient was performed small bowel repair + colostomy transposition (anterior wall of the right abdomen) + wide retroperitoneal debridement. Then, relaparotomy was performed 4 times with intervals of 2 days. The patient, whose clinical condition and laboratory values improved, was discharged from the intensive care unit to the clinic room. The patient is still in our clinic.

Conclusion

We think that resection anastomosis should be preferred instead of primary repair in the multiple injuries of the small bowel, especially those involving a short segment, in gunshot wounds. In addition, if ostomy is planned to be performed in GI patients with high kinetic energy, we believe that the injured side should not be considered as the first choice.

TJS. 2018;34(Suppl-1):S249–S250.

PP-0128 [Emergency Surgery and Trauma]. Are There Parameters Preoperatively Predicting Mortality in Peptic Ulcer Perforations (PUP)?

Osman Bardakçı ^1,^✉, Orhan Gözeneli ¹, Faik Tatlı ¹, Hüseyin Cahit Yalçın ¹, Abdullah Özgönül ¹, Ali Uzunköy ¹

Objective

Peptic ulcer perforation (PUP) constitutes about 5% of acute abdomen cases. Ulcer perforation is the second most common complication of peptic ulcer disease, leading to significant increases in mortality in late diagnosis. In our study, it was aimed to determine the parameters affecting mortality by evaluating preoperative clinical and laboratory values in cases operated for perforation of peptic ulcer.

Material and Methods

The files of 128 patients operated for peptic ulcer perforation in our hospital between January 2010 and December 2017 were reviewed retrospectively. The patients were divided into two groups as those with and without mortality. The patients were evaluated in terms of age, gender, comorbid disease, laboratory values, and duration of hospitalization. The collected data were analyzed by using SPSS (20.0 for Windows, SPSS Inc., Chicago, Illinois, USA) software. The Mann Whitney U test was used when the patients were evaluated between the groups. The p value less than 0.05 was considered to be statistically significant.

Results

Of the patients included in the study, 68 (53%) were male and 60 (47%) were female. The mean age of the cases was 52.5±21.1 years. 28 cases had comorbid diseases (DM, HT, COPD) and 4 cases had malignant disease (lymphoma, RCC, prostate Ca, bladder Tm). When the laboratory values of all patients were examined, the albumin value was 3.53±0.78 mg/dl, urea value was 51.55±37.46 mg/dl, and creatinine value was 1,15±0,68 mg/dl. Mortality developed in 14 (11%) of the patients. Of these cases developing mortality, 8 (57%) were male and 6 (43%) were female. The mean age was 79.1±3.08 years. When the preoperative biochemical parameters were examined, the albumin value was found to be 2.59±0.2 mg/dl, the urea value was 98±18.14 mg/dl, and the creatinine value was 1.91±0.27 mg/dl. Four cases with comorbid malignant disease died.

Of 114 cases not developing mortality, 60 (52%) were male and 54 (48%) were female. The mean age was 47±2,5 years. According to the analysis of preoperative biochemical values, albumin value was 3.69±0.89 mg/dl, creatinine value was 1,02±0,68 mg/ dl, and urea value was 43.55±3,43 mg/dl. When all parameters were examined, age, albumin, urea and creatinine levels were found to be statistically significant.

Conclusion

In our study, advanced age, low albumin level, impaired renal functions, and accompanying comorbid conditions seem to be effective parameters on mortality and, in these cases, caution should be taken in preoperative evaluation, intraoperative circulatory stabilization and postoperative intensive care protocols.

TJS. 2018;34(Suppl-1):S250–S251.

PP-0129 [Emergency Surgery and Trauma]. De Garengeot Hernia: A Rare Case Report

Yasin Kara ^1,^✉, Musa Diri ¹, Zeynep Betül Özkök ¹, Mustafa Uygar Kalaycı ¹

Introduction

De Garengeot hernia is described as an appendix in the femoral hernia sac. It is seen extremely rarely and constituted 0.5–5% of all femoral hernias. The incidence of this hernia when presented with acute appendicitis is reported to be 0.080.13%. In this article, a case of De Garengeot hernia in a patient who was admitted to the emergency unit with pain, swelling and redness in the right inguinal region and detected to have perforated appendicitis in the femoral hernia sac was shared.

Case

A 43-year-old female patient was admitted to the emergency unit due to the complaints of redness, and swelling in the right inguinal region and fever, nausea and vomiting, which were going on for 3 days. She did not have any known comorbidity. Her physical examination revealed erythema, swelling and tenderness in the right femoral region and tenderness in the right lower abdomen. No intraabdominal free fluid was observed in the ultrasonographic examination. The computed tomography of the abdomen showed no intraabdominal free fluid, but there was a lesion consistent with the inflamed and edematous appendix in the femoral hernia sac and fluid consistent with abscess in the sac. There were no abnormal findings, except increased leukocytosis and CRP in laboratory values. The patient underwent emergency operation. The hernia sac was reached by femoral incision on inflamed and edematous skin, it was separated from surrounding tissues with blunt and sharp dissection and when it was opened, 50 cc purulent fluid was aspirated. It was observed that the appendix was in the sac and perforated from the apex. The femoral canal was expanded by cutting the inguinal ligament and appendectomy was performed. The hernia sac was excised and closed. The intestine was replaced into the abdomen and a mesh plug was applied to the femoral canal. A drain was placed in the lodge. During the follow-ups, dual antibiotherapy was given by considering the presence of perforated appendicitis. was Patients were admitted to perforated appendicitis and double antibiotherapy was applied. She did not have fever in her follow-ups and the findings of skin cellulitis and laboratory values gradually regressed. The patient was discharged with full recovery on the 5th day and her appendix vermiformis pathology was reported as perforated appendicitis.

Conclusion

Although femoral hernia is usually seen on the right side, appendix vermiformis in hernia sac is a rare condition and often diagnosed during operation. In the presence of abscess, repair with graft is not recommended, but in our case, mesh plug method was applied and no complication developed. In literature, while there are publications reporting McWay’s repair method with inguinal incision approach, there are also studies beginning with laparoscopic approach and leaving appendectomy and post-drainage femoral hernia repair to the second operation. For the treatment of De Garengeot hernia, there is no standard approach, as it is probably very rare. In our case, the sac and appendix were reached with incision on femoral hernia, hernioplasty was performed with mesh plug method in the same session with appendectomy drainage, and the patient was discharged with recovery. De Garengeot hernia should be kept in mind in incarcerated femoral hernias that are encountered in the emergency units and appendectomy and hernia repair should be performed in the same session.

TJS. 2018;34(Suppl-1):S251.

PP-0130 [Emergency Surgery and Trauma]. Diagnostic Value of the “Appendicitis Inflammatory Response” Scoring System in the Diagnosis of Acute Appendicitis

Muhammed Doğangün ^1,^✉, Uğur Duman ¹, Hasan Eroğlu ¹, Eren İskender Demirbaş ¹, Berkay Demir ¹, Deniz Necdet Tihan ¹, Ayhan Hüseyin Kayaoğlu ¹

Objective

In this study, it was aimed to reveal the diagnostic value of the recently proposed “Appendicitis Inflammatory Response” (AIR) scoring system for the diagnosis of acute appendicitis (AA) and to investigate whether it had an effect on the negative laparotomy rate in patients with abdominal pain, who were operated for the pre-diagnosis of AA.

Material and Methods

Our cases consisted of patients over 16 years old, who were admitted to the emergency unit of our hospital and diagnosed with acute abdomen and AA between 01.09.2016 and 30.06.2017. Ethical committee approval for the study was obtained. The number of patients with postoperative diagnosis of AA was 153 and the number of those not having diagnosis of AA was 140. The study included patients who were pre-diagnosed with acute abdomen and AA by the emergency service physicians and consulted to the general surgery department, and whose hospitalization and operations for the pre-diagnosis of AA were planned by general surgeons. Before operation, the patients were informed about the study and their informed consents were obtained. The patient evaluation form was filled out, and the postoperative pathology results of the patients were recorded. The patients were asked about whether they had vomiting and pain in the right lower quadrant before the surgery. In physical examination, the presence of rebound, tenderness, and defense in the lower right quadrant of the abdomen was classified as mild, moderate, and severe, and these data were recorded. In addition, the values of body temperature, hemogram and CRP were recorded. All these values were scored by the scoring system.

Results

There was no statistically significant difference between between AA and non-AA groups in terms of age and gender distributions. While the mean AIR score was 5.32±1.22 in the non-AA group, it was 8.60±2.27 in the AA grup and this difference was statistically significant. In the ROC analysis, the most suitable cut-off value for AIR was determined as 7,5. For this value, the sensitivity was calculated as 71.9%, selectivity as 97.1%, positive predictive value as 96.5%, negative predictive value as 76%, and general (total) accuracy rate as 84%.

Conclusion

While the percentage of acute appendicitis detection is high in patients with an AIR score of ≥7.5, it would be more appropriate to decide laparotomy considering clinical and radiological findings for cases with an AIR score under 7.5.

TJS. 2018;34(Suppl-1):S251–S252.

Diaphragmatic rupture develops in 0.8–5% of the thoracic-abdominal traumas and approximately 30% of these cases are detected in the late period. Left diaphragmatic ruptures are more common than the right ones due to the protective effect of the liver. The stomach, colon and liver are the organs that are often herniated. In penetrating traumas, the risk is higher than in blunt traumas. Because the defect is small, the possibility of ischemia and herniation is greater and the risk of mortality increases with it. Treatment way for traumatic diaphragmatic rupture is surgery. Laparoscopic, transthoracic, transabdominal and thoracoscopic approaches are available. Laparoscopic surgery is preferred in recent years in terms of the duration of hospital stay, rapid wound healing, and postoperative pain.

TJS. 2018;34(Suppl-1):S253.

PP-0134 [Emergency Surgery and Trauma]. Patient Nonresponsive to Blood Transfusion: Progression of Femoral Catheter to the Intraabdominal Cavity-Case Report

Gökhan Pösteki ^1,^✉, Alper Kurt ¹, Alican Güreşin ¹, Veysel Sarı ¹, Turgay Şimşek ¹, Sertaç Ata Güler ¹

A 34-year-old male patient admitted to the emergency service after an in-car traffic accident was expected to undergo fluid and blood resuscitation due to his hypotensive course in the follow-ups. Femoral catheters were inserted for replacement to the patient whose peripheral vascular access could not be established and blood transfusion was started. He gave no response to the transfusion. He was performed CT and it revealed splenic rupture and the patient was taken into operation. Approximately 4000 cc of bloody fluid was evacuated from the abdomen in the exploration of the patient. After splenectomy, intra-abdominal cavity was examined and it was seen that the femoral catheter advanced to the intraabdominal distance. When the CT was re-examined after the operation, it was seen that the intraabdominal localization of the catheter could be detected. We believe that complication developing in the case is important with regard to that it reminds the vital importance of controlling the location of catheter in cases having femoral catheter and being nonresponsive to the treatment.

TJS. 2018;34(Suppl-1):S254.

PP-0135 [Emergency Surgery and Trauma]. The Relationship between Changes in the Diagnosis and Age in the Clinic of Acute Abdomen

Turgut Anuk ^1,^✉, Ali Cihat Yıldırım ²

Objective

Diseases confronted with the picture of acute abdomen are directly related to age and gender. While gynecologic pathologies are more prevalent in women, vascular pathologies and ileus are more common in geriatric patients. In our study, we aimed to examine the differences and variations of the pathologies in geriatric and non-geriatric patient groups in urgently operated patients due to the diagnosis of acute abdomen in our clinic and to provide the acceleration of interventions for early diagnosis and treatment by considering different pre-diagnoses in different age groups when acute abdomen picture was encountered.

Material and Methods

The file records of 375 patients who were urgently operated with the diagnosis of acute abdomen in our clinic between June 2012 and December 2017 were retrospectively evaluated. The patients’ ages, sexes, and intraoperative findings were recorded. The patients at the age of 65 and above were evaluated as geriatric (GP) and the patients younger than 65 years old were evaluated as non-geriatric (NGP).

Results

The median age of the patients in our study was 39 (18–86) years and the male/ratio was 3.2. While the most common pathologies were acute appendicitis (AA) (53.0%), mesenteric ischemia (25.0%), ileus (36.4%), and peptic ulcer perforation (PUP) (13.6%) in geriatric patients, they were AA (71,9%), PUP (8.9%), ileus (10.9%), and colon perforation (3.8%) in non-geriatric patients. There was a significant difference between the groups (p: 0.002).

Conclusion

With the prolongation of lifetime on earth, the mean age of operated patients is also increasing due to the increase in the number of aging people. While especially vascular pathologies-related ischemic bowel diseases and ileus diseases draw attention in the GP group, AA is more frequently detected in the NGP group.

TJS. 2018;34(Suppl-1):S254.

PP-0136 [Emergency Surgery and Trauma]. A Rare Case Causing Acute Abdomen: Primary Chylous Peritonitis

Bülent Dinç ^1,^✉, Özgür Cem Müsri ¹, Muhammed Raşit Yazar ¹, Umut Rıza Gündüz ², Mehmet İlker Turan ³

Introduction

Chylous ascites is the free accumulation of lymphatic fluid in the abdomen. As a result of damage to the lymphatic system, acid is seen in the milk consistency, which is a high triglyceride content. It is usually a chronic condition and is mostly asymptomatic. However, sudden extravasation of the lymphatic fluid can rarely lead to acute abdominal pain accompanied by peritonitis findings. In this case report, we presented a case of primary chylous peritonitis presenting with the picture of acute abdomen.

Case

A 19-year-old male patient was admitted to the emergency unit with sudden onset of abdominal pain. The physical examination revealed tenderness in all quadrants, defense rigidity, and rebond sensitivity. In the laboratory analysis, complete blood count and biochemical parameters were within normal intervals. Abdominal tomography revealed no pathology except the intraabdominal free fluid. The patient was scheduled for diagnostic laparoscopy. Laparoscopic exploration revealed widespread chylous fluid in the abdomen. Moreover, there was also a chylous accumulation in the ileum meso. Transverse colon and intestinal loops were dilated. The sample was taken from the pelvic fluid and aspirated. Surgical decision was made to evaluate the lymphatic system and retroperitoneum. Supra-subumbilical median incision was performed. The entire gastrointestinal system was screened for perforation. The retroperitoneum was evaluated in terms of lymphatic system. Biopsies were obtained from the omentum and peritoneum. A drain was placed into the pelvis and the operation was terminated. Malignancy, cirrhosis, tuberculosis, inflammation (radiation, pancreatitis, retroperitoneal fibrosis, etc.), postoperative traumatic causes were verified postoperatively and no pathology was found.

Conclusion

The incidence of chylous peritonitis is between 1/20,000 and 1/187,000 in the literature. It is rarely associated with the trauma of the lymphatic system, but may also be seen idiopathically. A widespread evaluation is not usually possible because it is a rare cause of acute abdomen. In cases of primary chylous peritonitis without any pathology, abdominal lavage and drainage are curative.

TJS. 2018;34(Suppl-1):S255.

PP-0137 [Emergency Surgery and Trauma]. Approach to a Patient with a History of Corrosive Substance Ingestion

Nurhak Aksungur ^1,^✉, Necip Altundaş ², Ercan Korkut ¹, Mesut Fakirullahoğlu ¹, Sabri Selçuk Atamanalp ¹, Gürkan Öztürk ¹

Introduction

The ingestion of corrosive substances is a medical emergency that is accompanied by high morbidity and mortality due to its high rates of sequelae. Its mortality rates are reported as high as 20%. The outcomes of the injury depend on the severity of the lesions, the general condition of the patient, and the speed of medical treatment. Rapid diagnosis and treatment is the most important factor in reducing mortality and obtaining optimal long-term results in the case of corrosive ingestion. Here, we aimed to present a patient who was admitted to our department due to the ingestion of a corrosive substance.

Case

A 32-year-old female patient was admitted to the emergency unit due to the complaint of abdominal pain that started two hours ago in association with the history of descaling agent ingestion approximately fifteen hours ago. Her blood pressure was 128/74 mm/Hg, pulse rate was 74min, body temperature was 36.8 °C, and respiration rate was 15min. His physical examination revealed tenderness in the epigastric region in the abdomen. There was no rebound and defense. At the time of admission, WBC was 8300 10^3/μL, Hg was 12.8g/dL, Glu was 123 mg/dL, Cre was 0.7 mg/dL, Na was135 mmol/L, K was 3.6 mmol/L, and other laboratory values were normal. In the contrast-enhanced abdominal tomography, there was impaired blood supply in the stomach wall and no other pathology was observed in the abdomen. Emergency endoscopy was required for the patient; however, the patient and her relatives did not accept the procedure. As a result, the patient was followed up in the intensive care unit in this condition. The patient, who developed the picture of acute abdomen in the follow-ups, was performed direct abdominal radiography in standing position and free air was observed under the diaphragm. Emergency laparotomy was performed. There was about 300 cc fluid associated with perforation. Necrotic and perforated areas were observed in stomach fundus and antrum. The abdomen was cleaned and total gastrectomy and nutritional jejunostomy were opened. The esophagus was removed from the thorax as a stoma. On the postoperative seventh day, the patient’s feeding protocol was adjusted and she was discharged. Four months after the procedure, the patient was re-hospitalized, the colon transposition was performed, and she was discharged with recovery. The patient, who developed esophageal stricture in her anastomosis line, was once performed dilatation.

Conclusion

The management of corrosive substance injuries begins with an assessment of the patient’s hemodynamic stability and airway adequacy. The principle of the first laparotomy is damage control, in other words, stopping the bleeding and contamination. In general, this includes total gastrectomy and feeding jejunostomy. The option of immediate restoration of the GI tract with esophagojejunostomy should only be used for stable patients with minimal intraperitoneal contamination. The restoration of the gastrointestinal system should be done when the patient is free of the systemic effects of corrosive substance injury. The most important long-term complication of corrosive substance ingestion is esophageal stricture, which is reported to be as high as 100% in transmural lesions. In addition, the risk of esophageal cancer extending to 40 or 50 years after exposure increases. For this reason, careful follow-up and routine screening are important for esophageal cancer, the protection of the quality of life, and the prevention of long-term complications following caustic esophagogastric injuries.

TJS. 2018;34(Suppl-1):S255–S256.

PP-0138 [Emergency Surgery and Trauma]. Vernix Caseosa Peritonitis in a Patient Undergoing Diagnostic Laparoscopy for Postpartum Acute Abdomen; Video Presentation

Mehmet İlker Turan ^1,^✉, Bülent Dinç ², Özgür Cem Müsri ², Umut Rıza Gündüz ³

Objective

Vernix caseosa peritonitis is a rare cause of postpartum acute abdomen. Its definite diagnosis and treatment are done by explorative laparotomy or laparoscopy because the diagnosis is difficult before the operation. In this video presentation, we aimed to present a case of vernix caseosa peritonitis diagnosed by diagnostic laparoscopy and its treatment management in a 20-year-old female patient who had a history of a cesarean section birth 10 days ago.

Material and Methods

The operation was initiated by placing two 10 mm trocars in the subumbilical region and left paramedian line and a 5 mm trocar from the midline in the suprapubic region. In the exploration, adhesions observed in the localization of the pfannenstiel incision in the posterior wall of the abdomen were separated from the surrounding tissue by sharp and blunt dissection. In the posterior wall of the wall, vernix caseosa and omental tissue and appendix that were adhered to the vernix caseosa were detected. Because of the presence of inflammation in the periappendicular tissues and appendiceal mesothelium, appendectomy was performed and vernix caseosa and appendix specimen were taken out. Subsequently, peritoneal lavage was performed and a drain was placed in the operation lodge, and the operation was terminated. The patient was administered antibiotherapy with ceftriaxone + metronidazole in the clinical follow-up and discharged on the third postoperative day.

Conclusion

Vernix caseosa peritonitis is a condition that should be kept in mind in the etiology of postpartum acute abdomen and it is difficult to diagnose it preoperatively. We believe that diagnostic laparoscopy can be performed effectively and reliably in order to confirm diagnosis and avoid inaccurate surgeries.

TJS. 2018;34(Suppl-1):S256.

PP-0139 [Emergency Surgery and Trauma]. Early Diagnosed Jejunal Volvulus

Celil Uğurlu ¹, Özhan Özcan ^1,^✉

Introduction

Volvulus is a special form of mechanical intestinal obstruction. It occurs when the intestinal loop is abnormally twisted around its own mesenteric axis. Its clinical picture looks like an acute abdomen. The cause of the onset of the symptoms may be due to narrowing of the intestinal segment or impairment of perfusion of the vascular structure that feeds the relevant segment. The delay in the diagnosis of volvulus results in irreversible results due to the deterioration in the feeding of the obstructed segment. Colonic volvulus is more common in adults. Small bowel volvulus (SBV) is relatively rare. It is classified as primer and secondary according to the causes. There are predisposing factors that can be congenital or acquired in secondary cases. Among them, anatomic malformation, malrotation or midgut nonrotation, fibrous band, and postoperative adhesions can be observed. In this study, we present a case of early diagnosed jejunal volvulus in an adult male patient.

Case

A 68-year-old male patient was admitted to the emergency unit due to abdominal pain. His pain had started in the epigastric region 24 hours ago. He defined a continuous and increasing pain. It was learned form his anamnesis that he had been operated for peptic ulcus 15 years ago. The physical examination revealed a midline incision scar of the previous operation. There were peritoneal irritation findings, more apparently in the epigastric region. The patient, whose vital signs were stable, had no pathology in the laboratory values, except for leukocytosis (12400/mm3). The direct abdominal radiography in standing position showed a large number of small intestinal air fluid levels in the upper and middle quadrants of the abdomen. The patient underwent emergency surgery with the pre-diagnosis of middle intestinal volvulus because the abdominal contrast-enhanced computed tomography revealed intestinal loops twisting around vascular structures on the mesenteric fat plane at the level of the duodenojejunal juncton and severe dilatation in the duodenum at the proximal area of this level. In the operation, it was observed that the small intestinal loops passed through the window under the previous distal gastrectomy and antecolic gastrojejunostomy anastomosis and they twisted around themselves and their feeding was deteriorated. Jejunal loops were detorsioned and their feeding was improved again. The space under the anastomosis of gastrojejunostomy was closed by detecting the jejunum meso. On the fifth day of hospitalization, the patient was discharged without any problems.

Conclusion

Small bowel volvulus is usually seen in newborns and children. It is extremely rare in adults and frequently occurs in the jejunum. Most of the cases have preliminary causes such as diverticulum, stromal tumor, and previous operation-related bands. Our patient had a history of a previous operation. In some cases, a torsion sign (whirpool sign) can be seen on direct radiographs. In the literature, it is reported that abdominal computed tomography is diagnostic at the rate of 83%. In our case, early diagnosis could be established through the contrast-enhanced abdominal CT. Laparoscopy can be used for both diagnostic and therapeutic purposes in cases with unclear diagnosis (5). In patients with good intestinal feeding, it is reported that the recurrence is 3,9% and only detorsion can be performed. It should be remembered that early diagnosis and treatment are the most important factors for reducing mortality.

TJS. 2018;34(Suppl-1):S256–S257.

PP-0140 [Emergency Surgery and Trauma]. Marginal Ulcer Perforations: 5 cases

Serkan Karaıslı ^1,^✉, Emine Özlem Gür ¹, Melek Gökova ¹, İbrahim Kokulu ¹, Haldun Kar ¹, Osman Nuri Dilek ¹

Objective

Marginal ulcer perforation (MUP) is a complication of gastroenteric reconstruction and is often described as the perforation at the edges of the gastroenterostomy anastomosis, typically perforation of the ulcer on the jejunal side. In this article, we aimed to present the cases that were urgently operated due to the MUP and to draw attention to the issue again.

Material and Methods

The files of 5 patients who were operated due to marginal ulcer perforation in İzmir Katip Çelebi University Atatürk Training and Research Hospital, General Surgery Clinic between June 2006 and June 2017 were examined retrospectively. Patients’ demographic features, surgical data, and surgical complications were recorded based on patient files and hospital database information.

Results

The mean age was calculated as 58±7.9 (52–71) years. Of the patients, one (20%) was female and 4 (80%) were male. Four of the patients (80%) had a history of previous ulcer surgery and the other patient had a operation history due to stomach cancer. In all patients during surgery, the first operation was found to be the Billroth-2 procedure. The perforation area was found(20%) in the jejunojejunostomy line in 1 patient and in the gastroenterostomy line in the other 4 (80%) patients. The surgical procedure was anastomosis revision in 2 patients (40%), distal gastrectomy + re-anastomosis in 2 (40%), and primary suture in 1 (20%) patient. The mean length of hospital stay was calculated as 9±4 days (7–16). Postoperatively, one patient (20%) had a low-output biliary fistula and it spontaneously ended within 10 days. No perioperative mortality was observed in any patient.

Conclusion

Despite the recent decline in peptic ulcer surgery, the MUP rarely arises. The possibility of marginal ulcer perforation should be considered in patients with a history of stomach surgery for a malignant or benign cause, who have acute abdomen findings or intraabdominal free air. Surgical approach may be anostomotic revision or primary repair, but the surgeon should determine the ideal method considering the intraoperative findings.

TJS. 2018;34(Suppl-1):S257.

PP-0141 [Emergency Surgery and Trauma]. A Rare Case: Paraduodenal Hernia

Hamdi Özşahin ^1,^✉, Sinan Cüneyd Hasçiçek ¹, Tuğba Ata ¹, Sıtkı Gürkan Yetkin ¹, Mehmet Mihmanlı ¹

Introduction

Internal herniation is one of the uncommon causes of small bowel obstruction. Paraduodenal hernias are the most common type of internal abdominal hernias and constitute about 50% of the cases. The left paraduodenal hernia is 3 times more common than the right paraduodenal hernia. Its diagnosis can be made by abdominal imaging performed during the symptomatic period, rarely in the preoperative period. In this study, it was aimed to examine a case presenting with acute abdominal symptoms associated with right paraduodenal hernia.

Case

A 33-year-old male patient was admitted to the emergency room with the complaints of abdominal pain, nausea and vomiting. The patient’s history included the complaints of abdominal pain and nausea that started five days ago and vomiting for the last two days. The palpation of the abdomen revealed tenderness, defense and rebound in all quadrants. His intestinal sounds could not be heard. He was unable to defecate approximately for 3 days and his leukocyte count was measured as 16000/ mm3. Other biochemical values were within normal intervals. It was learned from his anamnesis that he had abdominal pain attacks that started especially after the meals. The oral iv contrast-enhanced abdominal CT revealed dilated small intestine segments and the small intestines twisted around the meso. The patient was taken into operation with the pre-diagnosis of internal herniation. During surgery, it was observed that almost the whole small intestine formed a capsular hernia sac and the proximal portion of the jejunum entered into a defect in the duodeno-jejunal junction. The small intestine segments in the defect were removed and the defect in the peritoneum was repaired. Since no complication developed and his complaints disappeared in the postoperative follow-up, the patient was discharged.

Conclusion

It should not be forgotten that paraduodenal hernias may cause internal herniation and obstruction in cases with no history of a previous operation and no findings explaining the pathology in the examinations.

TJS. 2018;34(Suppl-1):S257–S258.

PP-0142 [Surgical Site Infection, Surgical Intensive Care]. Mortality Profile in General Surgery Intensive Care Unit

Arif Emre ^1,^✉

Objective

The purpose of this study is to investigate the pathologic causes of hospitalization indication, demographic data, possible causes of developing mortality, and factors affecting mortality in patients that died in the general surgery intensive care unit and to determine patient profiles with high risk of mortality.

Material and Methods

This study was performed to examine patients over 18 years, who were hospitalized in the general surgery intensive care unit of Kahramanmaraş Sütçü İmam University between April 2014 and December 2017. Their data were retrospectively reviewed by scanning patient registry in the intensive care unit, Enlil HBYS patient registry system, and patients’ model files. Patients who were hospitalized with neurosurgical or internal branch indications, and those transferred to other intensive care units for the continuence of their follow-ups and treatments were excluded from the study and other remaining patients were included in the study. Demographic data including the age and gender of the patients, number of admitted patients, the distribution of comorbid diseases according to the systems, emergency or elective way of the first admission, urgent or elective distinction of operations of the patients, malignant/benign distinction of pathological indications for surgery, distinction of traumatic/nontraumatic etiologic factors, the application of mechanical ventilation, the duration of mechanical ventilation shorter or longer than 24 hours, separation of patients into two groups as those who were operated and those who were followed-up without operation, the presence of peritonitis, and the time passed from the first admission to mortality in day were evaluated.

Quantitative data were expressed as mean + standard deviation and median range (min.–max) and qualitative data were expressed as n (%).

Results

Between April 2014 and December 2017, a total of 1944 patients were hospitalized in intensive care unit. A total of 739 patients were excluded from the study. Of the 1205 patients included in the study, 63 developed mortality and the mortality rate was found to be 5.22%. Twenty-two (34.9%) of the 63 patients were urgently operated and 9 (12.3%) were electively operated, and the remaining 32 (50.8%) patients were followed nonoperatively. Eight of the patients underwent mechanical ventilation for a time shorter than 24 hours and 35 patients underwent it for longer than 24 hours. Thirty-two patients had comorbid disease and 31 patients did not have serious chronic disease. The mean duration of hospitalization was 12.9 (min 1–max 224) days. 18 of the patients had the picture of peritonitis.

Conclusion

In this study, emergency surgeries, postoperative mechanical ventilation dependency and prolonged duration of ventilation in the operated patients, other accompanying morbid diseases, and the presence of peritonitis in patients were found to be the factors affecting mortality.

TJS. 2018;34(Suppl-1):S258.

PP-0143 [Surgical Site Infection, Surgical Intensive Care]. Predictive Factors for the Development of Surgical Site Infection After Colorectal Cancer Surgery

Oğuz Uğur Aydin ^1,^✉, Lütfi Soylu ¹

Objective

In this study, we wanted to reveal the predisposing factors and cut-off values for the development of surgical site infection in patients who were operated due to colorectal cancer.

Material and Methods

The data of 86 patients who were urgently or electively operated due to colorectal cancer in the Department of General Surgery at our hospital between 2015 and 2017 were retrospectively evaluated. It was aimed to investigate whether patients’ ages, genders, body mass index, ASA score, the presence of chronic pulmonary disease, Hct levels, albumin level, duration of operation, localization of the disease (colon or rectum), the presence or absence of ileostomy or colostomy in operation, the presence of hyperglycemia and surgical volume affected the development of superficial or deep surgical site infection.

Results

All parameters except sex and body mass index were found to be significant in the occurrence of surgical site infection. The cut-off values were 63,5 years for age, 167.5 minutes for the length of operation, 3.05 for the value of albumin, and 33,15 for the value of HCT.

Conclusion

We think that the probability of developing postoperative surgical site infection is higher in patients older than 63,5 years, who had surgery longer than 167.5 minutes, preoperative albumin value of 3.05 and Hct value of less than 33.15. If patients that are to be operated for colorectal cancer are diabetic and in ASA 3 risk group, are performed ileostomy or colostomy during surgery, have chronic pulmonary disease, have cancer localized in the rectum, and have disease at stage 3 according to the postoperative classification, they should be evaluated with above-mentioned cut-off values and it should be kept in mind that the possibility of superficial or deep surgical site infection development is high in these patients. And also, symptoms and findings associated with the infection should be well-evaluated.

TJS. 2018;34(Suppl-1):S259.

PP-0144 [Surgical Site Infection, Surgical Intensive Care]. A Method Decreasing Postoperative Ileus, Postoperative Pain and Intensive Care Need; Local Bupivacaine Infusion

Erol Kiliç ^1,^✉

Introduction

Postoperative pain treatment is important because of its positive effects on tissue healing.

Objective

The purpose of this study was to evaluate the effect of local bupivacaine administration on postoperative pain, ileus and the duration of stay in the intensive care unit.

Material and Methods

The patients followed up in the intensive care unit after median laparotomy and applied conventional analgesia and local bupivacaine-assisted conventional analgesia between 2016 and 2018 were retrospectively analyzed in terms of postoperative pain, ileus, and duration of hospitalization in the intensive care unit. The patients were divided into two groups as those administered 5ml/h/48h bupivacaine on the fascia in addition to postoperative conventional analgesia (nSAII + opioid)/ Group 1) and those applied conventional analgesia (Group 2). The groups were retrospectively evaluated in terms of preoperative age, gender, ASA score, surgical protocols and surgical durations, postoperative pain scores (VAS), postoperative ileus (POI), bowel sounds, and flatus/defecation time (hours). The data were analyzed by using the SPSS 21 software. The value of p<0.05 was accepted to be statistically significant.

Results

Patints’ age, sex, preoperative ASA score, surgical protocols and durations were similar. Postoperative 8–24h/24–48h period VAS value, ICU duration and flatus/defecation time of group 1 were significantly lower (p <0,05).

Conclusion

Postoperative ileus (POI) is a frequent complication that is defined as delayed defecation accompanied by hypo-kinetic bowel sounds that last for 3–5 days postoperatively [1,2]. In the case of POI development, nausea-vomiting, pain and abdominal distention develop, leading to delayed healing in patients undergoing major gastrointestinal surgery [2]. After abdominal surgery, POI develops in two phases as neurogenic and inflammatory and inflammatory phase clinically comes to the forefront [3]. POI can be prevented by reducing/preventing inflammation. Preventing/reducing inflammation with postoperative analgesia is very important in the prevention of POI [1,3]. Local anesthetic drugs have antiinflammatory effects in addition to analgesic effects [4,5]. It has been thought that bupivacaine reduces inflammatory cytokines and contribute to the tissue healing, thereby prevents the development of POI. Bupivacaine has been shown to positively contribute to the recovery of anastomosis even in peritonitis [6] and significantly reduce proinflammatory cytokines such as TNF-α, IL-1β and IL-6, leading to an anti-inflammatory effect [5]. In addition to reducing early postoperative pain, bupivacaine infusion on the fascia is an effective method because of the inhibition of POI and its contribution to less intensive care need due to these effects.

TJS. 2018;34(Suppl-1):S259–S260.

PP-0145 [Surgical Site Infection, Surgical Intensive Care]. Investigation of Antibiotic Activity of New Generation Polyurethane Material Containing Hypericum Perforatum

Selçuk Aktürk ¹, Özcan Dere ^2,^✉, Sultan Köşkeroğlu ¹, Alper Aksözek ³, Okay Nazlı ²

Objective

Increasing intravenous catheters-related infections, both in inpatient units and outpatient units, lead to life-threatening severe mortality and morbidity. The formation of colonization and infection in the catheter lumen is directly related to the formation of microbial biofilms on the catheter surface. The eradication of microorganisms in biofilm can be difficult with traditional treatment methods. Antibiotic penetration into the biofilm is difficult. For this reason, such a project has been carried out with the aim of reducing cost, shortening the length of hospital stay, and reducing resistance to antibiotics and related costs.

Material and Methods

After the herbal material extraction was achieved in the polyurethane production laboratory conditions,

C. Albians was used first in the study. However, because of inability to obtain sufficient efficiacy, two additional microorganisms, Gr + S. aerous and Gr-E. coli, were also added. The inhibition effect of hypericum perforatum extract on biofilm was determined by microplate biofilm method. The inhibitory effect of 100 mg/mL hypericum perforatum extract on the biofilm formation of S. aereus bacteria was detected as 56.85% when compared to the control group. This ratio, which was added to the catheter, was determined to be 92.85% in the continuance of the study. In other words, 90% less biofilm formation was observed on the catheter containing hypericum perforatum extract.

Results

In the well diffusion assay, the antimicrobial effect of the hypericum perforatum extract on the C. albicans strain was not observed. Similarly, a strong antimicrobial activity against the Gr (+) S. aerous strain was detected, while no activity against a Gr (−) strain E. coli was observed. It has been shown that the antimicrobial catheter produced from the polyurethane materials containing hypericum perforatum extract can prevent the probable formation of S. aureus type microorganisms due to the prolonged usage, but cannot prevent Candida albicans and Escherichia coli type microorganisms. If antimicrobial catheters that are produced unconventionally and inhibit the formation of biofilms are used, the expectation of reducing the antibiotic resistance of the patient and perhaps the need of antibiotics will be met.

TJS. 2018;34(Suppl-1):S260.

A total of 63 surgeons, including 39 (62%) male and 24 (38%) female, participated in the study. The demographic characteristics of the participants are shown in Graph 1, 2 and 3 and the distributions of survey results according to sex, occupational duration and related branch. The results of our study were shared with the relevant clinics and the hospital management.

Conclusion

The prevention of surgical site infections is known to reduce the rate of morbidity and mortality, the length of hospitalization, and costs (2). The purpose of the antibiotic used in surgical antibiotic prophylaxis is to reduce the possible contamination burden that may occur during the operation to the minimum level. The goals of antimicrobial prophylaxis are to prevent SSI, to decrease postoperative mortality and morbidity, to decrease the length of hospitalization and costs, to prevent the development of drug-induced side effects, and to avoid the occurrence of negative changes in patient and hospital flora (3). The use of unsuitable antibiotics is common in the surgical antibiotic prophylaxis. This improper use of antibiotics can lead to an increase in the cost and in the antibiotic resistance. It is recommended in many guidelines that the hospitals should intermittently review their surgical antibiotic prophylaxis attitudes and the obtained results should be reported back to the surgeons at the relevant clinics.

In conclusion, we think that it is very important the hospitals to have their own institutional guidelines on surgical prophylaxis in accordance with other scientific guidelines, to prepare and apply these guidelines in cooperation with the related surgical units, and to report the feedbacks to the relevant clinics and the management, and to conduct the process multidisciplinary way. Surgical prophylaxis should be paid attention by all surgeons and prophylaxis protocols should be followed.

TJS. 2018;34(Suppl-1):S261–S262.

PP-0149 [Surgical Site Infection, Surgical Intensive Care]. A Rare Complication of Gallstones Forgotten after Laparoscopic Cholecystectomy: Tranversus Abdominis Muscle Abscess

Conclusion

I believe that the maximum service is provided during an intensive work in the district conditions. Effective compulsory service period makes positive contributions to professional experience.

TJS. 2018;34(Suppl-1):S266.

PP-0156 [Endocrine Surgery]. Comparison of Conventional, Harmonic System and Thermal Welding Methods in Bilateral Total Thyroidectomy

Nuriye Özder ¹, Ömer Faik Ersoy ¹, Hakan Sarsılmaz ^2,^✉, Zehra Şahan ², Zeynep Tuğçe Polat ³, Serdar Kaman ², Coşkun Polat ²

Especially in endemic regions such as our country, thyroidectomy has been frequently performed in general surgery clinics since it was first defined. Because even a minor bleeding during thyroid surgery will prevent to observe the structures such as the Recurrent Laryngeal Nerve and parathyroid glands, it is very important that the environment is free of blood. In our study, the uses of conventional method, harmonic system and thermal welding systems in patients undergoing bilateral total thyroidectomy in an endemic goiter region were compared with regard to surgical duration, preoperative and postoperative amounts of bleeding, and complications.

The study included 60 patients who were planned to undergo bilateral total thyroidectomy in Karabük University Karabük Training and Research Hospital General Surgery Department between June 2013 and August 2014. The patients were randomly divided into three groups. Each group consisted of 20 patients. All the operations were performed by the same surgical team. In Group 1, all vessels of the thyroid lobes were ligated by using conventional suture and cut. In Group 2, all vessels were applied thermal welding method. And, in group 3, coagulation and cutting processes were carried out by Ultracision^® Harmonic Scalpel^® (Ethicon Endo Surgery, Cincinnati, Ohio, USA).

A total of 60 patients were included in the study and each group consisted of 20 patients. When the surgical durations were evaluated, the mean length of operation was 63,25±28,66 min in Group 1, 42,60±20,14 min in Group 2, and 49,60±9,17 min in Group 3 (p<0, 05). The shortest period was obtained in the Thermal Welding group when the groups were compared with each other (p<0,017). In terms of preoperative and postoperative bleedings, the amount of bleeding was 93,50±56,05 ml in Group 1, 25,60±15,21 in Group 2, and 62,50±23,31 ml in Group 3. The amounts of postoperative bleeding were 124,50±153,09 ml, 8,75±11,68 ml, and 35,75±25,91 ml, respectively (p< 0,05). In terms of hemostasis, 2 patients in Group 1 required hemostasis within the first 24 hours and no hemostasis was required in Group 2 and 3 (p=0,12). When evaluated in terms of Ca and parathormone, the Ca values were 8,39±0,56 mg/ dl in Group 1, 8,34±1,14 mg/dl in Group 2, and 8,37±0,78 mg/dl in Group 3 (p=0.86) and parathormone levels were found to be 52,72±35,85 pg/dl, 34,77±20,0 pg/dl, and 56,41±36, 56 pg/dl (p=0,09), respectively. In terms of complications, transient hoarseness was not seen in any patient in Group 1, but it was observed in one patient for each Group 2 and 3 (p=0.59).

In conclusion, we can say that thermal welding in thyroid surgery can be used safely because it reduces the amount of preoperative and postoperative bleeding, shortens the operation time, decreases the complication rates, and has lower cost values.

TJS. 2018;34(Suppl-1):S266–S267.

PP-0157 [Endocrine Surgery]. The Relationship between Thyroid Gland Weight and Postoperative Complications in Patients Undergoing Total Thyroidectomy

Azmi Lale ^1,^✉, Abdullah Bahadır Öz ¹, Alper Celal Akcan ¹, Erdoğan Mütevelli Sözüer ¹, Türkmen Bahadır Arıkan ¹

Objective

The most common complications developing after total thyroidectomy are hypocalcemia, vocal cord paralysis (VCP), bleeding, infection, and adjacent organ injuries. In this study, it was aimed to retrospectively evaluate the results of postoperative thyroid weight effects in patients undergoing total thyroidectomy, to identify the causes leading to postoperative complications and to determine the precautions for these causes.

Material and Methods

In this study, 263 adult patients who were performed total thyroidectomy in Erciyes University Medical Faculty Hospital between January 2011 and October 2015 were evaluated. Hospital automation system and patient files were reviewed retrospectively and the data were recorded. The demographic characteristics of the patients, preoperative imaging methods such as USG, scintigraphy and tomography, preoperative laboratory values, preoperative diagnoses, operations, cervical lymph node dissection (LND), postoperative pathologic diagnoses and specimen weights, bleeding, seroma accumulation, hypocalcemia, vocal cord paralysis, and postoperative complications such as infection were investigated.

Results

The incidence of total complications was 24.3% and these were detected to be hypocalcemia, VCP, hemorrhage in the surgical site and seroma. The rate of transient hypocalcemia was 20.1% (n=53) and the rate of permanent hypocalcemia was 1.5% (n=4). The rate of transient VCP was 0.3% (n=1) and no permanent VCP was seen in the patients. In patients without postoperative hypocalcemia, the median thyroid weight was measured as 50 gr, in hypocalcemia group as 40 gr (p=0,283). There was no significant relationship between the variability in thyroid weight and the development of postoperative hypocalcemia. However, there was a statistically significant relationship between cervical LND (p=0.006) and cervical dissection site (p=0.031) and postoperative complication development. In multivariate analyses, female gender and LND were found to be risk factors for the development of postoperative complications.

Conclusion

The most common complications after total thyroidectomy were hypocalcemia (21.6%), bleeding (1.5%), seroma (0.7%) and vocal cord paralysis (0.3%). Performing cervical LND with total thyroidectomy and female gender were found to be significant risk factors for the development of postoperative complications in multivariate regression analyses. There were no statistically significant results in our study for the risk factors that increase the incidence of postoperative complications, such as thyroid gland weight, history of thyroid surgery, malignancy of thyroid pathology, retrosternal localization of the thyroid tissue, and hyperthyroidism, which is inconsistent with literature findings.

TJS. 2018;34(Suppl-1):S267.

PP-0158 [Endocrine Surgery]. Double Pyramidal Lobe Detected During Surgery

Deniz Tazeoğlu ^1,^✉, Özgür Yüzer ¹, Nilay Tuğba Uzunay ¹, Hakan Tezer ¹, Orhan Yalçın ¹

Introduction

Thyroid gland may display various anatomic variations during the embryonic development. The most common of these variations is the pyramidal lobe. The pyramidal lobe is the embryological remains of the thyroid gland at the caudal end of the thyroglossal canal. It has an important place in in the diagnosis and treatment planning of thyroid diseases. The double pyramidal lobe is quite rarely encountered.

Case

A 54-year-old female patient with no known disease was palpated with a nodule consistent with right thyroid gland during examination, no additional pathology was observed. Total thyroidectomy was performed to the patient who was diagnosed with papillary carcinoma through FNAB (fine needle aspiration biopsy). The pyramidal lobe was seen from both sides of the trachea and the resection was completed by preserving the integrity of the thyroid gland. Pathology; papillary carcinoma of the right lobe of the thyroid. The patient was discharged with recovery on the first postoperative day.

The pyramidal lobe can be considered as an anatomical anomaly, a morphological variation, or a typical piece of the thyroid gland. Pyramidal lobe can originate from right - left lobes and isthmus. It can occur in various forms (Y, inverse Y and nodular form) and its prevalence is 12–65%.

The pyramidal lobe has an important place in the diagnosis and treatment of benign and malignant diseases. Total excision of the thyroid gland can be planned during the treatment of diffuse thyroid diseases. Pyramidal thyroid residues (residual thyroid tissue) cause the recurrence of disease after many years following the inadequate total thyroidectomy.

Conclusion

Diagnosis and treatment after recurrence will increase the cost. The reoperation, which is performed when recurrence occurs, has a higher risk of complications than carefully performed long primary total thyroidectomy.

The double pyramidal lobe is an extremely rare anatomic variation of the thyroid gland. It should be considered during surgery that the pyramidal lobe may be bilateral or not detected by preoperative imaging methods.

In our case, there were no findings in the preoperative imaging methods, but a double pyramidal lobe was detected after a carefully performed dissection and it was totally excised. It was also demonstrated through postoperative scintigraphy.

TJS. 2018;34(Suppl-1):S267–S268.

PP-0159 [Endocrine Surgery]. Evaluation of Patients Undergoing Incidental Parathyroidectomy after Total Thyroidectomy: A Restrospective Study

Tülay Dikenallahverdi ¹, Harun Bayram ¹, Kenan Binnetoğlu ^1,^✉, Uğur Bulut ¹, Turgut Anuk ¹, Barlas Sülü ¹

Objective

In this study, the evaluation of patients who underwent incidental parathyroidectomy after total thyroidectomy was presented.

Material and Methods

Patients who underwent thyroidectomy between January 2011 and March 2017 were evaluated retrospectively from their file records. The demographic characteristics of pathological diagnoses of the patients who were performed thyroidectomy were evaluated. From the specimens sent to the pathology, the number of excised parathyroid glands and their localizations were detected. Postoperative PTH was evaluated. On the second day, the value of calcium was checked. The patients with decreased PTH and calcium values were applied calcium replacement. The dose of calcium replacement was decided according to the biochemical values. After the patients were discharged, hypocalcemia was determined as permanent or temporary by evaluating calcium and PTH values in the control examinations in the outpatient clinic.

Results

Of 142 patients, 23 were male (16.2%) and 119 were female (83.8%). Their mean age was 49,5 years. Total thyroidectomy was performed in 131 patients, bilateral subtotal thyroidectomy in 3 patients, left total right subtotal thyroidectomy in 3 patients, right total left subtotal thyroidectomy in 2 patients, left thyroid lobectomy in 2 patients, and complementary thyroidectomy in one patient. Two of patients were performed unilateral neck dissection (levels II, III, IV, and V) and 82 patients were applied central lymph node dissections.

It was observed that the parathyroid tissues of 31 patients were removed incidentally. Of these patients, 29 were female and 2 were male. Five of the excised parathyroid tissues were intrathyroidal, 15 were located in and along the thymus tissue, and 5 were located in the central lymphatic fat tissue. Calcium levels below 8 mg/dL were considered to be consistent with hypocalcemia. The development of hypocalcemia findings was observed in patients whose serum PTH levels were below 15 pg/dL. Of these patients, 42 had transient hypocalcemia and 2 had permanent hypocalcemia.

Conclusion

In this study, it was postoperatively seen that even though the thyroid surgery was made in the experienced hands, there were unwantedly excised parathyroid glands. We suggest that postoperative PTH level is important in determining hypocalcemia and it protects patients against the risks caused by hypocalcemia.

TJS. 2018;34(Suppl-1):S268–S269.

PP-0160 [Endocrine Surgery]. Relation of Body Composition Analysis Data with Hypocalcemia after Total Thyroidectomy

Süleyman Utku Çelik ^1,^✉, Can Konca ¹, Akın Fırat Kocaay ¹, Volkan Genç ¹

Objective

Hypocalcemia is a common, often transient, and curable complication of thyroid surgery. However, it is not exactly known which patient will develop it, and it often occurs in the late postoperative period. This leads to longer hospitalization or unnecessary calcium prophylaxis. Therefore, the prediction of whether hypocalcemia will develop after total thyroidectomy in patients is important for optimal discharge, treatment planning, and follow-up. The aim of this study is to reveal the relationship between body composition parameters obtained by bioelectrical impedance analysis and hypocalcemia after total thyroidectomy.

Material and Methods

A total of 113 patients were included in this prospective study. Patients were divided into two groups as those developing biochemical hypocalcemia (calcium <8 mg/dL) and those not developing biochemical hypocalcemia (calcium ≥8 mg/dL) according to their postoperative calcium levels and groups as those developing and not developing symptomatic hypocalcemia according to their clinical features. Then, the association of the groups with individual body component parameters was evaluated. In addition, the other patient- and disease-related factors were also evaluated in terms of their relationship with hypocalcemia. The results were presented as mean, median, and frequency. The value of p<0.05 was accepted to be statistical significant.

Results

Of the patients, 95 were female and 18 were male, and the mean age was 50.7±12.9 (23–78) years. None of the patients had permanent hypocalcemia in the follow-ups. All of the hypocalcemia cases that were detected were transient. Symptomatic hypocalcemia was found in 23 patients (20.3%) and biochemical hypocalcemia was detected in 26 patients (23.0%). Height, weight, body mass index, body fat percentage, fat mass, fat-free body mass, muscle mass, bone mineral density, basal metabolic rate, metabolic age, visceral fat and obesity grade, which were obtained through body composition analysis in the preoperative period, were found to be at lower levels in patients with symptomatic hypocalcemia than in those without it. However, there was no significant relationship between these parameters and the occurrence of symptomatic and biochemical hypocalcemia. Only total body fluid was lower at the borderline significance level in the patients having symptomatic hypocalcemia than those not having symptomatic hypocalcemia (p=0.050). In terms of other variables, the incidence of symptomatic hypocalcemia was found to be higher in patients at older age, having a nodule greater than 40 mm, retrosternal thyroid, and specimen with a weight greater than 100 g, and undergoing parathyroid autotransplantation.

Conclusion

There was no significant relationship between symptomatic or biochemical hypocalcemia and body composition. However, it is quite noteworthy that the parameters related to body adiposity and obesity were found to be lower in the symptomatic hypocalcemia group and that the total body fluid in this group was measured to be significantly lower. Although studies on this subject are inadequate, the effect of obesity on calcium metabolism at the cellular level, hormonal level and visceral level is obvious. However, it is necessary to investigate whether obesity is a risk factor or a protective factor for hypocalcemia after thyroidectomy.

TJS. 2018;34(Suppl-1):S269.

Parathyroid carcinoma is one of the rare endocrine tumors and constitutes 1% of the cases with primary hyperparathyroidism. Patients usually present with the complaints of fatigue, nausea, vomiting, loss of appetite, constipation, and widespread bone pain. The incidence of parathyroid carcinoma is equal in men and women. The incidence of parathyroid carcinoma has increased in patients with a history of radiotherapy to the neck, familial hyperparathyroidism, HPT-JT syndrome, and secondary hyperparathyroidism associated with renal insufficiency. Imaging methods are helpful in determining tumor localization, but they cannot help to distinguish benign and malignant lesions. Although the final diagnosis is generally established with postoperative pathology specimen reports, high blood calcium levels (> 14mg/dl) and high parathormone (> 5 times higher of the upper limit,> 300pg/dl) levels in the preoperative laboratory tests should typically cause clinical suspicion. Diagnostic fine needle aspiration biopsy is contraindicated because of the risk of spreading the tumor. When parathyroid carcinoma is suspected peroperatively, frozen section can be performed. However, since some similar pathologic features of parathyroid carcinoma may be observed in some benign adenomas, the frozen section procedure is generally not reliable.

Because of similar imaging modalities and similar clinical findings, it is difficult to distinguish preoperative parathyroid adenomas and parathyroid carcinomas.

TJS. 2018;34(Suppl-1):S271.

PP-0164 [Endocrine Surgery]. Emergency Total Thyroidectomy in a Patient Diagnosed with Pneumonia and Retrosternal Goiter: A Rare Case Report

Bengi Balci ^1,^✉, Gizem Kılınç ¹, Halit Batuhan Demir ¹, Gökhan Akbulut ¹

Introduction

Retrosternal goiter is seen in the world with an incidence of 0.2–5%, and patients may also present with the symptoms of respiratory distress in addition to the symptoms of thyroid function disorders. The addition of a pulmonary pathology such as pneumonia in patients with respiratory distress due to retrosternal goiter may further impair the respiratory functions. In this case report, emergency total thyroidectomy performed due to respiratory dysfunction in association with the coexistence of pneumonia and retrosternal goiter is explained.

Case

A 50-year-old female patient was admitted to the emergency unit with respiratory distress. Due to respiratory arrest, the patient was intubated and performed cardiopulmonary resuscitation. In the examination of the patient, diffuse consolidation areas consistent with pneumonia in the bilateral lungs and a giant goiter with retrosternal extension leading to significant rightward deviation in the trachea were detected. The patient was referred to our hospital for advanced examination and treatment and she was hospitalized in the anesthesia intensive care unit. She was consulted to the department of infectious diseases and broad spectrum antibiotherapy was initiated with cefoperazone/sulbactam and linezolid. Despite trying extubation intermittently, the patient was unable to tolerate the extubation due to tracheal deviation and compression and she was consulted to our department for emergency total thyroidectomy. In the thyroid function tests of the patient who was assessed by our department, the value of TSH was 6.056 uIU/mL, free T4 was 0.0996 ng/dL, and free T3 was 3.35 pg/mL. The patient was taken to the operating room as intubated and emergency total thyroidectomy was planned with nerve monitoring. At the exploration, it was observed that the left thyroid lobe showed retrosternal extension and it was about 10×12 cm in dimension and had multinodular structure. Although the intraoperative right vagal and recurrent laryngeal nerve were monitorized, the voltage measurement of the left vagal nerve was low and the left recurrent laryngeal nerve could not be revealed. The patient with no additional intraoperative complication was extubated on the postoperative 1st day. Her antibiotherapy was continued due to pneumonia and the patient was consulted to the department of otorhinolaryngology on the postoperative 3rd day. The video laryngoscopy showed that the right vocal cord was fully mobile, but the left vocal cord was paralyzed. On the 13th day of the follow-up and on the 7th postoperative day, the treatment of pneumonia was completed and the patient was discharged. Postoperative thyroid specimen measurements are as follows; bilateral total thyroidectomy specimen that was 180 g in weight and 13×11×7.5 cm in size in total, 11 g and 6×4.5×2 cm right thyroid lobe, 3.7 gr and 3.5×1.5×1 cm isthmus, and 164.6 g and 12×7.5×7. 5 cm left lobe. Thyroid specimen pathology was consistent with multinodular hyperplasia displaying the signs of degeneration.

Conclusion

Although surgery is often performed under elective conditions in cases with retrosternal goiter, it should not be forgotten that emergency thyroidectomy may be required with the addition of pulmonary pathologies to the current partial upper respiratory tract obstruction.

TJS. 2018;34(Suppl-1):S271–S272.

PP-0165 [Endocrine Surgery]. A Rare Condition in Thyroidectomy: Thyroid Hemiagenesis

Mustafa Buğra Kardaşlar ^1,^✉, Abdullah İnal ¹, Ahmet Nart ¹

Thyroid hemiagenesis is a very rare thyroid pathology that is seen as a defect in the embryonic development of thyroid tissue. To date, 329 thyroid hemianagenesis cases have been reported in the literature. This condition can usually be detected by imaging methods such as ultrasound, tomography and scintigraphy, which are performed with a multidisciplinary approach in the preoperative period and can be prepared during the operation. Or, it can be encountered peroperatively as in our case. It is important to have information about this rare condition and to keep it in mind.

TJS. 2018;34(Suppl-1):S272.

PP-0166 [Endocrine Surgery]. The Nodule Reported As Parathyroid Neoplasm According To the Biopsy of Postoperative Specimen in a Patient Who Was Performed Thyroidectomy Due To the FNAB Result Interpreted As Suspected Follicular Neoplasia: A Rare Case Report

Çağrı Akalın ^1,^✉, Nazan Aksoy ²

Introduction

Thyroid gland nodules are nodules with cancer potential and imaging techniques-guided fine needle aspiration biopsy taken from thyroid nodules with malignancy potential helps to detect malignancy. In this case report, it was aimed to present a patient who was considered to have a thyroid nodule on ultrasonography, but suspected to have follicular neoplasm according to the result of fine needle aspiration biopsy (FNAB) taken from this nodular lesion and performed thyroidectomy, and whose postoperative specimen was interpreted to be parathyroid neoplasm.

Case

A 44-year-old female patient was admitted to the outpatient clinic due to the complaints of feeling of pressure on the neck and globus sensation going on for 8 months. She had a history of Type 2 diabetes. In her physical examination, there was a nodule (?) in the superior part of the thyroid gland left lobe. In the laboratory analyses, thyroid function tests were normal, fasting blood glucose was 342 mg/dl, and calcium was 10,4 mg/dl. In the ultrasonography (USG), the size of the thyroid gland was normal. A 31×19 mm hypoechoic solid lesion was observed in the posterior part of the thyroid left lobe and histological sampling for this nodule was suggested by the radiologist. The result of the USG-guided fine needle aspiration biopsy (FNAB) of the thyroid was interpreted as a suspected follicular neoplasm (Bethesda IV). Bilateral total thyroidectomy was performed to the patient. On the first postoperative day, the patient was discharged with recovery. The result of postoperative pathology specimen was reported as parathyroid neoplasia + thyroid tissue with normal margins. It was stated by the department of pathology that the tissue considered to be thyroid left lobe was completely an encapsulated parathyroid neoplasia and malignancy could not be ruled out in the present microscopic images.

Conclusion

Parathyroid tissue cannot be ultrasonographically visualized in normal conditions, but can be viewed with 75–80% probability in cases like neoplasia. In our case, the serum calcium level below 10,5 mg/dl, the inability to visualize the parathyroid tissue in USG, and the interpretation of the FNAB result as suspicious follicular neoplasm were primarily considered in favor of thyroid disease. Histopathological malignancy criteria in parathyroid neoplasms are invasion to the surrounding soft tissues and vital organs such as thyroid, esophagus, pharynx, and larynx, vascular, and perineural invasion, or histologically documented regional or distant metastases. In cases for which definite criteria cannot be determined, at least three of some findings such as capsular invasion, high mitosis (> 5/10BBA), intratumoral broad fibrous bands, coagulative tumor necrosis, and diffuse cellular atypia should be involved. We think the entire thyroid gland left lobe’s being involved by encapsulated parathyroid neoplasm might have caused by deceptive appearance due to the formation of capsular non-neoplastic adhesions in the thyroid parenchyma over time caused by the neoplastic lesion. In addition, broad intratumoral fibrous bands and lesion were observed to partially invade the capsule in the specimens. This case had none of definite criteria for the diagnosis of parathyroid carcinoma. Possible parathyroid pathologies should always be kept in mind in patients planned to be operated for thyroid nodule because parathyroid neoplasms cannot be definitely ruled out ultrasonographically and the result of FNAB cannot eliminate the parathyroid pathology.

TJS. 2018;34(Suppl-1):S272–S273.

PP-0167 [Endocrine Surgery]. Papillary Thyroid Cancer Case Presenting with Calvarium Metastasis

Bahri Çakabay ^1,^✉, Abidin Tüzün ¹, Serdar Gümüş ¹

Introduction

Thyroid cancers are known to have the best cure, long survival rate, and well-differentiated histological features when compared to other cancers. Papillary thyroid cancer is the most common ly encountered type and it constitutes approximately 80% of thyroid cancers. The rate of bone metastasis varies between 10% and 40%, but skull metastasis varies between 2.5% and 5.8%.

Case

A 77-year-old female patient was admitted to the outpatient clinic of neurosurgery due to the compliant of swelling on the scalp. She had a history of previous laparoscopic cholecystectomy and she had medication-regulated hypertensive asthma. She was performed computed tomography by the department of neurosurgery due to swelling on the cranial region. There was a heterogeneous, isodense, well-circumscribed 4,5×2,5 cm solid mass lesion with the density of 48 HU, causing destruction in the right temporofrontal region. This mass was radiologically evaluated to be multiple myeloma or eosinophilic granuloma. It was totally excised by a neurosurgeon. When the pathology of the patient was reported as papillary thyroid carcinoma metastasis, she was referred to our department. The patient whose ultrasonography revealed multinodular goiter was performed FNAB and it was interpreted as atypia with undetermined significance. Postoperative Pet CT was performed to the patient and no involvement was found except thyroid nodules in which Suv max value was measured as 10. She was applied thyroidectomy and central lymph node dissection. She was postoperatively given RAI treatment. The patient has been living for 50 months without a new metastasis.

Conclusion

Thyroid cancers are encountered at the rate of approaximately 1% among all cancers and its incidence has increased especially in females in recent years. This rate is 2% for females and 0.5% for males in all malignancies. The incidence of thyroid cancers has increased in recent years due to the increasing prevalence of diagnostic tests. Thyroid cancers are known to have the best cure, long survival rate and well-differentiated histological features compared to other cancers. Papillary thyroid cancer is the most common type and it constitutes about 80% of thyroid cancers. Papillary thyroid cancer tends to spread lymphatically and may develop in 20% of distant metastatic cases. The most common metastases occur to the lung, bone, brain, and liver. Bone metastasis varies between 10% and 40%, but skull metastasis varies between 2.5% and 5.8%. Bone metastases may be osteolytic or proliferative. It can cause bone pain and swelling or it can also be incidentally found without giving any symptoms. As in our case, the cases of papillary thyroid carcinoma presenting with cranial mass are very rare. The survival differs in distant metastases. While the 10-year survival is 30–50% for lung metastasis, this rate is 1 year in brain metastasis.

Clinicians should keep in mind that papillary thyroid carcinomas may rarely present with metastasis to the calvarium as a distant organ.

TJS. 2018;34(Suppl-1):S273–S274.

PP-0168 [Endocrine Surgery]. Giant Multinodular Goiter with Hyperthyroidism Resistant to Medical Treatment: Case Report

Burak Veli Ülger ^1,^✉, Mesut Gül ¹

Introduction

Toxic multinodular goiter usually develops in elderly individuals with a history of multinodular goiter that is often non-toxic previously. It gains sufficient thyroid nodule autonomy over several years and causes hyperthyroidism. The signs and symptoms of hyperthyroidism are similar to those of Graves’ disease, but there are no extrathyroidal signs. Its standard therapy is surgery. It is important to make the patient euthyroid before surgery. In our study, we present a case with a toxic multinodular goiter that cannot be controlled by medical therapy.

Case

A 70-year-old female patient was admitted to our outpatient clinic due to the complaints of swelling in her neck existing for 30 years and recently developed difficult breathing and difficulty swallowing. Although she had previously been recommended to undergo surgery, she stated that she had no surgery because she was afraid. It was determined that the size of the thyroid gland was severely increased. Her arterial blood pressure was 110/85 mmHg and pulse rate was 104/min. In the ultrasonography, the size of the right lobe of the thyroid gland was measured as 81×101 mm and the size of the left lobe as 61×61 mm, and there were a lot of nodules in both lobes and isthmus, the largest of which was 6 cm in size. In blood tests, TSH was measured as 0.01 mcIU/ml (Normal values: 0.27–4.2), and sT4 was measured as 93 pmol/l (Normal values: 12–22). The patient was started methimazole 2 × 20 mg and propanolol 2 × 20 mg. In blood tests performed after 3 weeks, TSH was 0,01 and T4 was 59. The patient was consulted to the department of endocrinology and 2 × 4 g of cholestyramine was added to her treatment. In the follow-ups, her thyroid functions did not normalize and she was hospitalized in the endocrinology clinic. Prednol tb 2 × 20 mg was added to her medical treatment, but her thyroid functions were not normalized after 1 month of follow-up. Then, on the council, it was decided to perform surgery after plasmapheresis. After giving three sessions of plasmapheresis, bilateral total thyroidectomy was performed. During the operation, nerve monitoring was performed and bilateral recurrent laryngeal nerves were preserved.

Conclusion

The treatment of toxic MNG is surgery. Hyperthyroidism should be corrected before surgery. For this purpose, PTU, methimazole, and steroids and cholestyramine for resistant cases are used. In hyperthyroid patients who do not recover despite medical treatment, plasmapheresis should be kept in mind to restore thyroid hormone levels before surgery.

TJS. 2018;34(Suppl-1):S274.

PP-0169 [Endocrine Surgery]. Thyroid Hematoma Developing Without Trauma in the Neck: Case Report and Literature Review

Veli Vural ¹, Mustafa Örmeci ^1,^✉, Amil Huseynov ¹, Abdullah Kısaoğlu ¹

Introduction

Soft tissue injuries are relatively common after blunt trauma of the neck and they can be dangerous for many vital structures due to the complicated anatomy. Isolated trauma to the thyroid is very rare, and there are a few cases reported in the literature. The risk is higher especially in patients using anticoagulants.

Case

A 59-year-old female patient with known hypertension and using Clopidogrel Hydrogen Sulphate due to CVE (cerebrovascular event) was admitted to the emergency room with swelling and pain in the left frontal lobe of the neck without a history of trauma. The superficial hematoma finding was not visualized, and there was no pressure symptoms in the respiratory tract. Hematoma was observed in the left thyroid lobe in the contrast-enhanced CT scanning and improved without any surgical intervention.

Conclusion

Although soft tissue injuries are seen after blunt neck trauma, isolated thyroid gland injury is extremely common. It is present in about 1–2% of cases and there is an underlying pathology in the glands in most of them. Most patients consult to the emergency unit with neck swelling, pain, respiratory distress, dysphagia, and hoarseness although they are hemodynamically stable in the early stages. In the strategy of diagnosis, a sensitive decision must be made to prevent respiratory or vascular extra-trauma. While hematoma resorbs spontaneously in many patients, surgical exploration continues to be a widespread treatment strategy in unstable patients.

Although this condition is rare, physicians should keep in mind the possibility of thyroid damage, especially in those using anticoagulant without blunt neck trauma. Early diagnosis and immediate treatment can reduce life-threatening complications. Its management should be individualized according to the characteristics of the patient and the experience of the surgeon.

TJS. 2018;34(Suppl-1):S274–S275.

Adrenal tissue arises from two different embryological origins, the cortex from the mesoderm and the medulla from the ectoderm. The adrenal cortex develops from the mesodermal dorsal cells in the 4th–5th gestational weeks. Interstitial cells of the testis and theca cells of the ovary develop from the ventral cells of the same region. The transposition of the cortex tissue during the migration and descending of the gonads and mechanical separation during the early embryological period are accepted to be effective in the formation of adrenal residues. While some adrenal heterotopic tissues remain in the adrenal tissue area in the neighborhood of the kidney, others can migrate with the gonads’ descending to the pelvis and scrotum. Some authors predict that these residues may be present in 50% of newborns, but most of them undergo atrophy in adulthood. In adults, the incidence of ectopic adrenal tissue in the spermatic cord is less than 1%. Tumor development from ectopic adrenal has rarely been reported.

Ectopic adrenal tissue is a rare condition encountered in inguinal hernia surgery. For surgeons interested in hernia surgery, the possibility of ectopic adrenal tissue should be kept in mind when yellow-orange nodular structures are encountered around the hernia sac. It is suggested that this nodule should be excised and histologically examined considering its hormone production and malignancy transformation.

TJS. 2018;34(Suppl-1):S276–S277.

PP-0173 [Endocrine Surgery]. An Interesting Surrenal Adenoma Case: Was It Phaeochromocytoma?

Tolga Kalaycı ^1,^✉, Ümit Haluk İliklerden ¹, Mehmet Çetin Kotan ¹

Introduction

Pheochromocytomas are neoplasias originating from the chromaffin cells of the sympathoadrenal system. The most commonly used biochemical parameters for diagnosing pheochromocytoma, which can be symptomatic due to irregular, episodic and excessive catecholamine release, are the blood/urine catecholamine and catecholamine degradation products. These tests have high sensitivity and specificity. The main problem is that the patient gives symptoms of pheochromocytoma causing morbidity/mortality during adrenal surgeries or other surgeries despite negative biochemical tests. The purpose of presenting this case is to raise awareness about this interesting aspect of pheochromocytoma.

Case

A 22-year-old female patient was admitted to our clinic with the complaints of pain and swelling in the right flank area. The patient had no complaints such as nausea, vomiting, and dysuria. She did not have any features in her history. The 24-hour urine metanephrine level, which was measured in an external center, was 79 mcg/day and the normetanephrine level was 216 mcg/day. Other laboratory parameters were normal. Twenty four-hour Holter monitoring was applied to the patient and the mean blood pressure of the patient was measured as 130/77 mm Hg. The contrast-enhanced abdominal computed tomography of the patient revealed a 40 * 35 mm lesion in the right surrenal lodge. In the PET CT, a lesion with a SUV max of 15.7 was observed in the right surrenal area. Moreover, lesions in the axial sections passing through L2 and L3 levels, which may be metastasis with high SUV max value, were viewed. The patient was evaluated as nonfunctioning surrenal adenoma/adenocarcinoma and preoperative surgical preparation was performed for the patient. Pheochromocytoma was not considered for the patient who was consulted to the endocrinology department preoperatively. All surgical preparations of the patient were completed. During anesthesia induction, her blood pressure level increased to the levels which could not be controlled (300/200 mm Hg). Therefore, patient’s surgery was abandoned and the patient was extubated after about 1-hour blood pressure regulation and stabilization on the operating table. The patient was taken to the postoperative area of the operating room for follow-up. The patient suffering from respiratory distress during her follow-up was re-intubated and taken into the anesthesia intensive care unit for follow-up. In the examination of the patient performed in the anesthesia intensive care unit, intense crepitant rales were observed in the bilateral lung bases. In deep tracheal aspiration, abundant amount of foamy fluid secretion was aspirated. The patient was primarily considered to have hypertensive pulmonary edema. During the intensive care follow-ups, the patient had cardiopulmonary arrest several hours later. The patient, who did not respond to routine cardiopulmonary resuscitation, died.

PP-0177 [Endocrine Surgery]. The Effect of Hyaluronic Acid Carboxymethyl Cellulose on the Prevention of Postoperative Adhesion in Radiotherapy Added Thyroid Surgery

Berk Gökçek ^1,^✉, Semra Günay ¹, Deniz Özcan ², Orhan Yalçın ¹

Objective

The application of radiotherapy after thyroid surgery increases the adherence in the operation site and causes complications to increase in later interventions. Studies on the effect of hyaluronic acid carboxymethyl cellulose (Seprafilm^®) on intraabdominal adhesions have been conducted and its positive effects have been shown. In this study, the effect of Seprafilm^® on the development of adhesion after thyroid surgery with radiotherapy was examined.

Material and Methods

The study was carried out at the Istanbul University Cerrahpaşa Medical Faculty, Experimental Animals Production and Research Laboratory with permission from the ethics committee of Istanbul University. In our study, 200–250 g and 4–5-month-old female Spraque Dawley rats were used. Four groups including10 rats were formed for the study. A group was given Seprafilm^® and radiotherapy, B group was given radiotherapy, C group was given Seprafilm^®, and D group was identified as the control group. In all rats, dissection to the thyroid lodge was performed. Seprafilm^® was placed into the thyroid lodge in groups A and

C. After 30 days, 2 Gray/day radiotherapy was applied to the neck region in A and B groups for 5 days. The rats, which were followed for 90 days after radiotherapy, were sacrificed and the severity of adhesions in the thyroid lodge was macroscopically evaluated as 0-1-2. In addition, the tissue samples were examined histopathologically. In the histopathological examination, histiocytes, fibroblast, fibrosis, collagen, vascularization, granulocyte, giant cell, and fat necrosis were evaluated and graded as 0-1-2-3. The results were statistically evaluated through the Chi-square test and the value of p <0.05 was considered to be significant.

Results

During anesthesia administration for radiotherapy, two rats from groups A and B died. No severe adhesion was observed in group A, but more severe adhesion was seen in group B given only radiotherapy. The p value was found to be 0,047, which was significant. The macroscopic features of the groups were not significantly different when compared to each other. In the comparison of the results of histopathological examination, a statistically significant result could not be obtained.

Conclusion

Post-operative adhesions are an important cause of morbidity. Radiotherapy applied after surgery increases the fibrosis and also the adhesions. This situation further increases the morbidity of the procedures applied for recurrences developing after cancer surgery. Laryngeal nerve damage and hypoparathyroidism are the most important complications in cases of the need for re-intervention after thyroid surgery. The most important factors in the development of these complications are dissection difficulties due to adhesions and invasion of the recurrent mass. Although many methods, drug and anti-adhesion barriers have been used for post-operative adhesions, no ideal method has been found. Seprafilm^®, which is mostly used intra-abdominally to prevent adhesions, was used in the thyroid lodge in our study and its effectiveness with radiotherapy was assessed. The results were not found to be significant due to the a few number of subjects and the short duration of waiting.

TJS. 2018;34(Suppl-1):S279–S280.

PP-0178 [Endocrine Surgery]. Maxillary Brown Tumor Associated with Parathyroid Carcinoma

Amil Huseynov ^1,^✉, Demet Sarıdemir ¹, Veli Vural ¹, Cumhur Arıcı ¹, Burak Kocabalkan ², Alper Sindel ²

Brown tumors are osteolytic bone lesions arising as a result of persistent hyperparathyroidism. They are usually recognized late in the natural development of the disease and they are still very rare due to the earlier diagnosis of primary hyperparathyroidism. We presented a 51-year-old male patient with a history of maxillary abscess recurring for two months. An osteolytic bone lesion was seen in the maxillary alveolar process in the computed tomography. Biopsy was performed and the histopathological result was consistent with a Brown tumor. The aforementioned localization is rare for such tumors and therefore, a difficulty occurred in the primary diagnosis. However, in this case, the association with primary hyperparathyroidism was a clue to the diagnosis, and there was a significant change in the patient’s complaints after parathyroidectomy. A case of Brown tumor secondary to parathyroid carcinoma has been rarely reported. As we know, this is one of a few Brown tumors that have been identified in these localizations and the first case occurring secondary to parathyroid carcinoma.

TJS. 2018;34(Suppl-1):S280.

PP-0179 [Endocrine Surgery]. Our Rates of Recurrent Laryngeal Nerve (RLN) Damage after Total Thyroidectomy

Ahmet Topçu ^1,^✉, İldem Deveci ², Muhammed Taha Demirpolat ¹, Şamil Şahin ², Sema Yüksekdağ ¹, Ömer Faruk Özkan ¹, Ethem Ünal ¹, Fikret Ezberci ¹

Objective

It was aimed to determine and clinically evaluate the RLN damage rates in patients undergoing total thyroidectomy.

Material and Methods

The files of 260 patients, who were performed total thyroidectomy by a single surgeon for benign (toxic nodular goiter, nodules with benign cytology and size of 4 cm or larger) and malignant (papillary thyroid cancer) thyroid disease in the Department of General Surgery at the Health Sciences University, Umraniye Training and Research Hospital between May 2014 and January 2018 were retrospectively evaluated. All patients underwent the neuromonitorization of both cords (nim response 3 version, Medtronic, USA). All cases suspected to have vocal cord paralysis were examined by an ENT specialist. Demographic data, underlying etiologic diseases and the efficacy of surgical treatment were evaluated. The data were collected in an Excel file and the obtained results were presented in number (n) and percentage (%).

Results

The diagnosis of vocal cord paralysis was established by the ENT department in 12 patients (4.6%) with respiratory distress and low voice volume and/or quality in the postoperative period. Eight patients had unilateral paresis (n=8/260, 3%) (Right RLN 50%, Left RLN 50%) and 4 patients (n=4/260, 1.5%) had bilateral (BRLN) paresis. Nine of the patients (75%) were female and 3 were male (25%). These patients were initiated steroid therapy. The mean age of patients with RLN paralysis was 51 (range, 3267) years and the mean duration of follow-up was 23 months (range, 1–43). The mean duration of hospital stay was 4 days (2–14). When the pathology reports were examined, papillary carcinoma (58%) was detected in 7 patients, parathyroid adenoma (8%) in 1 patient, and multinodular goiter (34%) in the ground of thyroiditis in 4 patients. Of the patients with BRLN paralysis, a 57-yearold female patient with multiple foci papillary cancer pathology developed respiratory distress on the postoperative 2nd day and she was performed tracheotomy under emergency conditions (n=1,% 0.3). In this patient, the left RLS became active in the 4th month and radioactive iodine treatment was initiated after closing the tracheostomy. One of the other patients with BRLN paralysis was applied left thyroplasty in the first postoperative month and the other was applied lateralization with suture. Five patients with unilateral paralysis and one patient with BRLN paralysis were found to have vocal cord mobility in the 6th month in the ENT control (temporary paresis, n=6/260% 2.3). It was observed that these patients did not develop any significant morbidity and their voice quality improved. A patient with permanent left RLN damage was applied fat injection in the first postoperative year, and a patient with right arytenoid subluxation (intubation crush injury) was performed reduction.

Conclusion

To reveal and preserve RLN with careful dissection and intraoperative nerve monitoring in cases undergoing total thyroidectomy is the surgical technique that should be preferred. Moreover, in the occurrence of RLN injuries despite any surgical attention, close follow-up and cooperation with patient are essential for minimizing morbidity.

TJS. 2018;34(Suppl-1):S280–S281.

PP-0180 [Endocrine Surgery]. Ectopic Parathyroid Adenoma with Mediastinal Localization: Video-Thoracoscopic Parathyroidectomy

Koray Baş ^1,^✉, Ayberk Dursun ¹, Mustafa Demirpençe ², Özgür Samancılar ³

While parathyroid adenoma is the most common cause of primary hyperparathyroidism with the rate of 80%–85%, 5–10% of these adenomas have ectopic localization. Ectopic parathyroid adenomas are located in the thymus in 95% of cases, but about 5% are mediastinal. In this report, we aimed to present videoendoscopic excision of parathyroid adenoma detected in the anterior mediastinal location in a 40-year-old female patient. When routine laboratory analyses demonstrated hypercalcemia, advanced techniques were performed and primary hyperparathyroidism was detected. In the Tc-99m MIBI scintigraphy, an appearance consistent with parathyroid adenoma was observed out of the neck region. The computed tomography revealed that the mass was located in the anterior mediastinum, but distinct from the thymus tissue. The parathyroid adenoma, which was preoperatively localized with videoendoscopic minimally invasive approach with 2 trocars from the right hemithorax, was found and excised. The excision of the adenoma was confirmed by postoperative laboratory and histopathological analyses.

Surgical excision in parathyroid adenomas is still the most effective treatment option. Surgical success depends primarily on the correct localization of the adenoma in the preoperative period. With the use of current video-endoscopic minimally invasive technologies, we think that these patients can be protected from additional morbidities that can be caused by classical surgical methods.

TJS. 2018;34(Suppl-1):S281.

PP-0181 [Endocrine Surgery]. Squamous Cell Carcinoma Originating from Sternotomy Scar and Displaying Thyroid Invasion: Case Report

Gökhan Pösteki ^1,^✉, Alican Güreşin ¹, Veysel Sarı ¹, Sertaç Ata Güler ¹, Nihat Zafer Utkan ¹

Skin cancers are very common across the World. The most common type of them is squamous cell carcinoma. Squamous cell carcinoma is seen at a high rate in chronic scar tissues, which are defined as Marjolin ulcer. In this study, we presented a case of squamous cell carcinoma associated with an incision scar and displaying a thyroid invasion.

TJS. 2018;34(Suppl-1):S281–S282.

PP-0182 [Endocrine Surgery]. Insulinoma in the Left Lower Quadrant

Bartu Badak ¹, Muhammed Kandemir ^1,^✉

Introduction

Insulinoma is a rare benign tumor with an incidence of 1 to 4 per a million. They are pancreatic tumors arising from the β-cells of Langerhans islets. They are often originated from the pancreas. In very rare cases, it is known to arise from the spleen, perisplenic tissues, hepaticoduodenal ligament and treitz ligament, and ectopic pancreatic tissues. Insulinomas constitute the majority of neuroendocrine tumors (60%). In endocrine tumors, the distinction of benign and malignancy, being hormonally active, the relationship with multiple endocrine neoplasia 1 (MEN-1) are important for prognosis. The malignancy rate of insulinomas is around 10%. In these cases, typical Whipple’s triad is seen (the presence of hypoglycemia symptoms, blood sugar level lower than 50 mg/dl, and regression of symptoms with glucose intake). Because of the hormonal effects of endocrine tumors, and the risk of malignancy, surgical intervention should be considered in the first place. Medical treatment is planned in cases for which surgical resection is not possible.

Case

A 68-year-old female patient in our present case was admitted to our hospital with the complaints of fainting when hungry and trembling in the hands and feet that began 2 years ago. It was learned from the anamnesis of the patient that she had applied to the an external center for these complaints and she had been initiated phenytoin 100 mg tb 1×1 with the pre-diagnosis of epilepsy. However, with the use of phenytoin, it was learned that the complaints had not regressed. Apart from that, she did not have any comorbid disease. In the blood analysis, her blood glucose level was found to be 45 g/dL (70–110 g/dL) and other biochemical parameters and hemogram parameters were evaluated as normal. Because the blood glucose level was low, the patient was thought to have insulinoma. Fasting insulin level was measured as 113.6 uU/ml (2.6–24.9 uU/ml) and C peptide was

10.81 ng/ml (1.1–4.4 ng/ml). Since the anterior pituitary hormones, which were evaluated with the suspicion of MEN-1, were at normal levels, MEN-1 was ruled out. In the reuslt of Ga-68 Dotatate PET CT and the whole abdominal CT performed for the purpose of advanced examination, an active mass was detected in the left lower quadrant and the patient was taken into operation. The histopathological examination result was reported as ‘insulinoma’, which was presented with imaging techniques.

Conclusion

Insulinoma is a pathology that require the clinicians to be in constant alarm in terms of both symptoms and localization. The diagnosis of insulinoma with symptoms for which inadequate imaging methods are used and ectopic localization areas should be kept in mind. In this case report, we aimed to contribute to the literature and to include this region in the ectopic areas by presenting a case of left lower quadrant ectopic insulinoma, which is encountered in very few cases.

TJS. 2018;34(Suppl-1):S282.

PP-0183 [Endocrine Surgery]. Ganglioneuroma in Adult Patient

Bartu Badak ¹, Muhammed Kandemir ^1,^✉

Introduction

Ganglioneuroma is a neurogenic tumor like neuroblastoma and ganglioneuroblastoma, originating from the common primitive cells of neural crest. It is a benign tumor frequently consisting of sympathetic ganglion cells. It rarely originates from the adrenal medulla, sympathetic and peripheral nerves. It is more frequently seen in the posterior mediastinum and then retroperitoneum. Less than 30% of ganglioneuromas occur in the surrenal region. Because the tumor is not metabolically active, it is usually asymptomatic and it is rarely detected before reaching large sizes. The treatment of ganglioneuroma is its surgical removal.

Case

Our case was a 47-year-old female patient. Because of the detection of right surrenal mass in the abdominal ultrasonography performed in an external center, she was referred to our clinic. The patient was examined in our clinic for the existing surrenal mass. She had no history of a known disease. No abnormality was found in her familial history. There was no active pathology in the physical examination. Laboratory findings showed that the present tumor did not have an endocrinological component. The tumor marker values were normal. The abdominal ultrasonography revealed 3 cm hypodense lesion in the right adrenal gland. In the surrenal computed tomography performed for advanced examination, a 30 × 18 mm space-occupying nodular formation was observed in the localization of the right adrenal gland. The patient was followed up for surrenal mass. The patient was also consulted to the endocrinology department and the mass was accepted to be non-functional according to the results of examinations. After 6 months, surrenal CT was repeated. In CT, a 36 × 21 mm space-occupying nodular formation was observed in the right surrenal gland. As a result of the present imaging techniques, operation was planned for progressed adrenal mass. The patient was performed right surrenalectomy. No complications developed during and after the operation. The right surrenalectomy material was evaluated. S100 positive, calretinin and ganglion cells were observed. Chromogranin, Synaptophysin and CD34 were evaluated as negative. The findings were reported to be consistent with ganglioneuroma. Ganglioneuroma is a tumor originating from the neural crest and developing from neuroectodermal cells. It can develop along the sympathetic chain extending to the base of the head, neck, posterior mediastinum, retroperitoneum and adrenal gland. It is frequently seen in the posterior mediastinum and retroperitoneum. Adrenal gland is involved at the rate of 21%. It is often diagnosed in childhood. Two-thirds of the cases are under the age of 20 years. In our case, the patient’s age was 47 years. It may develop as a spontaneous tumor or as a maturation or metastasis of the neuroblastoma after chemotherapy or radiotherapy. It is a usually benign, slowly-growing, and asymptomatic rare tumor. Although rare, hypokalemia, hypertension, masculinisation, and diarrhea in association with vasoactive intestinal polypeptide that they secrete can be seen. Thanks to the accessibility of imaging techniques nowadays, the detection of ganglioneuromas has increased. However, these masses are difficult to diagnose preoperatively because they are similar to other tumors radiologically. The pathway to follow in the treatment of incidental adrenal masses depends on many factors. Hormonally active tumors must be removed surgically regardless of their size. Tumors smaller than 4 cm and hormonally inactive should be followed and surgery should be planned in the presence of progression. There is no clear approach for asymptomatic adrenal masses with the size of 4–6 cm. Surgery should be recommended only for adrenal masses larger than 6 cm. In our case, the tumor was non-functional and displayed progression within 6 months. The first treatment option for adrenal ganglioneuromas is surgery.

TJS. 2018;34(Suppl-1):S282–S283.

PP-0184 [Endocrine Surgery]. Laparoscopic Adrenal Surgery: Five-year Results in Bakırköy Dr. Sadi Konuk Training and Research Hospital

Mehmet Kulus ^1,^✉, Ahmet Cem Dural ¹, Cevher Akarsu ¹, Alper Şahbaz ¹, Deniz Güzey ¹, Sema Çiftçi Doğansen ², Halil Alış ³, Mehmet Emin Güneş ¹

Objective

In this study, we aimed to share the results of the cases of adrenal surgery performed after beginning to provide the branch service.

Material and Methods

Demographics, biochemistry, imaging, outpatient clinic, surgery, and histopathology data of all cases undergoing minimally invasive surgery between June 2012 and December 2017 were analyzed retrospectively.

Results

A total of 102 patients were included in the study. The median age of the patients was 52 (27–79) years and the F/M ratio was 83/19. It was seen that the number of operated patients increased with years. Of the detected lesions, 50% (n=51) were non-functioning adenomas, 22.5% (n=23) were Cushing’s disease, 18.6% (n=19) were pheochromocytoma, and 6.9% (n=7) were Conn Syndrome. One patient had Carney Complex, and another had von Hippel-Lindau Syndrome. The mean preoperative tumor size was 49,224.2 mm in the imaging techniques. The most frequently used imaging method was MR (72.5%, n=74). The rate of conversion to open surgery was 4.9% (n=5). Open surgery for repair was performed due to the oncologic causes in 3 cases, unsafe surgical site in one case, and renal venous injury in one case. In one patient, a pancreatic capsule injury developed during left adrenalectomy and the operation was completed laparoscopically. This patient was conservatively followed after surgery. The mean duration of surgery, including patient positioning after intubation, was 143,752.3 minutes. Histopathological examination revealed adrenocortical carcinoma in 3,9% of patients (n=4). Metastases were detected in two patients (1.9%). In cases with adrenocortical carcinoma, the mean tumor size was 98.013.9 mm, which was significantly larger than in those not having tumor (p<0.001). The mean duration of hospital stay was 3,10,8 days. There was no mortality in our series during the 30day post-operative period and subsequent follow-ups.

Conclusion

With increasing volume of the cases in our clinic, laparoscopic surgery can be safely applied for adrenal gland pathologies and larger sized masses can be safely removed with minimally invasive technique with increased experience in accordance with the literature.

TJS. 2018;34(Suppl-1):S283–S284.

PP-0185 [Endocrine Surgery]. Cases of Pheochromocytoma: Examination of 8-year Results

Bahadır Kartal ^1,^✉, Cevher Akarsu ¹, Ahmet Cem Dural ¹, Alper Şahbaz ¹, Deniz Güzey ¹, Meral Mert ³, Halil Aliş ², Mehmet Emin Güneş ¹

Objective

It was aimed to examine the results of cases who were planned to be operated by the Multidisciplinary Endocrinology Council due to the pre-diagnosis of pheochromocytoma in our clinic.

Material and Methods

The demographics, biochemistry, imaging, outpatient clinic, surgery and histopathology data of all cases undergoing surgery due to the pre-diagnosis of pheochromocytoma between January 2010 and January 2018 were analyzed retrospectively.

Results

Totally 28 patients were included in the study. Their median age was 54,5 (31 – 83) years and the F/M ratio 20/8. Of the patients, 75% (n=21) had hypertension (HT) and 6 patients used HT medications more than one. The mean age of HT disease was 19.7±9.2 years in patients. All of the patients were operated with a pheochromocytoma protocol after a minimum 3-week use of alpha-blocker. They were routinely hospitalized one night before the surgery and applied IV hydration and DVT prophylaxis. The mean mass size on imaging was 48.9±18.6 cm.

Of the patients, 89.3% (n=25) were operated laparoscopically and 10.7% (n=3) were operated with robotic approach. The rate of conversion to open surgery was 3.5% (n=1). In the peroperative period, atrial fibrillation occurred in one patient and ventricular tachycardia in another patient. Postoperatively, 89.3% (n=25) of the patients were monitorized in the intermediate intensive care unit in the operating room overnight. In the postoperative period, alpha blockers were discontinued in all patients. In the 28.5% (n=8) of the patients, the antihypertensive need was totally disappeared.

The mean duration of operation was 118.6±50.2 minutes as of the first trocar insertion. On average, the time for reaching the adrenal vein was 44.1±4.8 minutes. Adrenal vein was not closed with Hem-o-lok clip in 67.8% (n=19) and with metallic clip in 32.2% (n=9). None of the cases was closed only with vascular sealing device. In the result of histopathological examination, the PASS score was above 8 in two cases. These two cases did not show local recurrence or infiltrative-metastatic features in their follow-ups. Paraganglioma was detected in the sections of another mass excised from the retroperitoneum in the case converted to open surgery. Pheochromocytoma and ganglioneuroma were seen as fusion in the sections of another mass. The mean duration of hospital stay was 3.1±1.7 days. One patient developed a hernia in the trocar site, and then the hernia was operated for repair.

Conclusion

Pheochromocytoma should be examined in detail radiologically and endocrinologically before surgery and should be prepared for surgery. Both preoperative and peroperative hypertension control are ultimately important. The clamping of the adrenal vein should primarily be paid attention and it should be kept in mind that malignant cases may be encountered although rare.

Therefore, when performing minimally invasive surgery, the oncologic principles should be considered.

TJS. 2018;34(Suppl-1):S284.

PP-0186 [Endocrine Surgery]. Preoperative Parathyroid Adenoma Localization with Ultrasound-Guided Percutaneous Injection of Blue Dye

Koray Baş ^1,^✉, Murat Bayram ¹, Zehra Adıbelli ², Mehmet Yıldırım ¹

The placement of the parathyroid glands can occur at different localizations depending on the embryological migration. Particularly in primary hyperparathyroidism patients, for whom clear information about the localization site cannot be obtained with the scintigraphy, minimally invasive methods have been begun to be used recently because of the high morbidity and worse cosmotic results of conventional neck region dissection for the detection of pathological gland. However, accurate localization is very important for detecting the target parathyroid gland in preoperative period and excising it with minimally invasive methods. For this purpose, many methods have been developed and continued to be developed. Despite all this, the detection of the correct localization still preserves its difficulty in some cases. The same method in every case does not give the same result. The choice of the appropriate method for each case is important, and maximum effort should be made for preoperative correct localization.

In this report, we present a method for preoperative localization of the right inferior parathyroid adenoma, the localization of which could not be clearly performed with Tc-99m MIBI study but could be visualized with the ultrasound of the neck for the target. A 47-year-old female patient had a sonographic parathyroid gland, which was consistent with an adenoma that was visualized with ultrasound, and it was percutaneously marked with Patent Blue dye. For the current localization, the lodge was entered with a 2.5 cm incision over the marking carried out with a pencil on the skin and it was seen that the gland was partially stained with the blue dye and visually separated from the surrounding tissues. The PTH value, which was 139 preoperatively, was decreased to 31 at the measurement at the 10th minute after the excision of the gland. And, the histopathological examination confirmed the parathyroid adenoma. The postoperative period of the patient with no drainage was normal.

The method that we presented can be a practical and inexpensive preoperative localization choice that can be used in appropriate cases for minimally invasive parathyroid surgery.

TJS. 2018;34(Suppl-1):S284–S285.

PP-0187 [Endocrine Surgery]. Did the King Suppiluliuma have Graves ophthalmopathy associated with hyperthyroidism in the 9th century BC?

Mehmet Eren Yüksel ^1,^✉

Introduction

Graves orbitopathy is an autoimmune process that affects the orbital tissues in patients with Graves’ disease. Local inflammation leads to enlargement of the extraocular muscles and increased orbital fat, resulting in proptosis, diplopia, eyelid swelling and retraction. The incidence of Graves’ disease is about 3 out of 100,000 people in men and 16 out of 100,000 people in women.

Case

The appearance of the eyes of the statue, which allegedly belongs to the King Suppiluliuma, at the Hatay Archeology Museum, is consistent with Graves orbitopathy; proptosis and live gaze are evident. The absence of eyelids on the statue may be due toeyelid retraction frequently seen in Graves’ patients. In the information of the statue, it is written that, “This statue belonging to Suppiluliuma was found in the inner castle gate of Tayinat Mound on the left side of the road at the 20th kilometer of Antakya-Reyhanlı highway of Hatay Province. The Luvice hieroglyphic inscription on the back of the statue shows that this statue belongs to the King Suppiluliuma, ruling in Tayinat (ancient Kunulua) at the beginning of the 9th century BC, in Late Hittite Patina/Unqi kingdom.

Conclusion

While Graves orbitopathy is usually seen in Graves patients with hyperthyroidism, it can also occur in euthyroid patients without a history of thyroid gland disease or in hypothyroid patients with Hashimoto’s thyroiditis. The severity of Graves orbitopathy can be determined through Hertel’s exophthalmometer.

The findings indicate that Graves orbitopathy was seen in Anatolia in the 9th century BC.

TJS. 2018;34(Suppl-1):S285.

PP-0188 [Endocrine Surgery]. Robotic Adrenal Surgery: Cases of Bakırköy Dr. Sadi Konuk Training and Research Hospital

İlkay Halıcıoğlu ^1,^✉, Cevher Akarsu ¹, Ahmet Cem Dural ¹, Alper Şahbaz ¹, Sina Ferahman ¹, Pınar Karakaya ³, Halil Alış ², Mehmet Emin Güneş ¹

Objective

We aimed to share the results of robotic surgeries performed for adrenal gland diseases in our clinic over the last six years.

Material and Methods

Demographic, biochemistry, imaging, outpatient clinic, surgery and histopathology data of all cases undergoing robotic adrenalectomy between December 2011 and December 2017 were obtained from the hospital recordings and evaluated retrospectively.

Results

A total of 17 patients were included in the study. The mean age of the patients was 50 (26 – 71) years and the F/M ratio was 13/4. In the preoperative functional evaluation of detected lesions, 23.5% (n=4) were found to be non-functional. The most common (58.8%) functional mass was Subclinical or overt Cushing Syndrome (n=10). The mean preoperative tumor size was 31.7±11.3 mm. While it was switched to laparoscopic surgery in one patient (5.8%), no open surgery was performed. In one patient (5.8%), diaphragm injury developed during right adrenalectomy, and it was repaired with robotic procedure. Ten patients (58.8%) were operated with the DaVinci Si platform and 7 (41.2%) were operated with the DaVinci Xi platform. The mean clamping time was 22.7±3.9 minutes. It was observed that docking in the DaVinci Xi platform was slightly faster (p=0.4). The mean operation time from the intubation of the patient was 170.8±21.7 minutes. Histopathologic examination revealed cortical adenoma in 82.3% (n=14) of the patients. The mean hospital stay was 3.6±2.1 days. There was no mortality in our series during the post-operative 30 days and subsequent follow-ups. The average cost for robotic adrenalectomy was 3776.1±1016.2 TL and this cost was higher than the standard package amount of 2403.7 TL determined for laparoscopic adrenalectomy.

Conclusion

In our clinic, robotic surgery can be safely applied for adrenal gland pathologies, and the docking and operation time has been reduced with increasing experience. However, the high cost is still the most fundamental problem.

TJS. 2018;34(Suppl-1):S285–S286.

PP-0189 [Endocrine Surgery]. Peroperative Localization of Parathyroid Adenoma under the Guidance of Gamma Probe

Koray Baş ^1,^✉, Anıl Tükenmez ¹, Rıfat Topçuoğlu ², Hamiyet Yilmaz ³

Good localization of parathyroid adenomas, the most common cause of primary hyperparathyroidism, before surgery is very important for avoiding unnecessary dissections that increase morbidity and for implementing minimally invasive surgical principles. Although many methods have been described for this purpose, Tc-99m MIBI scintigraphy is the most commonly used imaging tool in preoperative diagnosis and localization at present. The same method can also be used to mark the adenoma area on the skin. In our report, we present a patient with parathyroid adenoma excised by minimally invasive surgery using peroperative gamma probe, who was operated after calculating the late phase washout time after Tc-99m MIBI application in the nuclear medicine unit. A 65 year-old female patient with a diagnosis of primary hyperparathyroidism was taken into operation two hours after the application of Tc-99m MIBI. After making measurements in the neck region with the gamma hand probe prepared in sterile conditions, the parathyroid gland with left inferior location was localized. Minimally invasive dissection was initiated and gamma probe was used as a navigation tool during dissection. The gland that was thought to have a parathyroid adenoma was excised where the signal was maximum, the diagnosis was confirmed by a 10-minute PTH measurement and histopathologic examination. It was observed that there was a difference of about 2.5 cm between pre-operative scintigraphy-guided skin marking performed with lead money and localizations performed with gamma probe on the surgical site. In this application, it was seen that there might be localization difference between preoperative scintigraphic marking and peroperative gamma probe marking. The difference was thought to be resulted from the difference in the degree of maximum hyperextension during scintigraphy when patient is conscious and in the position given under general anesthesia, but this angulation difference could not be quantified because an objective measurement method could not be used. Although this difference can be overlooked in parathyroidectomies with classical Kocher’s necklace incison, we believe that it will be significant for the minimization of dissection site in minimally invasive procedures and the use of gamma probe in appropriate cases will be useful in the detection of gland localization.

TJS. 2018;34(Suppl-1):S286.

PP-0190 [Endocrine Surgery]. The Comparison of Thunderbeat and Clamp-Tie Techniques in Thyroid Surgery

Barış Hazır ^1,^✉, Alp Togan Kıraç ¹, Seher Demirer ¹, Hakan Uncu ¹

Region 1: The area under the point where the inferior thyroid artery enters the thyroid and it crosses the recurrent laryngeal sinus
Region 2: The region between the area where the superior thyroid artery penetrates to the thyroid gland and the intersection of the inferior thyroid artery and recurrent laryngeal nerve, towards the back of the thyroid.
Region 3: The region covering the area from where the superior thyroid artery penetrates to the parenchyma to the posterior part of the artery towards the cranial region.

Four regions were defined with regard to the localization of lower parathyroid glands. These are;

Region 1: Including the posterolateral gland, the region between the point where the inferior thyroidal vein penetrates into the thyroid gland and the point where the inferior thyroidal artery penetrates into the gland.
Region 2:By considering the area where the inferior thyroidal vein penetrates into the thyroid gland as the beginning, the region covering 1–1,5 cm inferior of this beginning point.
Region 3: Through the thyrothymic ligament
Region 4: The area between the carotid sheath and the esophagus towards the inferior of the lower pole of the thyroid gland

Conclusion

Our 36 patients had iPTH level at normal levels on the postoperative 1st day and the removed tissues were verified with pathological findings. In 9 of our patients, persistent hyperparathyroidism developed after the first operation. The most frequent localizations were region 2 for the upper glands and region 1 for the lower parathyroid glands. Locations may be seen in ectopic localizations due to defects in parathyroid embryogenesis and developmental stages, especially in secondary hyperparathyroidism. The low success rate of preoperative imaging methods increases the knowledge of surgical anatomy by two-times.

TJS. 2018;34(Suppl-1):S288–S289.

PP-0193 [Endocrine Surgery]. Surgery of Thyroid Diseases: An Analysis of 1444 Cases from a High-Volume Center

Seymur Abdullayev ^1,^✉, Ahmet Cem Dural ¹, Cevher Akarsu ¹, Alper Şahbaz ¹, Deniz Güzey ¹, Sema Çiftçi Dogansey ¹, Halıl Alış ², Mehmet Emin Güneş ¹

Objective

In this study, it was aimed to share the results of the patients who were decided to undergo surgery for thyroid gland diseases and performed thyroid gland surgery in our clinic.

Material and Methods

Demographics data, the results of preoperative laboratory and imaging examinations, fine needle aspiration biopsy (FNAB) findings, surgical findings, complications, and histopathologic data were retrospectively evaluated in patients who underwent thyroid surgery in our hospital between January 2009 and December 2017.

Results

Of 1444 cases undergoing thyroid surgery, the median age was 47 (14–82) years, and the F/M ratio was 1164/280. The most frequent (66.7%) cases were multinodular goiter (MNG) (n=964) and 20.7% (n=200) of them were toxic MNG cases. 11.3% (n=109) of the nodules detected in ultrasonographic examination were subcentimetric. Fine needle aspiration biopsy (FNAB) was performed on 1232 patients. According to this, 122 patients were evaluated as Bethesda 6 (malignant) and 82 patients as Bethesda 5 (malignancy suspicion). All patients with Bethesda 3 to 6 were discussed at the Multidisciplinary Endocrinology Council (MEC) for the indications for surgery and for the surgery to be performed. According to years, the percentage of operations performed with malignancy pre-diagnosis increased from 2.9% to 19.6%. Bilateral total thyroidectomy was performed in 64.4% (n=931) of the operated patients. Functional lateral neck dissection was performed in 30 patients (14.7%) while ipsilateral or bilateral central neck dissection was performed in 37 (18.1%) of 204 cases operated for the pre-diagnosis of malignancy. Functional neck dissection was performed in the case of positive results of FNAB or thyroglobulin washout examinations performed on lymphadenopathy determined by ultrasonography. Intraoperative intermittent nerve monitoring was used for all of the patients who had been operated since 2013 (n=1024). While the bipolar sealing device was used for hemostasis in the operations performed until 2014 (n=558), the ultrasonic vessel closure device±ligation was used by 2014 (n=886). The rate of transient hypocalcemia was 12.1% (n=175) and the rate of permanent hypocalcemia was 1.2% (n=17). Temporary hoarseness rate was 2.2% (n=32), permanent hoarseness rate was 1.1% (n=16), and four cases required (0.2%) tracheostomy. In fourteen cases, per-operative complication developed (0,9%). Histopathological evaluation revealed papillary carcinoma in 297 patients (20.5%), of which 73 were micropapillaries. Medullary carcinoma was detected in 13 patients (0.9%) and follicular carcinoma was found in 10 patients (0.6%). Postoperative management of all cases with malignant histopathological examination was carried out by MEC.

Conclusion

The rates of case volume and oncologic surgery have increased in our clinic according to years, and management of cases with malignant pre-diagnosis is performed by a multidisciplinary team. The rates of temporary and permanent complications after surgery are similar to those in the current literature.

TJS. 2018;34(Suppl-1):S289.

Very rarely seen cystic adrenal lesions were examined with a prevalence of 1% in the large series of Song JH et al. including 1049 adrenal lesions. In the series of Cavallaro et al., which included 432 adrenalectomy cases, these lesions were reported in 21 cases, 9 of which were associated with hypertension and 7 with other endocrine diseases such as hyperthyroidism. While 11 endothelial cysts, 6 epithelial cysts, 3 pseudocysts, and 1 cystic pheochromocytoma were reported by the pathology department, no malignancy was reported. In literature, there are cases with the etiology of hydatid cyst. Despite surgical indications, symptom onset, size, and suspicion of malignancy, these lesions are often benign and dysfunctional. In the review of Neri and Nance on 515 cases, they reported the malignancy potential as 7% in adrenal cysts. Ricci et al., in their work in 2013, stated that the growth in size did not induce malignancy. In radiologic evaluation, the content, density, wall thickness, calcification pattern, and the absence of contrast enhancement are assessed. Pseudocysts are typically unilocular lesions. The treatment approach is the same with that in non-cystic adrenal masses. Although fine needle biopsy is recommended for the differentiation of malignancy, it has a risk of spreading in the presence of neoplastic cells, as mentioned for laparoscopic unroofing, in the smooth walled, homogeneous, clear cysts. Mini-invasive adrenalectomy should be preferred because of its additional advantages such as patient’s return to the normal course more comfortably, especially in the early postoperative period. While the duration of the operation was 98 min in our case, it has been reported as 92 min in the open approach and 86 min in the laparoscopic approach in various series. The open approach should be previously preferred for lesions with a risk of serious malignancy when en-bloc resection, which is the appropriate procedure, cannot be performed.

TJS. 2018;34(Suppl-1):S293–S294.

PP-0201 [Endocrine Surgery]. Synchronous Papillary and Medullary Carcinoma of the Thyroid Gland in Pregnant Patient: Case Report

Mustafa Salış ^1,^✉, Enver İhtiyar ¹, Bartu Badak ¹, Arda Şakir Yılmaz ¹, İsmihan Gülden Karataş ¹

Introduction

The mixed type carcinoma of the thyroid gland is a term used to describe tumors showing immunophenotypic and morphologic features of both papillary-medullary and follicular-medullary tumors in the same thyroid gland. Although a few cases have been reported in the literature, there are studies at the molecular level about how these tumors develop. In this study, it was aimed to present a 6-month pregnant patient with synchronous papillary and medullary thyroid carcinoma of the thyroid gland.

Case

A 33-year-old 6-month pregnant patient presented to our general surgery clinic with a complaint of swelling on her neck existing for 7 months. There was no radiation exposure history in the patient’s anamnesis. She had a history of a known venous insufficiency and a 6-month pregnancy. She had no history of a previous operation and comorbidity. In the physical examination, an immobile, rigid 3.5 × 1.5 cm mass was detected on the right side of the neck. Her thyroid gland was palpable. There were no other palpable masses. In the analysis of the laboratory parameters, routine biochemical values and complete blood count were normal. Thyroid Function Tests are euthyroid. The ultrasound examination of the thyroid revealed that the thyroid gland was larger than normal and there was a 15 mm isoechoic nodule in the left lobe, anechoic colloid cystic structures in the right lobe, and a 4 × 2.5 cm atypical lymph node at the level 5 in the right cervical region. Fine needle aspiration biopsy was performed from the nodule in the left lobe and the pathological lymph node in the right side. The pathologic result of the nodule was reported to be suspected in terms of papillary carcinoma and the lymph node was evaluated as an inadequate material. Then, considering the presence of metastatic lymph nodes in the patient, Bilateral Total Thyroidectomy + Left and Right Functional Neck Dissection was planned. After completing preoperative preparations, the operation was performed. The patient, who did not have any problems in the postoperative follow-ups, was discharged with recovery after replacing the thyroid hormone.

In the postoperative pathological result, it was reported that the tumor in the right lobe was found to be consistent with medullary carcinoma and the tumor in the left lobe was consistent with follicular variant papillary carcinoma. The metastatic lymph nodes in the left lobe were detected to be medullary carcinoma metastases.

Conclusion

Although the presence of synchronous or metachronous tumors is an accepted condition in the thyroid gland, approximately 50 cases have been reported in the literature. However, some authors reported an incidence of 19% between papillary microcarcinoma and medullary thyroid carcinoma. In a study by Machens et al., it was found that 26 of 727 patients with thyroid medullary carcinoma had synchronous thyroid papillary carcinoma, and medullary carcinoma was hereditary in 6 of them and sporadic in 20 of them. In our case, the medullary carcinoma was decided to be sporadic based on the result of familial scanning. In these cases, the treatment approach is based on papillary thyroid cancer. In our study, the presence of pregnancy and the metastasis of medullary carcinoma to the other lobe are the distinguishing features of our case.

TJS. 2018;34(Suppl-1):S294.

PP-0202 [Endocrine Surgery]. The Effect of BRAF Gene Mutation on Regional Lymph Node Involvement in Patients with Papillary Thyroid Cancer

Samet Şahin ^1,^✉, Gül Dağlar ¹, Büşranur Çavdarlı ², Ebru Menekşe ¹, Tolga Bağlan ³, Vehap Topçu ²

The most common type of thyroid cancer, papillary thyroid carcinoma (PTC), accounts for 80% of all thyroid cancers. It is one of the most common cancers in the world with 20,000 new cases per year. It is the most frequently encountered cancer among young women under the age of 25 years, with eighth place among the most common types of cancer in the world. At diagnosis, lymph node metastasis is found in 20% of patients, but distant metastases (lung or bone metastases) are rarely encountered. Although many risk factors related to PTC have been described, most of the patients do not have any risk factors in their medical histories at the diagnosis process.

Although the BRAF V600E gene mutation is confronted as the most common gene mutation in PTC, the effect of this mutation on the development of PTC-related mortality and lymph node metastasis has not been clearly demonstrated. Therefore, we aimed to investigate the relationship between BRAF V600E gene mutation and demographic, tumoral and clinicopathological findings in patients with PTC and to evaluate the effect of BRAF V600E gene mutation on regional lymph node involvement in our study.

The BRAF V600E gene mutation analyses of 63 patients (45 female and 20 male) with the diagnosis of PTC between January 2013 and January 2017 was retrospectively performed with PCR. The relationship between the demographic, tumoral and clinicopathologic data of the patients and the BRAF V600E gene mutation was revealed through both univariate and multivariate analyses.

The BRAF V600E gene mutation positivity was detected in 31.7% of the whole patient group. The rate of positive gene mutation was 36% in classical PTC and 100% in TCV-PTC. In the univariate analysis, tumor diameter (p: 0.015), capsule invasion (p: 0.021) and regional lymph node metastasis (p: 0.001) were found to be associated with BRAF V600E gene mutation. In the multivariate analysis, BRAF V600E gene mutation was shown to be an independent risk factor for regional lymph node metastasis. However, no relationship was found between the BRAF V600E gene mutation and regional lymph node metastasis in papillary microcarcinomas (p=0,999).

In conclusion, BRAF V600E gene mutation was found to be associated with the aggressive course of tumor, especially in macro-PTCs, and with regional lymph node metastasis. The appropriate surgical treatment for thyroid cancer, adjuvant treatment, and patient follow-up are still controversial. As seen in the BRAF V600E gene mutation, which was firstly defined in PTC and found to have effect on tumor aggressiveness and regional lymph node involvement, technological advances in molecular biology of thyroid cancer are helpful in eliciting tumor aggressiveness in PTCs.

TJS. 2018;34(Suppl-1):S294–S295.

PP-0203 [Endocrine Surgery]. 598 Parathyroidectomy Cases: A Single Center

Ali İbrahim Sevinç ¹, Süleyman Özkan Aksoy ^1,^✉, Merih Güray Durak ², Mehmet Ali Koçdor ¹, Mehmet Serdar Saydam ¹

Objective

Parathyroid glands were first described by Sir Richard Owen in 1850 with an autopsy performed in an Indian rhino. Hyperparathyroidism, which was considered to be a rare disease presenting with severe skeletal-muscle and renal system complications at the beginning of this century, has been demonstrated to be an illness not as rare as thought as a result of the improvements in radiology, nuclear medicine and biochemical screening tests.

Material and Methods

In the Department of General Surgery at Dokuz Eylül University Medical Faculty, 598 patients with hyperparathyroidism were operated between January 1988 and 2018. These patients were retrospectively evaluated with regard to the establishment of the diagnosis, detection of lesion location, selection of the type of surgery, and approach to postoperative follow-up. Thyroid surgery was performed simultaneously with parathyroid surgery in 255 patients (37.6%) who had multinodular goiter.

A 55 - year - old female patient was admitted to the outpatient clinic of general surgery due to the complaint of palpable swelling on her neck. She had no complaints other than swelling on her neck. In the physical examination, there was a 2.5 cm nodule on the left. Her laboratory values were found to be normal. The neck ultrasonography revealed hypoechoic multiple nodules, the largest of which was 29 mm in the left side and 9 mm in the right side and there was no lymph node. Total thyroidectomy was recommended to the patient as a result of the examinations performed. In the operation, routine nerve dissection was performed for both sides. On the left side, recurrent laryngeal nerve (RLN) was found. However, there was no evidence of a nerve in the dissection performed near the inferior thyroid artery (ITA) on the right side. When the dissection was extended, NRLN extending from the carotid sheath to the Berry ligament was detected. The dissection was carefully continued and the nerve was completely isolated and preserved. The patient did not have Zuckerkandl’s tubercle. On the first postoperative day, the patient was discharged without any complication. The pathological evaluation was reported as multinodular goiter.

Conclusion

Nerve injury can result from the presence of anatomical variations and the inconstant pathway of the recurrent laryngeal nerve (RLN) a constant pathway as well as the surgeon’s inexperience, incorrect dissection, used surgical instruments, and adhesions due to surgical surgery in the surgical lodge. The most effective method for the recognition of this variation is to perform appropriate nerve dissection intraoperatively. The majority of nerve injuries are at the entrance of the nerve to the larynx. For this reason, the nerve dissection should be performed from the bottom to the top. Generally, the nerve is searched at the point where it first crosses with the ITA. If not present here, the dissection is advanced upwards and the nerve is revealed by continuing careful dissection around the Berry ligament and the entrance of the nerve to the larynx. In some cases, NRLN may not be found with standard nerve dissection. In such a case, NRLS can be found with careful dissection starting from the carotid sheath to the medial part. It has been reported that the use of intraoperative nerve monitoring facilitates the detection of NRLN and reduces the rate of nerve damage. However, it is not routinely used due to cost problems, although its use is increasingly becoming widespread.

No anatomic model should be evaluated in a standard way during thyroid surgery and the nerves, veins, and their anatomical variations that affect their placement with respect to each other should be known. It should not be forgotten that being aware of these anatomical variations is vital for patient.

TJS. 2018;34(Suppl-1):S298–S299.

PP-0210 [Endocrine Surgery]. Do the Sizes of Thyroid Nodules Reported as Bethesda Category 3, 4, and 5 Affect Malignancy Rates?

Ahmet Karayiğit ^1,^✉, Niyazi Karaman ¹, Kaptan Gülben ¹, Ali Uğur Berberoğlu ¹

Objective

Fine Needle Aspiration Cytology (FNAC) is an important and widely accepted method used for the diagnosis of patients with thyroid nodules. The procedure is simple, safe for patient, and low-cost. For the FNAC to be used with higher sensitivity and accuracy, the US National Cancer Institute established the “Bethesda System for Reporting of Thyroid Cytopathology” in 2007. The validity of this new reporting system has been demonstrated by many researchers.

Material and Methods

In this study, in patients with FNAC results of Bethesda Category 3 (AUS: atypia of undetermined significance, AFLUS: follicular lesion of undetermined significance), Bethesda Category 4 (SFN: suspicious for a follicular neoplasm, HCN: suspicious for Hurthle cell neoplasm) and Bethesda Category 5 (SM: suspicious for malignancy), the actual malignancy rates and patient age, gender and radiological diameter that could affect them were investigated. The records of 239 patients whose thyroid nodules were examined through FNAC according to their clinical and radiological findings in our hospital between 2013 and 2017 were retrospectively reviewed.

Results

The mean age of the patients included in the study was 49 (21–77) years and 205 (86%) of them were female. In this series, the mean size of the nodule was 15 mm (2–65) and it was determined that 66 nodules (28%) were 20 mm and larger. Total thyroidectomy was performed in 224 patients (94%). In the Bethesda Category 3, 69 nodules (29%) were reported as AUS, and 4 nodules (2%) as AFLUS. In the Bethesda Category 4, 35 nodules (15%) were reported as SFN and 21 nodules (9%) as HCN. In the Bethesda Category 5, 110 nodules (46%) were reported. The mean tumor sizes in these groups were 18, 9, 17, and 12 mm, respectively. Malignancy was detected in 173 patients (72%) in the whole series. Of these, 146 were papillary carcinoma (61%), 24 were micropapillary carcinoma (10%), two were medullary carcinoma (1%), and one was follicular carcinoma. The cancer rate in the Bethesda Category 3 was 56.5% and 100% for AUS and AFLUS, respectively, which are higher than the expected rates of 5–15%. In the Bethesda Category 4, the cancer rates for SFN and HCN were 71% and 48%, respectively, which is higher than the expected rates of 15–30%. In the Bethesda Category 5, the cancer rate was detected to be 86%, which is also higher than the expected rates of 60–75%. It was observed that age (1–50 vs >50), sex, and radiological diameter (0–15 vs. 15–100 mm and 0–19 and >20 mm) had no effect on the prediction of malignancy in univariate and multivariate analyses.

Conclusion

In this study, the malignancy rates in the Bethesda Category 3, 4, and 5 lesions were found to be higher than the expected rates in the literature, independent of nodule size. These results might have been due to the timid behaviors of pathologists for diagnosing cancer with cytological findings and reporting not performed by a single hand. All clinics using the Bethesda reporting system should know their own malignancy rates and establish appropriate clinical approaches.

TJS. 2018;34(Suppl-1):S299.

PP-0211 [Endocrine Surgery]. An Alternative Approach to Parathyroid Adenoma Treatment: Radiofrequency Ablation

Tuğrul Kesicioğlu ^1,^✉, İsmail Aydın ¹, Selahattin Vural ¹, Mert Güngör ¹, Tuncer Öztürk ¹, İlker Şengül ¹, Zafer Ünsal Coşkun ²

Objective

Parathyroid adenoma is the major cause of primary hyperparathyroidism (80–85%). Today, its main treatment is surgery. However, it has some limiting factors such as conditions with high surgical risk, the appearance of the scar tissue on the neck after the procedure, and the difficulty in the localization of adenoma during surgery. Moreover, in those having previously undergone a surgery on the neck region, the re-operation of this region is also a limitation. The use of minimally invasive thermal ablative technology, which has been developed in recent years, under the guidance of ultrasound has led to a new approach.

Material and Methods

The findings of 5 patients diagnosed with parathyroid adenoma in our clinic in 2017 were retrospectively evaluated.

Patients’ Ca and PTH levels before and after the RFA procedure were evaluated. In the first patient, pre-RFA value of Ca was 11,8 and PTH was 140 and post- RFA value of Ca: was 9.2 and PTH was 42. In the second patient, pre-RFA value of Ca was 12 and PTH was117 and post-RFA value of Ca was 10.7 and PTH was 67. In the third patient, pre- RFA value of Ca was 11.38 and PTH was 104.7 and post-RFA value of Ca was 8.93 and PTH was 29.31. In the fourth patient, pre-RFA value of Ca was 10.8 and PTH was 385 and post-RFA value of Ca was 9.8 and PTH was 9.87. In the fifth patient, pre-RFA value of Ca was 11.4 and PTH was 230 and post-RFA value of Ca was 10.8 and PTH was 148.6.

Results

RFA has been successfully used in the treatment of primary and secondary tumors in the thyroid, lung, and liver for a long time. The RF ablation method is successfully used in parathyroid adenomas under the guidance of the high resolution of ultrasound. The RF ablation denaturalizes the functioning parathyroid tissue thermally. It creates this thermal effect through the friction effect associated with the oscillation of the ionic medium in the tissue in the direction of the frequency of the radio waves coming from the antenna. In a live tissue, 55–60 C of heat is required for a permanent thermal lethal effect. All of our patients first applied with high PTH value. Adenoma was diagnosed by 99m Tc MIBI scintigraphy and characteristic ultrasonographic findings. The patients were treated with sedation after the necessary anesthesia consultations. The RF antenna placed in the adenoma under ultrasound guidance was ablated with energy level and duration adjusted according to the adenoma size, by observing in real time under ultrasound. It has gradually decreased after the procedure.

Conclusion

RFA is an ambulatory procedure that can be an effective alternative to surgery in parathyroid adenomas. Its morbidity is low. However, it is necessary to pay careful attention to recurrent laryngeal nerve injuries during the procedure.

TJS. 2018;34(Suppl-1):S299–S300.

PP-0212 [Endocrine Surgery]. A Rare Adrenal Mass in an Adult Patient: Ganglioneuroma

Mehmet Arif Usta ¹, Mehmet Uluşahin ^1,^✉, Arif Burak Çekiç ¹, Reyyan Yıldırım ¹, Serdar Türkyılmaz ¹

Introduction

Ganglioneuroma is a rare tumor of the surrenal gland. It originates from the neural crest cells. In this article, a case pathologically reported as mature ganglioneuroma after laparoscopic left surrenalectomy will be presented.

Case

A 57-year-old female patient, who was performed the abdominal magnetic resonance imaging (MRI) due to another reason at an external center a few months ago and detected to have an approximately 7×5 cm mass lesion with heterogeneous contrast enhancement in the left adrenal, was admitted to the outpatient clinic of endocrinology in our hospital. The patient had no active complaints. She had a history of hysterectomy due to uterus myoma. No pathological findings were found in the blood and hormone tests performed by the department of endocrinology. The abdominal computed tomography (CT) of the patient showed a 7×5 cm mass and it was reported to be possible non-adenoma mass lesion or adenoma with poor fat. The patient was recommended to undergo an operation by the endocrinology council. The operation was laparoscopically performed by using two 10 and one 5 trocars in the right lateral decubitus position. The left surrenal adenoma and gland were found without any complications and they were totally excised after the vessels were clipped. In the postoperative period, the patient had no problems and she was discharged on the 4th day. The pathological result was reported as 7×5×4 cm mature ganglioneuroma. Endocrinology outpatient clinic controls continued without any adverse events.

Conclusion

Ganglioneuroma is a rare tumor of the surrenal gland which is usually asymptomatic and not functioning hormonally. These tumors are among the benign tumor of the sympathetic nervous system and they can be encountered in any region where the sympathetic nerves are present. They are most commonly seen in the mediastinum and retroperitoneum. They usually grow slower. They are reported to be seen more frequently in women and in those at the ages under 20s. They are usually asymptomatic and incidentally encountered. In large-sized ones, various symptoms related to the pressure may occur. A small portion of them may be hormonally active and may cause symptoms such as hypertension, sweating, and virilisation due to secreted hormones such as catecholamines and androgens. Although the mass can be viewed by imaging methods such as CT and MRI, it is not possible to differentiate it from other surrenal masses. The definite diagnosis can only be made by pathological examination after surrenalectomy. While only ganglioneuroma existis in the mature form, neuroblastoma and ganglioneuroblastoma components can be observed in the mature form. From this respect, the pathological examination needs to be done carefully. Excision is an option of curative treatment. Recurrence is not expected. Although these tumors are considered as benign, there are some studies reporting that they can lead to lymph node metastasis.

Ganglioneuroma is a rare lesion of the surrenal gland. In surrenal-associated masses, it should be remembered in the preliminary diagnoses. The final diagnosis is established by pathological examination after surgery.

TJS. 2018;34(Suppl-1):S300–S301.

PP-0213 [Endocrine Surgery]. Parathyroid Adenoma: Our Single-Center Experience on 57 Cases

Kaptan Gülben ¹, Ahmet Karayiğit ^1,^✉, Uğur Berberoğlu ¹

Objective

To retrospectively evaluate the data of 57 patients who were operated due to primary hyperparathyroidism (PHPT) and histopathologically diagnosed with parathyroid adenoma (PTA).

Material and Methods

The data obtained from hospital records of 57 patients who underwent surgery for PHPT in our surgical clinic between January 2010 and December 2015 and diagnosed with PTA were retrospectively evaluated in terms of the demographic, histopathologic and biochemical.

Results

The median age of the patients was 54 (17–77) years, and 48 were female (84%) and 9 were male (16%). The median follow-up was 28 months. The most common complaints were bone and joint aches, weakness, and fatigue. Preoperative parathormone (PTH) and calcium levels of all patients were evaluated. Preoperative hypercalcemia was detected in 47 (82%) of the patients. The median preoperative serum PTH level was 287±348 ng/L and calcium level was 11.5±1.4 mg/dL. As preoperative imaging methods, neck ultrasonography (US) was performed in 15 patients (26%), neck US and 99mTc-MIBI in 38 patients (67%), and other methods in the remaining 4 patients (7%). Thirty-nine patients (68%) were applied unilateral and 18 patients (32%) were applied bilateral neck exploration. The number of patients who also underwent thyroid surgery was 16 (28%). 51 (89.5%) of the patients had single adenomas, 5 (8.7%) had two adenomas and 1 (1.8%) had 3 adenomas. Of the lesions, 16 (28%) were located in the upper pole of the thyroid, 38 (67%) in the lower pole, and 3 (5%) in the other localizations. The mean size of the removed adenoma was 1.9±0.9 cm. The mean postoperative serum PTH level was 49±52 ng/L and calcium level was 8,6±0,8 mg/ dL. Persistent hypercalcemia was detected in one patient (1.7%) and recurrence in another patient, and subjective complaints continued in 3 patients (5%).

Conclusion

The cause of PHPT is single adenoma at the rate of 80–85%, hyperplasia at the rate of 10–15%, multiple adenomas at the rate of 3%, and parathyroid carcinoma at the rate of 1%. Only patients who were diagnosed with PTA were included and examined in this study. In the vast majority of patients, a single adenoma was present and the rate of multiple adenomas was detected as 10.5%. Two thirds of the patients had adenomas located in the lower pole of the thyroid. These ratios were found to be consistent with the literature. The most common complaints in PHPT patients are bone and joint pains. PTA should be kept in mind in patients with nonspecific bone and joint pains with unknown etiology because the PHPT picture caused by PTA is a highly curative disease with surgical treatment.

TJS. 2018;34(Suppl-1):S301.

PP-0214 [Endocrine Surgery]. Assessment of Thyroid Cancer Frequency in Graves’ Disease

Hakan Yabanoğlu ¹, İlker Murat Arer ¹, Nazım Emrah Koçer ², Abdirahman Sakulen Hargura ^1,^✉, Tevfik Avcı ³

Objective

Graves’ disease is the most common cause of hyperthyroidism. Thyroid cancers are the most common cancers of the endocrine system. Although Graves’ disease and thyroid cancers are frequently encountered diseases, the coexistence of both diseases is a rare case, which suggests that hyperthyroidism has a protective effect against thyroid cancer. In this study, we aimed to determine the incidence of thyroid cancer in patients performed thyroidectomy due to Graves’ disease.

Material and Methods

The files of 210 patients who underwent thyroidectomy for Graves’ disease between 2009 and 2018 were retrospectively reviewed. Of them, 38 patients performed thyroidectomy for Graves’ disease and pathologically diagnosed with thyroid cancer were evaluated in terms of their demographic and clinical characteristics. Thyroidectomy was decided to be performed in patients followed for Graves’ disease, who did not respond to drug treatment, had side effects related to drug treatment, had malignancy findings in fine needle aspiration biopsy, and were not eligible for radioactive iodine therapy (RAI). The patients with non-Graves’ disease and having toxic nodular and multinodular goiter causing hyperthyroidism were excluded from the study.

Results

Of the patients, 25 (65.8%) were female and 13 (34.2%) were male, and the mean age was 40 (17–68) years. Twenty-five (11.9%) patients had a familial history of Graves’ disease. Ultrasonographic examination revealed nodules in the thyroid gland in 22 patients. Fine needle aspiration biopsy (FNAB) was performed in ten (26.3%) patients. Of the patients, 7 (18%) had benign suspect, 2 (5.3%) had malignancy suspect, and 1 (2.6%) had papillary neoplasia. Pathologic examinations of the patients undergoing thyroidectomy revealed thyroid cancer in 38 (18%) patients. Micropapillary lesions were found in 24 (63.2%) patients, papillary carcinoma in 10 (26.3%) patients, papillary and micropapillary carcinoma in 2 (5.3%) patients, medullary carcinoma in 1 (2.6%) patient, and follicular and micropapillary carcinoma in 1 (2.6%) patient. The most common complication after thyroidectomy was hypocalcemia in 11 (28.9%) patients. One patient underwent neck dissection after thyroidectomy. Twelve patients were applied RAI therapy. The mean follow-up period of the patients was 30 (3–108) months. In the follow-ups, 2 (5.2%) patients had papillary cancer recurrence in the thyroidectomy lodge in the 12th and 18th months. The RAI treatment was applied to both patients. No recurrence was observed in the follow-ups. In the postoperative follow-ups of one patient with the diagnosis of medullary thyroid cancer, the level of calcitonin was low and no pathology was observed in the neck USG. Therefore, no additional central and lateral neck dissection was performed. No recurrence developed in the 23-month follow-up of this patient.

Conclusion

Although the coexistence of Graves’ disease and thyroid cancer is rare, FNAB should definitely be performed particularly in patients followed for Graves’ disease and detected to have nodule in USG. Surgical treatment option should be primarily considered in Graves’ disease patients with nodule in the thyroid gland.

TJS. 2018;34(Suppl-1):S301–S302.

PP-0215 [Endocrine Surgery]. Adrenal Cystic Lymphangioma: Two Case Reports

Hakan Yabanoğlu ^1,^✉

Introduction

Cystic lymphangioma is an extremely rare lesion originating from lymphatic endothelial cells. Anatomically, these lesions are often seen in the axilla and neck region, but 5% of them are encountered in the intraabdominal region. We aimed to present 2 cases of adrenal cystic lymphangioma, which is extremely rare and therefore present as case reports in the literature.

Case 1

A 19-year-old female patient was performed ultrasonography due to loss of appetite and right side pain. The ultrasonography revealed an 8x6 cm thick-walled cystic lesion in the liver segment 6 localization and the patient was referred to our center with the pre-diagnosis of a hydatid cyst of the liver. No abnormal feature was observed in the physical examination and laboratory tests performed at admission. Oral and iv opaque computerized tomography revealed a 59x99 mm, slightly lobulated-contoured pure cystic lesion with the localization of right surrenal gland and with the wall including small septation and millimetric calcification. The patient was operated with the pre-diagnosis of adrenal cyst hydatid and simple adrenal cystic lesion. At the exploration, a well-demarcated cystic lesion with the right adrenal origin was detected and removed. On the same day after the surgery, oral feeding was started and the patient was discharged on the postoperative 2nd day. A week later, she was evaluated for control and no problem was observed. The pathological result was reported as right adrenal-derived cystic lymphangioma. No recurrence was observed during the 27-month follow-up of the patient.

Case 2

A 28-year-old male patient was found to have a 20x18 cm mass in the intraabdominal region in the lumbar MR performed due to backache. In the whole abdominal MR carried out for the investigation of the etiology of intraabdominal mass, a cystic mass thought to be mesenteric origin was observed. No abnormal feature was detected in the physical examination and laboratory tests of the patient who was referred to our hospital with these findings. The patient was taken into operation with the pre-diagnosis of mesenteric cystic mass. The examination demonstrated a giant cystic mass, which pushed the transverse colon completely filling the midline of the abdomen to the lower quadrant of the abdomen and pulled up the right kidney and adrenal gland, which it originated from, to the right upper quadrant of the abdomen. During the dissection, the cyst was opened and aspirated. Samples for cytology were taken from the fluid. Cystic lesion was removed with right adrenal gland. Oral feeding was started on the first postoperative day and the patient was discharged on the postoperative third day. A week later, the patient was evaluated for control and no problem was observed. Pathological result was reported as right adrenal-derived cystic lymphangioma. No recurrence developed in the 18-month follow-up of the patient.

Conclusion

tal excision should be performed on adrenal cystic lymphangiomas which do not have a common diagnosis and treatment algorithm because they are available as case reports in the literature. In the cases undergoing total excision, recurrence is not observed in long term follow ups. Surgery is the sufficient and effective treatment method.

TJS. 2018;34(Suppl-1):S302.

PP-0216 [Endocrine Surgery]. The Effects of Genetic Factors on the Clinical Course and Prognosis of Papillary Thyroid Cancer

Mesut Gündüz ¹, Yavuz Poyrazoğlu ^2,^✉, İsmail Yılmaz ³, Zafer Küçükodacı ³, Yavuz Kurt ², Bülent Güleç ²

Objective

The aim of this study was to investigate the effects of BRAF, RAS, and TERT gene mutations and c-Met gene overproduction, which are thought to be associated with recurrence and metastasis, on the clinical course and prognosis of papillary thyroid cancer.

Material and Methods

In the tissue blocks of 84 patients with papillary thyroid carcinoma between 2005 and 2015, the c-Met gene amplification was investigated with the FISH method, and BRAF, RAS and TERT gene mutations were investigated with the PCR-Based Direct Sequencing Method. The findings were compared with clinicopathological features such as age, gender, histological type, tumor size, type of invasion, multicentrism, extrathyroidal spread, presence of metastatic lymph nodes and recurrence. Statistical analysis was performed by using the SPSS software. The categorical data were compared with the Chi-Square and Fisher’s exact tests. The factors influencing disease-free survival were evaluated by using the Multivariate Analysis and Cox Regression analysis. The value of p<0.05 was considered to be statistical significant.

Results

The BRAF mutation was found to be positive in 80.4% of 56 classic variant cases, which was statistically significant (p=0,001). The TERT mutation was found to be associated with advanced age (p=0,033) capsule invasion (p=0,004), lymphatic invasion (p=0,012) and increased recurrence rates (p=0.041), high MACIS score (p=0.001), and disease-free survival (p=0.004). There was no correlation between clinicopathologic features and c-Met gene amplification and RAS mutation (p>0.05).

Conclusion

t was evaluated that, in papillary thyroid cancer, classical variant cases frequently display BRAF mutation and those with TERT gene mutation should be followed for risk of recurrence.

TJS. 2018;34(Suppl-1):S303.

PP-0217 [Endocrine Surgery]. Our Experience of Thyroidectomy and Parathyroidectomy (TOETVA/TOEPVA) with Transoral Endoscopic Vestibular Approach

Koray Baş ^1,^✉, Değercan Yeşilyurt ¹, Hakan Öğücü ¹, Gizem Kılınç ¹

Thyroid and parathyroid surgery with the transoral endoscopic vestibular approach (TOETVA/TOEPVA: Transoral endoscopic thyroidectomy/parathyroidectomy vestibular approach), has become increasingly widespread as a new surgical method that is promising for its long-term outcomes, which has been demonstrated to be safe and effective and offers almost excellent cosmetic results without suture marks by providing a chance of natural access (NOTES: Natural orifice transluminal endoscopic surgery) among the minimally invasive neck surgery techniques described up to now. In this study, we aimed to present our experience of thyroid and parathyroid surgery with a transoral endoscopic vestibular approach that we applied. The first TOETVA surgery was practiced on August 23, 2017, and so far, we have had 3 TOETVA (1 total thyroidectomy, 2 lobectomies) and 3 TOEPVA experience. In two of them (one was total thyroidectomy and the other was parathyroidectomy), the operations were completed by conversion to open surgery. The reason for conversion to open surgery was severe adhesion in the total thyroidectomy case and the development of hypotension and bradycardia, which occurred at the beginning of surgery and were reported as vasovagal reflex by the anesthesiologists, in the parathyroidectomy case. After informing the patients, they were administered oral care before surgery, chlorhexidine solution was used for intraoral cleaning, and appropriate antibiotic prophylaxis was applied for oral flora. After nasotracheal intubation with a suitable intubation tube for nerve monitoring, the classical neck surgery position and hyperextension were provided. The head region of the patient, which was the operation site, was covered with a sterile material. The oral vestibular area was entered with a 10mm camera port in the middle and two operative ports of 5 mm in both lateral areas and the subplatysmal region was insufflated. The maximum CO2 insufflation pressure was adjusted as maximum of 6 mmHg. In the anterior neck region, the subplatysmal area was dissected until the sternal notch below and the sternocleidomastoid muscles in the lateral parts. The strap muscles were opened at midline with a power device and hanged on the front wall of the neck with percutaneous hanging sutures to provide better vision. For thyroid lobectomy cases, lobectomies were completed by starting with isthmectomy and progressing from the cranial to the caudal and from the medial to the lateral areas. For vascular checking, energy device was used. For monitoring recurrent laryngeal nerve, monopolar nerve stimulation probe, which was modified and extended for endoscopic surgery, was used. The resected material was expanded according to the specimen size, if necessary, and removed from the 10 mm port site. No drain was used in any case. The port sites were closed with absorbable sutures. In the postoperative period, the patients did not have any events and they were given oral amoxicillinclavulanic acid antibiotherapy and antiseptic oral rinse solution for 5 days. Except the temporary hoarseness in the first thyroid lobectomy case, the only early morbidity was mild and moderate ecchymosis in the traces of the port sites. However, all disappeared in a week at the latest. No mental nerve damage was observed. In the follow-ups of the patients, it was observed that their treatment satisfaction with this technique was at a high level.

TJS. 2018;34(Suppl-1):S303–S304.

In the etiology of cystic masses in the neck, metastases of many tumors, mainly gastrointestinal system, and primary tumors of that region (sarcoma, lymphoma) are included in addition to benign diseases such as branchial cysts and dermoid cysts. Occult thyroid cancers should also be considered in the differential diagnosis and should be investigated in detail to avoid from time loss and multiple surgeries. Its treatment includes surgery, radioactive iodine therapy, and close follow-up.

TJS. 2018;34(Suppl-1):S305–S306.

PP-0221 [Endocrine Surgery]. Adrenal Giant Pheochromastoma: Laparoscopic Adrenalectomy

TJS. 2018;34(Suppl-1):S308–S309.

PP-0226 [Endocrine Surgery]. Examination of Paraganglioma Case Seen After Papillary Thyroid Carcinoma with Video

Bahadır Kartal ^1,^✉, Nuri Alper Şahbaz ¹, Ahmet Cem Dural ¹, Yasemin Akdeniz ², Serdar Altınay ³, Kemal Tekeşin ⁴, Mehmet Emin Güneş ¹

Introduction

It was aimed to present the detection of paraganglioma at the level of aortic bifurcation in the follow-ups of a patient who had been operated for papillary thyroid cancer previously in our clinic and its laparoscopic excision with video images.

Case

We wanted to demonstrate in the video record that an approximately 5 cm paraganglioma at the level of the aortic bifurcation on the iliac veins can safely be removed with laparoscopic approach. We also aimed to demonstrate that, in these types of masses located on important structures, the problems that could develop in association with dissection difficulty due to adhesions in that region and manipulation especially in functional masses could be overcome in experienced centers and we wanted to share our experience in our clinic. In the video, dissection technique, strategies for coping with dissection difficulty, and the strategies that could be applied when complications such as bleeding occurred were presented.

Conclusion

The coexistence of paraganglioma and papillary thyroid cancer is rarely reported in the literature. It is difficult to determine whether this coexistence is incidental or genetic predisposition, and it is specified to be associated with many different mechanisms. As in our case, laparoscopic approach is suitable in rare cases of neurogenic tumors and it is preferable method due to its shorter duration of hospitalization.

TJS. 2018;34(Suppl-1):S309.

PP-0227 [Endocrine Surgery]. Use of Plasmapheresis for Preoperative Preparation of Patients with Thyreotoxicosis

Azer Farahim Hümmetov ¹, Abbas Hüseyn Abbasov ¹, Ağa Mirli İsmayiılov ^2,^✉, Süreddin Musa Zeynalov ¹

Objective

The accurate choice of treatment for diffuse toxic goiter is one of the actual problems of clinical endocrinology. In thyreostatic treatment, 20% of patients cannot tolerate the therapy or have drug resistance and 47% have recurrence. The most radical treatment is surgery, which leads to healing in 80–90% of the cases. The results of surgical treatment mostly depend on the quality of preoperative preparation. For all patients, preoperative preparation is essential for reducing the possibility of intraoperative and postoperative serious complications. One role of preoperative preparation is to provide euthyroidism. In preoperative preparation methods, euthyroidism is temporary, generally ineffective. Plasmapheresis is recommended for increasing the quality of drug therapy and preoperative preparation. In this study, it was aimed to determine the effect of plasmapheresis on reducing the time of preoperative preparation.

Material and Methods

Eleven patients operated for toxic goiter in our clinic between February 2017 and December 2017 were retrospectively evaluated. The values of Serum TSH, free T4, and free T3 were analyzed before and after plasmapheresis. In the study, discontinuous plasmapheresis was used. Plasmapheresis was performed with the “Haemonetics” PCS2 device, with LN625 B/1 m NAll program. The procedure was performed twice at 3-day interval.

Eritromat in the extract and centrifuged serum were separated. The form elements were mixed with 50–80 ml solution. The amount of blood in total time was 1980 ml, the amount of serum in each session was 652 ml, and the duration of the procedure was 88 minutes. After the completion of the procedure, IV Ringer 500 ml and 4 mg dexamethasone were administered.

Results

Of the patients, 9 were female and 2 were male. Their mean age was 28,34±16.63 years. The patients were divided into two groups: those given preoperative thyreostatics (6 patients) and those applied both thyreostatics and plasmapheresis (5 patients). Plasmapheresis is well-tolerated by the patients and it does not have serious complications. In Graves patients, plasmapheresis allows to reduce the signs of hyperthroidism in the preoperative preparation and it is more effective in improving thyroid dysfunction. The duration of preoperative preparation was shorter in Group 2 than in Group 1 (15,4±3,4 days). And, the side effects of thyreostatic drugs did not develop and serious postoperative complications did not occur. Plasmapheresis decreases the time of preoperative preparation by 1,5-2 times in DTG patients and postoperative complications including thyroid crisis. It is not against the other complex therapy methods.

Conclusion

We think that plasmapheresis can be applied successfully in the preoperative period for diffuse toxic goiter particularly in selected patients.

TJS. 2018;34(Suppl-1):S310.

PP-0228 [Endocrine Surgery]. Does the Risk of Hypocalcemia Increase in Complementary Thyroidectomy Performed for Papillary Thyroid Cancer?

Mahmut Kaan Demircioğlu ^1,^✉, Mehmet Taner Ünlü ¹, Zeynep Gül Demircioğlu ¹, Ozan Çalışkan ¹, Mert Tanal ¹, Sıtkı Gürkan Yetkin ¹, Mehmet Mihmanlı ¹, Mehmet Uludağ ¹

Objective

Thyroid nodules rarely have thyroid malignancy in the pathologic examination, and complementary thyroidectomy may be required for the opposite lobe after lobectomy for the cytologic results in the categorical group that does not have a definite diagnosis in preoperative fine needle aspiration biopsy. Hypocalcemia is the most common complication after thyroidectomy. Whether complementary thyroidectomy increases the risk of developing hypocalcemia compared to total thyroidectomy remains controversial. In this study, we aimed to evaluate whether the application of complementary thyroidectomy with the diagnosis of papillary thyroid carcinoma (PTC) increases the risk of hypocalcemia compared to total thyroidectomy.

Material and Methods

The data of patients who were diagnosed with papillary thyroid carcinoma (PTC) preoperatively or postoperatively and operated between 2014 and 2017 were retrospectively evaluated and 2 patient groups were formed. After performing lobectomy in the first surgery, 19 patients who were found to have PTC in the pathological examination and were performed complementary thyroidectomy on the opposite lobe were included in Group 1. Of the patients who underwent total thyroidectomy with preoperative diagnosis at the same period, 53 patients with similar characteristics to Group 1 in terms of age and gender were selected for Group 2. Biochemical parameters related to calcium metabolism in preoperative and postoperative period, parathyroid autotransplantation and involuntary removal of the parathyroid gland, postoperative hypocalcemia and treatment rates were compared between the two groups.

Results

Group 1 and Group 2 included 19 patients (13K, 6E) with the mean age of 48.3+12.1 years and 53 patients (40K, 13E) with the mean age of 46.3+9 years, respectively. There was no significant difference between the groups in terms of age and gender. No significant difference was found in terms of preoperative parathormone (PTH), phosphorus (P), magnesium (Mg), alkaline phosphatase (ALP), vitamin D deficiency ratio, parathyroid autotransplantation and the presence of parathyroid gland in thyroid specimen. Preoperative calcium (Ca) value was 9.33+0.46 in Group 1, which was lower than in Group 2 (9.65+0.41) (p=0.012). There was no significant difference between the values of postoperative 0th day Ca, P, Mg, PTH and postoperative 1st day Ca, P, Mg, PTH. The postoperative 1st day P level was significantly lower in Group 1 (2.86+0.72) than in Group 2 (3.6+0.83). The rates of postoperative hypocalcemia were 21.1% and 30.2% in Group 1 and 2, respectively, and the difference was not statistically significant (p=0.558). Hypocalcemia was temporary in both groups and no permanent hypoparathyroidism was detected. Postoperative Ca and sometimes active vitamin D application rates were 10.5% in group 1 and 22.6% in group 2 and there was no significant difference between the groups in terms of getting treatment (p=0.327).

Conclusion

Complementary thyroidectomy does not increase the risk of hypocalcemia compared to total thyroidectomy. Complementary thyroidectomy can also be performed with similar complication rates to total thyroidectomy. Postoperative follow-up and treatments of these patients are similar to those of patients undergoing total thyroidectomy.

TJS. 2018;34(Suppl-1):S310–S311.

In order to be able to discharge patients early and to reduce the medication and hospital costs, patients who will develop hypocalcemia after total thyroidectomy need to be determined before developing hypocalcemia. We suggest that Postresection serum PTH, PTH reduction percentage and serum PTH, calcium and phosphorus measurements on the day after the operation are the tests with high diagnostic value; their diagnostic values increase when they are evaluated with postresection serum PTH and the serum calcium levels on the next day of the operation; and serum FGF-23 measurements do not have high diagnostic value.

TJS. 2018;34(Suppl-1):S315.

PP-0236 [Endocrine Surgery]. Adrenal Cortical Carcinoma Patient with Compression Findings

Veysel Karahan ^1,^✉, Haydar Öcal ¹, Ahmet Aslan ¹, Nurhan Haluk Belen ¹, Yüksel Beyaz ¹, Mehmet Uzun ¹

Case

In the physical examination of a patient admitted due to the complaints of abdominal pain increasing within the last one month and dyspnea, tenderness was found in the left upper quadrant. Except for leukocytosis (26000) and elevated AST (640), routine hemogram and biochemical values and tumor markers were detected to be normal. The levels of ACTH (15.7), cortisol (19.5), and aldosterone (5.69) were normal. Urinary adrenaline (12.2), HVA (0.4), 5-HIAA (0.71), dopamine (448), VMA (0.7), and noradrenaline (60.0) values were normal. In the abdomen CT and MR, a well-circumscribed solid mass including cystic necrotic areas of approximately 115x100x93 mm, which displayed the pancreas body-tail section into the anterior superior area and the kidney to the posterior inferior area, was detected in the left adrenal lodge. In the exploration, a 12x12x15cm mass pushing the descending colon meso to the anterior area, the left kidney to the pelvis, and the pancreas and the spleen to the antero-superior area was detected. The mass invasive to the pancreas, left kidney, and splenic flexure was resected with as en bloc by involving the distal pancreas, the left kidney and the spleen. The pathologic examination revealed that the encapsulated 14x12x10 cm mass, which was found to be invasive to the pancreas and kidney, contained necrotic and locally light yellow areas. The mass with Vimentin (+), Synaptophysin (+), Chromogranin (+), Melan-A (+), Inhibin (+), S-100 (+), and Ki-67 index 8–10% was evaluated as adrenal cortical carcinoma.

The patient was discharged on the 10th postoperative day with recovery. The patient, who did not have systemic metastasis on PET CT, was started adjuvant radiotherapy.

Conclusion

Of the patients, 210 (70%) were female and 70 (30%) were male and the female/male ratio was 6.3/1. Of 280 patients, 20 were performed unilateral total thyroidectomy+near-total thyroidectomy, and 260 (96.8%) were performed bilateral total thyroidectomy. The complications included bleeding in 1 (0.3%) patient, wound site infection in 1 (0.8%) patient, seroma in 2 (1.8%) patients, transient hypocalcemia in 32 (0.4%) patients, permanent hypocalcemia in 1 (0,6%) patient, and transient recurrent nerve damage in 8 (1.3%) patients. No permanent recurrent nerve injury and mortality were observed.

Conclusion

We believe that total thyroidectomy can safely be performed with acceptable complication rates. In patients with nodular goiter, total thyroidectomy should be preferred because it reduces the risks of recurrence, complications associated with re-operation, and malignancy.

TJS. 2018;34(Suppl-1):S322–S323.

PP-0251 [Endocrine Surgery]. Peroperative Fast Parathormone Measurement in Surgical Treatment of Primary Hyperparathyroidism

Emil Guseinov ^1,^✉, Gökçe Aylaz ¹, Hüseyin Yüce Bircan ¹, Serdar Ahmet Karaca ¹, Feza Yarbuğ Karakayalı ¹

The data of 70 patients (51 females, 19 males) who were operated for primary hyperparathyroidism between January 2013 and January 2018 were prospectively recorded. The duration of follow-up varied from 4 to 75 months. Localization study was performed with the neck USG and parathyroid scintigraphy before the operation. In the localization, neck USG with superficial probe and Tc-99m sestamibi scintigraphy were used. If discordant and/or insufficient/suspicious data were obtained in the localization study, these patients were excluded from the study. Calcium levels were measured at the morning of the operation. With peroperative incision, hPTH was evalauted from the peripheral venous blood. At the 20th minute after the adenoma excision, hPTH was measured. Bilateral neck exploration was not performed and focus surgery was performed. Each time, 8 ml blood was sent to the laboratory in ice and in a time less than 5 minutes. Analyses were performed with ECLIA (electrochemiluminescence immunoassay method) using Cobas e 411^®, Roche-Hitachi device, and intact parathormone was measured. If the decrease in hPTH was over 50%, the operation was considered as successful and terminated. The levels of calcium were measured on the postoperative 2nd day. The patients who were discharged were followed up with the endocrinology department.

Intraoperative hPTH (IOhPTH) measurement allowed us to catch an undetermined double adenoma case in our study. Minimally invasive methods, focus surgery and unilateral exploration can be routinely performed as an alternative to bilateral neck exploration in the surgical treatment of primary hyperparathyroidism. With these methods, the complication rate will decrease but the presence of a possible double adenoma may pose a problem for the surgeon as a recurrent disease. In addition to good preoperative localization, the determination of IOhPTH may reduce the risk of recurrent disease.

TJS. 2018;34(Suppl-1):S323.

PP-0252 [Endocrine Surgery]. Adrenal Neuroblastoma in an Adult Patient

Mehmet Arif Usta ¹, Mehmet Uluşahin ^1,^✉, Reyyan Yıldırım ¹, Arif Burak Çekiç ¹, Serdar Türkyılmaz ¹

Introduction

Adrenal neuroblastoma is a malignancy that involves the peripheral sympathetic nervous system. It is most common in infants. It is rarely seen in the adult age group. It is a member of small round-cell tumors.

Case

A 29-year-old male patient consulted to an external center with the complaints of chest tightness and abdominal pain. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) were performed on the patient and a 6x4 cm adenoma was reported in the left surrenal gland. In the patient who was examined for the functionality of the adrenal adenoma, no abnormal value was found. Positron emission tomography (PET) was applied to the patient for malignancy and the result was reported to be an approximately 55x44 mm mass lesion with an SUV-max of 6 in the left surrenal gland, which was accompanied by calcification in the peripheral region, had central area that was ametabolic secondary to the possible degeneration, and had increased peripheral FDG uptake becoming more apparent in late images. Based on the present findings, surgery was recommended to the patient. The operation was laparoscopically started in the right lateral decubitus position with two 10 and one 5 trocars, but it was switched to open surgery with left subcostal incision because intraoperative arterial bleeding developed in the left surrenal gland. After the bleeding was controlled, the left surrenal gland and adenoma were excised without leaving residual tissue. The patient, who had no postoperative problems, was discharged on the 5th day. The result of pathological evaluation on a 7x5,5x4,5 cm excisional material was reported as a 5,5x5x5 cm encapsulated undifferentiated neuroblastoma from the poor histopathological group, displaying multinodularity in itself and having necrosis and hemorrhagic areas. In his follow-ups, metastasis in the 11th thoracal vertebra and local recurrence were detected in the postoperative 5th month. The patient continues to receive cisplatin and etoposide chemotherapy treatment under the supervision of the medical oncology department.

Conclusion

Introduction

Of the patients admitted to the emergency unit due to abdominal pain, those diagnosed with organ perforation, bowel obstruction, and mesenteric vascular disease are usually performed surgical intervention. The good anamnesis and physical examination taken from these patients are essential for the establishment of diagnosis. In this case, we wanted to emphasize a rarely seen surgical reason in a patient consulting with the clinical picture of acute abdomen.

Case

A 50-year-old female patient underwent gastroscopy in our endoscopy unit and consulted to our emergency department with a complaint of abdominal pain that started suddenly in 2 hours after eating food after the procedure. In the examination, the patient was tachycardic and hypotensive. She had defense and rebound in the abdomen. Leukocyte was above 13,000/ mm3. The presence of suspicious free air image under the right diaphragm in the chest X-ray suggested perforation. In the abdominal tomography, it was observed that the diaphragm on the right side was elevated upward and the small intestine loops were between the liver and diaphragm. The patient was diagnosed with Chilaiditi syndrome. However, due to the deterioration of the patient’s clinical state, emergency surgery was performed. It was observed in the laparotomy that there was internal herniation in the small intestine at 80 cm from the treitz. In the proximal area, the intestinal loops were between the liver and the diaphragm and necrosis occurred on the approximately 10-cm intestinal loop in the herniation site.

Conclusion

The complication of upper GIS endoscopy is very rare. Perforation and bleeding may occur while removing a foreign body, performing polypectomy, or taking a deep biopsy. If there is a history of endoscopy in patients admitted to the emergency unit, iatrogenic complications should be kept in mind for pre-diagnosis. In patients with abdominal pain, anamnesis and physical examination are essential. In patients who are suspected to have perforation and pre-diagnosed with Chilaiditi syndrome, as in this case, intestinal obstruction may occur both at the level of the small intestine and at the level of the large intestine. In the treatment of Chilaiditi syndrome, fluid replacement and bowel decompression should be applied primarily. Surgery is performed in patients who do not respond to conservative treatment. In internal herniations, mortality due to intestinal ischemia increases up to 20%. Internal herniation is caused by congenital mesenteric defect in children and previous surgeries or blunt traumas in adulthood. We wanted to present and discuss a patient who was considered to have stomach perforation at the anamnesis, found to have Chilaiditi syndrome in the examinations, and operated due to the surgical abdomen picture and detected to have small bowel internal herniation.

TJS. 2018;34(Suppl-1):S330–S331.

PP-0265 [Endoscopy (Gastroscopy, Colonoscopy, ERCP)]. Complications Encountered in our Endoscopy Unit and Our Treatment Methods

Sercan Büyükakıncak ^1,^✉, Banu Karapolat ¹, Şule Esen Türkyılmaz ², Ali Tüten ³

Objective

Gastroscopy and colonoscopy are the most commonly used interventional procedures for diagnosis and treatment in the gastrointestinal system. During colonoscopy, rarely serious and frequently minor complications are encountered. Hemorrhage and perforation can considered to be the most important complications in upper and lower gastrointestinal endoscopic procedures. In this study, we wanted to present the major complications and their treatments in our endoscopy unit in the last 5 years.

Material and Methods

A total of 16006 endoscopic procedures were performed in our endoscopy unit between the years of 2011 and 2016. Of them, upper endoscopy was performed in 11420 (71%) patients, total colonoscopy in 4316 (26%) patients, and percutaneous endoscopic gastrostomy in 270 (3%) patients. In 200 gastroscopic procedures and 725 colonoscopes, polypectomy was applied. Two patients had respiratory arrest. Diverticular perforation in the descending colon occurred in 2 patients and cecal tumor perforation in one patient. The most interesting was the development of transverse colon perforation and pneumothorax in a patient who was not known to have morgagni hernia, which is a rare complication in literature. Because colon cleanse was complete, primary repair was applied on diverticular perforations. In the patient with cecum perforation, because the intraoperative view was also in favor of tumor, left hemicolectomy and approximately 10 cm small bowel segment were removed and anastomosis was performed. In another patient, who was later found to have a morgagni hernia, it was found that perforation and pneumothorax developed in the transverse colon. The perforated area was not suitable for primary repair, resection anastomosis was applied, hernia repair was performed, and the patient was followed and treated with a chest tube. Another rare complication was the presence of Chilaiditi syndrome, impaired blood supply of the 5-cm jejunum loop due to internal herniation in the small intestine and then the application of resection anastomosis in a patient admitted to the emergency unit with the picture acute abdomen after gastroscopy.

Conclusion

Perforations in endoscopic procedures are rarely encountered, but have high morbidity and mortality. In diagnostic colonoscopies, perforation is observed at a rate of 0,01–0,4%. Diverticular diseases, previous abdominal surgery, malignancy, advanced age, and inflammatory bowel diseases can be considered as risk factors in perforations. Complications rarely ocur in experienced hands and early diagnosis and treatment are essential.

TJS. 2018;34(Suppl-1):S331.

PP-0266 [Endoscopy (Gastroscopy, Colonoscopy, ERCP)]. An Unusual Complication During ERCP: Supracrural Stomach Perforation

Sezgin Yılmaz ¹, Ramazan Serdar Arslan ^2,^✉

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is widely used in the diagnosis and treatment of hepatobiliary and pancreatic diseases. However, there is a risk of complication associated with ERCP at the rate of approximately 5–10%. Pancreatitis, bleeding, cholangitis, perforation, pneumothorax, air embolism, spleen injury, and rarely basket impaction are some of the complications. However, the most frigtening complication of ERCP is perforation because of its high mortality. The peripapillary area is the most common site of perforation after ERCP. Besides that, perforations can also be seen in different anatomical locations. In this study, we present a case of supracrural gastric perforation detected during ERCP.

Case

An 86-year-old female patient was referred to our clinic with the diagnosis of cholelithiasis and choledocholithiasis. Large type III hiatal hernia was detected during the ERCP procedure. Despite the absence of any difficulty during the application of duodenoscope along the esophageal and gastric lumen, the greater curvature of the stomach and omentum were viewed suddenly. The duodenoscope was retracted and the procedure was restarted. Perforation area was not observed, normal anatomical structures were passed, and ERCP procedure was completed. Gastroscopy was performed to rule out perforation. Gastroscopy revealed perforation of the stomach in the supracrural area and the patient was operated.

Conclusion

A detailed and well-documented anamnesis for the symptoms of hiatal hernia and reflux should be taken from the patients before the ERCP procedure. While advancing with duodenoscopy, the intraluminal structures should be seen clearly and the procedure should be continued. If there is any doubt about perforation, gastroscopic evaluation after ERCP should be performed to confirm the pathology. ERCP endoscopists should be aware of that perforation may occur not only in the juxtapapillary region but also in almost everywhere from the esophagus to the Trietz ligament.

TJS. 2018;34(Suppl-1):S331–S332.

PP-0267 [Endoscopy (Gastroscopy, Colonoscopy, ERCP)]. Assessment of the Incidence of Helicobacter Pylori Colonization in Northeastern Anatolia Region

Tolga Önder ^1,^✉

Objective

The frequency of Helicobacter pylori (HP) colonization was investigated in patients who were admitted to our hospital and performed elective gastroscopy.

Material and Methods

We retrospectively reviewed 1,400 patients admitted to Sarıkamış State Hospital between the years of 2012 and 2016 and performed elective gastroscopy, whose files could be reached. The frequency of HP was investigated.

Results

HP positivity was detected in 994 (71%) of 1400 patients, 798 of whom were female (57.0%). The mean age was calculated as 36.9 (min 14, max 82) years. Gastroscopically, 607 patients had isolated antral gastritis (43,4%), 330 patients had erythematous pangastritis (23,6%), 359 patients had bulbititis accompanying stomach inflammation (25,7%) and 44 patients had other findings (inflammation in the extra-antrum areas, esophagitis, polypoid lesion) (3,2%). Endoscopic findings were reported as normal in 56 patients (4%). In addition, gastric ulcer (2.6%) was found in 36 patients, duodenal ulcer in 235 patients (17.8%), and Barrett metaplasia in 88 patients (6.3%).

Conclusion

The HP frequency in the Northeastern Anatolia Region was determined as 71.1%. There was a strong correlation between gastric ulcer and HP.

TJS. 2018;34(Suppl-1):S332.

PP-0268 [Endoscopy (Gastroscopy, Colonoscopy, ERCP)]. Unusual Perforations in ERCP Procedure

Murat Çilekar ^1,^✉, Ramazan Serdar Arslan ², Murat Akıcı ¹, Sezgin Yılmaz ¹

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is an interventional method used in the diagnosis and treatment of benign or malignant hepatopancreaticobiliary diseases. The rate of complication risk is between 5% and 10% during ERCP procedure. The most frightening complication of ERCP is perforation because of the highest mortality rate. The most common location of perforation after ERCP is the peripapillary region. However, perforations can also be seen in unusual anatomical localizations. Clinical findings and diagnostic features of unusual perforations resemble peripapillary perforations, but their morbidity and mortality differ.

Erkan Oymacı ¹, Nurettin Kahramansoy ², Sedat Tan ², Burak Dede ^2,^✉, Mehmet Yıldırım ²

Introduction

Foreign bodies in the esophagus are not frequently encountered, and if accompanied by perforation, it is a problem that can cause serious morbidity and mortality. Because the narrowest part of the upper gastrointestinal system is the cervical part of the esophagus, attachments and perforations occur frequently in these regions. The most frequently encountered foreign objects are coin and toy pieces in children and inadequately chewed foods and bone-fishbone fragments in adults. In this study, it was aimed to present a case that was admitted to the emergency unit with perforation and retropharyngeal abscess associated with the ingestion of a foreign body that was stuck in the esophagus and that was diagnosed and treated endoscopically.

Case

A 54-year-old female patient was admitted to the emergency unit and taken under monitorization in the ENT clinic due to globus sensation, difficulty in swallowing, and pain following oral intake 2 days before. Because her complaints gradually increased and fever, hyperemia, edema and redness in the neck region developed, she was performed the computerized tomography and a foreign body with about 25 mm length and 5 mm thickness was detected at the oropharynx-cervical esophagus junction in the posterior prevertebral area. Retropharyngeal diffuse free air and multiloculated collection extending to the hypopharynx in the inferior and to the epiglottis in the superior were detected in the neighborhood of foreign body. This appearance was evaluated as perforation of the cervical esophagus and associated retropharyngeal neck abscess. The patient underwent endoscopic procedure under general anesthesia and it revealed a bone fragment at the pharyngoesophageal and cervical esophagus junction, causing perforation by sticking into the anterior and posterior areas of the esophageal mucosa. The foreign body was released from the esophagus with the aid of endoscopic tripod and basket snare and taken out of the mouth with the help of a gastroscopic cap. Approximately 150 cc of purulent abscess fluid was drained from the esophageal perforation area and aspirated. The perforation area in the esophagus mucosa was closed with endoscopic hemoclips. The patient was initiated broad-spectrum antibiotherapy and she was followed-up for 2 days in the postoperative intensive care unit. The patient, whose swelling on the neck was reduced and fever was regressed, was taken into the clinic on the 3rd day. The control USG and CT scans of the neck and thorax were performed and the retropharyngeal abscess cavity was observed to have disappeared. On the 8th day after endoscopic intervention, oral liquid foods were started and on the 11th day of follow-up, the patient was discharged with healing.

Conclusion

Perforations due to esophageal foreign bodies constitute the clinical conditions with severe mortality and morbidity. Today, increasing endoscopic intervention opportunities and modern endoscopic equipment open new horizons in approaches to these cases. With these endoscopic interventions performed by experienced specialists, treatment and follow-up are possible without surgery.

TJS. 2018;34(Suppl-1):S335.

PP-0273 [Endoscopy (Gastroscopy, Colonoscopy, ERCP)]. Approach to Esophageal Foreign Bodies in a District Hospital: 2 Case Reports

Mehmet Sertkaya ^1,^✉

Introduction

Esophageal foreign bodies are more frequently seen in children and it can also be encountered in adult patients. In this study, we wanted to present our experience on 2 different cases of foreign bodies that we encountered in the district hospital.

Case

Case 1

A 54-year-old male patient was admitted to the emergency unit with retrosternal pain and stinging sensation. In the physical examination of the patient, who stated that he accidentally ingested a bone while eating, there was no abnormal finding. His laboratory values were normal. In the endoscopy performed in emergency conditions, a piece of bone attached to the esophagus at about 25 cm from the incisor teeth was observed. The bone piece caught with biopsy forceps was taken out. There were no abnormal findings in the clinic and laboratory values of the patient who was followed up for 2 days in the clinic. Then, the patient was discharged.

Case 2

A 14-year-old male patient consulted to the emergency unit due to the history of swallowing a coin and retrosternal pain. The chest X-ray showed a round object enhancing in the middle of the esophagus. In the endoscopy, it was seen that there was a coin hanging up in the esophagus at a distance of about 25cm. It was tried to be caught with a biopsy forceps, but it advanced towards the stomach. After several trials, it disappeared in the undigested food in the stomach. In the radiography taken immediately after the process, it was seen that the coin was already in the small intestine. The patient was recommended a potato diet. The patient who did not come to the control examination was called by phone and it was learned that the foreign body got out with defecation after about 36 hours following the ingestion.

Conclusion

Direct radiographs can detect most of the radiopaque foreign bodies, but food bolus impactions, fish or chicken bones, wood, plastic, glass and thin metal objects are not easily viewed. Surgery, which is a costly and invasive procedure, is avoided. In addition to being less invasive, endoscopic maneuvers are the primary treatment approach because of their technical simplicity, excellent imaging, and the ability to view other diseases simultaneously. If the swallowed object is impacted on the esophagus, it can lead to esophagitis, mucosal ulceration, bleeding, obstruction, and perforation. Endoscopic interventions performed within the first 24 hours give better results. However, the type and characteristic of the object, technical opportunities, and personal endoscopic experience are very important.

TJS. 2018;34(Suppl-1):S335–S336.

PP-0274 [Endoscopy (Gastroscopy, Colonoscopy, ERCP)]. Endoscopic Management of a Rare Foreign Body in the Stomach

Ömer Faruk Özkan ^1,^✉, Şükrü Taş ², Erdem Akbal ³

Introduction

Swallowing foreign bodies is an important problem in psychiatric patients. In the literature, the removal of foreign bodies such as fishbone, fork and various metallic objects has been reported. The treatment is endoscopic removal of foreign bodies after diagnosis (1). Surgical approach is necessary in case of failure in endoscopic approach. In this article, we aimed to present the endoscopic removal of the swallowed watch in a patient having impaired hearing and receiving psychiatric treatment.

Case

A 25 year-old male patient with hearing impairment consulted to the emergency unit with the complaint of abdominal pain. Except for epigastric tenderness, his physical examination was normal. His laboratory findings were also normal. In the direct radiography, a round metallic object was detected. Emergency endoscopy was planned and a watch was detected in the stomach in the endoscopic examination. The object was successfully removed with an esophageal overtube approach under direct endoscopy.

Conclusion

Delay in the diagnosis and removal of sharp or large foreign bodies may lead to serious complications such as mucosal laceration, obstruction, bleeding and perforation. For the removal of large foreign bodies, esophageal overtube, which prevents the occurrence of esophageal injury with endoscopic approach, should be preferred in order to avoid mucosal laceration, perforation, and surgical treatment.

TJS. 2018;34(Suppl-1):S336.

PP-0276 [Endoscopy (Gastroscopy, Colonoscopy, ERCP)]. A Foreign Body in the Stomach: “Fork”

Server Sezgin Uludağ ^1,^✉, Yunus Emre Bölükoğlu ¹, Osman Şimşek ¹, Mehmet Velidedeoğlu ¹, Salih Pekmezci ¹

A 22-year-old female patient was admitted to our emergency surgery outpatient clinic by asserting that she had swallowed a foreign body (fork). There was no abnormal feature in the physical examination. The image of the fork was viewed in the upper quadrant midline in direct abdominal x-ray in standing position. In the abdominal CT, a foreign body image (fork), the longest axis of which was measured as 12 cm, was observed in the stomach lumen, extending from the fundus to the corpus. There was no free liquid and air inside the abdomen. No radiological finding requiring emergency surgery was found. Gastroscopy was planned for the patient. From medicolegal aspect, the risks of the procedure were explained and the patient’s consent was received. After attaching a cap for foreign body extraction, gastroscopy was performed. The ‘fork’ in the stomach was pulled into the cap by catching with polypectomy snare. In the control endoscopy performed after the removal of the foreign body, new pathology was not detected in the esophagus and stomach, except the superficial local bleeding. After the procedure, the patient was monitored for 24 hours in the hospital by stopping the oral intake. At the second 24th hour, the oral intake was started. The patient, who did not develop any complications, was discharged with the recommendations. In the control examinations, it was observed that the patient’s general state and oral intake were natural.

TJS. 2018;34(Suppl-1):S336–S337.

PP-0277 [Endoscopy (Gastroscopy, Colonoscopy, ERCP)]. A Solid Organ Pathology Diagnosed by Endoscopic Biopsy

Zehra Ünal Özdemir ¹, Hakan Özdemir ¹, Mehmet Torun ^1,^✉

Introduction

The purpose of this study is to present the difficulties experienced during the diagnosis stage of a patient with a splenic mass and the advantage that endoscopic biopsy provides to the patient.

Case

A 55-year-old female patient was admitted to the outpatient clinic with the complaints of pain in the epigastric region, vomiting, and hiccup. There was sensitivity in the epigastric region and in the left upper quadrant of the abdomen in the patient’s physical examination. There was no defense and rebound. The traube was closed. The patient was hospitalized to be examined. The laboratory results of the patient was as follows: Hb: 11.5 g/dl, Wbc: 7700 x 103/μl, and Plt: 299 x 103/μl. Her biochemical values were normal. The abdominal ultrasonography revealed an approximately 6 cm hypoechoic mass in the superior-medial segment of the spleen. In the abdominal tomography, a 9 cm lesion with necrotic areas in the upper pole of the spleen and multiple lymph nodes showing conglomeration in the periceliac, paraaortic region were detected. In the abdominal MR, a mass lesion with necrotic center, the widest point of which was 10 cm, was observed in the upper pole of the spleen. It was stated that the mass was invasive to the stomach and diaphragm and also had suspected invasion to the liver.

A 19 mm diametered nodular lesion (metastasis?), which was thought to be located in the lung parenchyma and had a similar characteristic to the mass on the left costophrenic sinus localization, was described. Since there was no extraabdominal pathological finding in the patient, who was thought to have a lymphoproliferative pathology, a true cut biopsy was planned for the mass in the spleen after consulting to the department of hematology. The result of the true cut biopsy was reported as a spindle cell neoplasm. With this result, the diagnosis of lymphoproliferative disease was ruled out. The patient was discussed at the tumor council, and the total excision of the mass was recommended for the precise sub-typing of the spindle cell neoplasia. To determine the area of stomach invasion indicated in the radiology report, gastroscopy was scheduled for the patient. The gastroscopy revealed an about 2x1 cm fibrin-covered area at a distance of 3 cm from the esophagogastric junction. Considering that this was the area of the invasion, biopsies were taken from this area. The result of endoscopic biopsy was reported as the anaplastic variant of diffuse large-cell lymphoma originating from the non-germinal center. With this pathological result, the plan of surgery was abandoned and the patient was referred to the department of hematology.

Conclusion

In patients without peripheral lymph node, being thought to have lymphoma, and displaying invasion to the gastrointestinal system, endoscopic biopsy, instead of taking biopsy with laparotomy or laparoscopy, can be considered as a minimally invasive method that will help in diagnosis.

TJS. 2018;34(Suppl-1):S337–S338.

PP-0278 [Endoscopy (Gastroscopy, Colonoscopy, ERCP)]. Who is Afraid of Endoscopy? How can the Patient’s Anxiety be Resolved?

Selami Ilgaz Kayılıoğlu ¹, Tolga Dinç ^1,^✉

Objective

Esophagogastroscopy and colonoscopy have an important role in the screening, diagnosis and follow-up of related regional diseases. Due to fear and anxiety of patients for both methods, the number of patients who do not come to the appointment is not negligible. From another point of view, it is known that anxious and fearful patients experience more compliance problems during endoscopic procedures. In this questionnaire study on patients for whom endoscopy was planned, it was aimed to reveal the frequency, causes and characteristics of anxiety caused by endoscopic procedures.

Material and Methods

The study included adult patients who came to the General Surgery Endoscopy Laboratory for esophagogastroscopy and/or colonoscopy appointment and accepted to attend the study. The patients who had impaired general state, whose states of consciousness were not suitable for giving consent and replying the questionnaire, who refused to attend the study, and who had a known anxiety disorder or psychiatric disease were excluded from the study. In the endoscopy unit, the patients included in the study were asked to complete the two questionnaire forms under supervision before the procedure.

In the first questionnaire form, in addition to the questions about the patients’ demographic data, endoscopic experience, whether they were afraid of endoscopy, and whether they had knowledge about the procedure to be performed, the item “Evaluate your experience of endoscopy in terms of its difficulty for you by rating with the scores from 1 to 5 (1: very comfortable, 5: very difficult)”, which would be answered after the procedure, was included. The second questionnaire form was the State-Trait Anxiety Inventory for Adults ™ (STAI-AD). The STAI-AD consists of two main parts. While the S-Anxiety section seeks to assess the ongoing anxiety state of the individual, the T-Anxiety section aims to assess the state of anxiety over the situation in which it occurs.

Results

A total of 90 patients admitted between January 2017 and January 2018 were included in the study. Thirty-nine of the patients were male (43.8%) and 51 (56.2%) were female. While esophagogastroscopy was performed in 90.3% of the patients, colonoscopy was performed in 8.1% and both procedures were performed in the same session for 1.6%. The mean age of the patients was found to be 46.56±15.53 years. In female patients, the fear of endoscopy was higher than in male patients (39/51, 79.6% vs 18/39, 45%, p=0.001). In the patients adequately informed before the procedure, anxiety associated with the procedure was found to be less (p <0.05). The recognition of the physician who performed the procedure led to decreased anxiety level (p <0.05). There was no relationship between anxiety and fasting duration before the procedure. When the test result was accepted as the gold standard, the sensitivity was 81%, specificity was 57%, positive predictive value was 74%, and negative predictive value was 67% in terms of anxiety for the question “Are you afraid of endoscopy?” It was detected that the patients administered sedation were more comfortable during the procedure than those not given sedation (p <0.05).

Conclusion

In the majority of patients saying “I am afraid of endoscopy”, anxiety for the procedure develops. Fearing from the procedure and not complying with the procedure because of this fear are an important vicious cycle of this process. In order to resolve this situation, particularly good communication should be established with female patients expressing their fear and they should be informed about the process by the physician who will apply the procedure. If possible, the procedure should be carried out under sedation.

TJS. 2018;34(Suppl-1):S338.

PP-0279 [Endoscopy (Gastroscopy, Colonoscopy, ERCP)]. The Histological Relationship Between Gastric Cancer and Helicobacter Pylori

Aziz Arı ¹, Kenan Büyükaşık ¹, Özhan Albayrak ^1,^✉

In the final report of the meeting held with experienced cancer specialists from 11 countries in 1994, the International Agency for Research on Cancer reached the conclusion that H. pylori was carcinogenic for the stomach. The first studies investigating the relationship between cancer type and bacteria showed higher rates of H. pylori infection in intestinal type gastric cancers than in diffuse types. Then, the rate changed in favor of the diffuse type of cancers.

We aimed to compare the frequency of H. pylori infection in our gastric cancer cases with the control group. In our study, the presence of H. pylori in the stomach was proven by histological methods. Moreover, the relationship between the localizations and types of cancer and H. pylori infection was also investigated. The study included 60 patients with gastric carcinoma, for whom local ethical committee approval was received, who were diagnosed in the Istanbul Training and Research Hospital Endoscopy Unit, and 40 of whom were operated in the Department of General Surgery at different times. The main complaints and their durations, the habits of tea and alcohol consumption and smoking, familial history, and previous gastric surgery were questioned. The localization, macroscopic appearance, histology, and spread of tumor were determined in the operated cases. In the patients undergoing stomach resection, sections taken from both the tumor and the surrounding mucosa during operation were firstly fixed with 10% formaldehyde. Then, it was transformed into paraffin embedded blocks and 4–5 micron-thick sections were taken. Histological examination was performed by hematoxylin-eosin staining through conventional methods. In addition, the samples taken from the surrounding mucosa were stained with modified Gimsa and the presence of H. pylori was investigated. In 40 cases undergoing resection, tumors were divided into 3 types according to the Lauren classification. Esophagogastroduodenoscopy was performed in the Endoscopy Unit in the control group including 15 patients who were admitted to Istanbul Education Hospital Outpatient Clinic of General Surgery and who had no upper gastrointestinal system complaints. At least 2 biopsy specimens taken from the stomach antrum were sent to Istanbul Education Hospital Pathological Research Laboratory for paraffin section in 10% formaldehyde. Here, histological sections were examined in terms of the presence of H. Pylori by Gimsa staining and in terms of the presence of gastritis by H. Eosin staining. The relationship between the tumor localization and H. Pylori was examined. In 40 patients undergoing resection, the histological presence of H. pylori in the neighbor tissue was detected in 28 patients (70%). When all the cases were evaluated together (60 patients), H. pylori infection was found in 40 (66.7%) patients. In the comparison of the intestinal type and diffuse type, although the rate of H. Pylori infection seemed to be higher in the diffuse type, there was no statistically significant difference. Histological presence of H. pylori was investigated in 15 cases of the control group. H. pylori was found to be positive in 11 cases (73.3%). All of the H. pylori (+) patients had chronic active gastritis. Of gastritis cases, 8 were diffuse, 2 were superficial, and 1 was atrophic.

In conclusion, there was a significant correlation between H. pylori positivity and gastric cancer, and both intestinal and diffuse gastric cancer cases had H. pylori infection. No statistically significant difference was found in terms of the frequency of H. Pylori in the comparison with the control group.

TJS. 2018;34(Suppl-1):S338–S339.

PP-0280 [Endoscopy (Gastroscopy, Colonoscopy, ERCP)]. Can Cannulation Failure be Prevented During Endoscopic Retrograde Cholangiopancreatography?

Yahya Kemal Çalışkan ^1,^✉, Mustafa Uygar Kalaycı ¹

Objective

Endoscopic retrograde cholangiopancreatography (ERCP) is often used in the diagnosis and treatment of hepatic, biliary and pancreatic diseases. Cannulation failure, however, requires other interventions. The aim of this work is to create the parameters that can be used to predict failure during ERCP.

Material and Methods

Case control study was planned. The ERCP procedures performed between December 2016 and February 2018 were evaluated. Recurrent interventions and their causes and cannulation states were recorded. The factors affecting cannulation were examined. Descriptive analyses were used for statistical evaluation. The Chi-square test for categorical data and t-test for continuous data were used. In the analyses, the p value of 0.05 or less was considered to be statistically significant.

Results

A total of 458 ERCP procedures were performed in 288 patients during the study period. Of the patients, 159 were female and 129 were male. The female/male ratio was 1,2 and the mean age was 59±17,9 years (age range: 17–105). When ERCP indications were evaluated, it was observed that the procedure was performed in 258 patients (89.6%) due to choledocholithiasis. In the first process, selective choledochal cannulation was successful in 257 (89.3%) patients, with ERCP catheter in 229 patients and with auxiliary methods in 28 patients. In 236 patients, the cannulation was successful in less than 15 minutes. In 31 (10.7%) patients, cannulation failed in the first process. There was no difference among the failed patients in terms of age and gender (p: 0,270, 0,256, respectively). The causes of failure were previous stomach-duodenum surgeries, the duodenal diverticulum, and pancreas head tumor. Cannulation with planned recurrent procedures was successful, except in 2 patients. In the first process, 264 patients were diagnosed, particularly with choledocholithiasis (n: 214).

Conclusion

It has been shown in literature that the gender of the patient and structural differences such as duodenal diverticulum do not affect the success of cannulation during ERCP. The Billroth II and Roux-en-Y gastrojejunostomy operations decrease the success rate of cannulation. The results of our study are similar. Our cannulation success rate is consistent with the success rate of the large series presented in the literature. It is thought that there is a correlation between the experience of endoscopists and cannulation success.

TJS. 2018;34(Suppl-1):S339.

PP-0281 [Endoscopy (Gastroscopy, Colonoscopy, ERCP)]. Determination of the Incidence of Lipomas with the Localization of the Upper GIS; a Single-center Retrospective Study

Hakan Seyit ^1,^✉, Kıvanç Derya Peker ¹, Eyüp Gemici ¹, Sezer Bulut ¹, Mehmet Emin Güneş ¹, Halil Alış ²

Objective

Objective

The aim is to share the experience of a surgeon, who was inexperienced in flexible endoscopy, after the course of surgical endoscopy training organized in Afyon Kocatepe University, Faculty of Medicine in the framework of continuing medical education and continuing professional development activities by the Turkish Society of Surgery.

Material and Methods

Patients admitted to the outpatient clinic and clinic of general surgery in Afyon Kocatepe University Medical Faculty between 28.09.2017 and 27.12.2017 were included in the study. The patients that were applied emergency surgical endoscopy at the weekend were excluded form the study. Patients’ demographic data, procedures and complications were presented.

Results

Results

The results of the biopsies were as follows: Helicobacter pylori in 450 patients (60%), Gastritis in 170 patients (23%), Intestinal metaplasia in 58 patients (8%), hyperplastic changes in 14 patients (2%), adenocarcinoma in 13 patients (2%), peptic ulcer in 9 patients (1%), esophagitis in 8 patients (1%), duodenitis in 4 patients, chemical gastritis in 6 patients, foveolar hyperplasia in 5 patients, diffuse large B-cell lymphoma in 2 patients, necrotic exudate in 3 patients, lymphoid hyperplasia in 2 patients, alkaline reflux gastritis in 2 patients, undifferentiated epithelial dysplasia in 1 patient, squamous epithelial polyp in 1 patient, and normal biopsy results in 14 patients (2%). At the end of the endoscopies, no complication requiring medical treatment developed.

Conclusion

Upper GIS endoscopy is a highly effective diagnostic and treatment procedure in the demonstration of possible lesions, which is frequently used in recent years and has low rate of complications. General surgeons can safely apply the procedure with adequate training and, at the same time, treat the possible complications very quickly and effectively. The biopsy results include a wide spectrum of diseases ranging from infectious processes to malignancies. Endoscopic procedures are an effective diagnostic tool that helps surgeons to strengthen their hands in the treatment of existing pathologies and for surgical decision-making and prevents unnecessary procedures.

TJS. 2018;34(Suppl-1):S344.

PP-0289 [Endoscopy (Gastroscopy, Colonoscopy, ERCP)]. Case Report on Bilateral Pneumothorax Developing After Endoscopic Retrograde Cholangiopancreatography

Arda Şakir Yılmaz ^1,^✉, Bartu Badak ¹

Introduction

PP-0293 [Endoscopy (Gastroscopy, Colonoscopy, ERCP)]. Rectum Injury Penetrating to the Mesorectum: A Rare Cause of Lower Gastrointestinal System Bleeding

Emran Kuzey Avcı ^1,^✉, Semra Demirli Atıcı ¹, Can Arıcan ¹, Murat Akalin ¹, Halit Batuhan Demir ¹, Cem Tuğmen ¹, Gökhan Akbulut ¹

Lower gastrointestinal (GI) system hemorrhage refers to bleeding originating from a region in the distal part of the Treitz ligament. Lower GI system hemorrhages can manifest themselves in different ways (anemia, fecal occult blood, etc.), but some can be acute bleedings which can be life-threatening. In this case report, it was aimed to present chronic rectum perforation, which a rare lower GI system hemorrhage. Our case was a 94-year-old male patient with a history of Alzheimer’s disease, coronary artery disease, and aspirin use. He was brought to the emergency unit because of the presence of blood in the diaper. The patient was assessed by the emergency department. She had no tachycardia, hypotension, and abdominal pain. At admission, the value of Hgb was 13.4, Hct was 41.5, PLT was 110000. Biochemistry and coagulation parameters were normal. The physical examination revealed that all the abdominal quadrants were normal in palpation. External hemorrhoids and bright-color bleeding were observed at the rectal examination. The patient was hospitalized for follow-up. In the control analysis after 24 hours, Hgb value was 9,1 and Hct value was 27,7. Colonoscopy was performed. A 10 mm perforation area with epithelialized edges having a blood leakage was observed at the 15 cm proximal of the anal canal. The leaking hemorrhagic area was cauterized. Two hemoclips were placed in this area. The bleeding was observed to have stopped. In the advanced age group, GIS hemorrhages can be seen more frequently due to the comorbidities and the medications used (NSAID, antiplatelet, anticoagulant, etc.). As a matter of fact, the use of NSAIDs and antiplatelet drugs in rectal perforations without definite etiology can cause bleeding.

TJS. 2018;34(Suppl-1):S346.

PP-0294 [Endoscopy (Gastroscopy, Colonoscopy, ERCP)]. 1416 Endoscopic Retrograde Cholangiopancreatography Procedure Analysis

Hakan Yiğitbaş ^1,^✉, Candaş Erçetin ¹, Ali Solmaz ¹, Eyüp Sevim ¹, Aydın Zilan ¹, Fatih Çelebi ¹, Atilla Çelik ¹

Introduction

Endoscopic Retrograde Cholangiopancreatography (ERCP), an irreplaceable diagnostic and treatment method for bile duct diseases, is an important element of General Surgery practice. In our study, the ERCP procedures performed at the Endoscopy Unit of Health Sciences University Bağcılar Training and Research Hospital, General Surgery Department were evaluated.

Material and Methods

The ERCP procedures performed at the Endoscopy Unit of Health Sciences University Bağcılar Training and Research Hospital, General Surgery Department between January 2010 and December 2017 were retrospectively evaluated in electronic environment.

Results

In this period, 1416 ERCP procedures were performed. Of them, 581 (41%) were performed on males and 835 (59%) on females. It was applied twice in 178 patients, 3 times in 58 patients, 4 times in 32 patients, and 5 times and more in 23 patients. The mean age was 58.8±18.6 (16–96) years. The procedures were performed by 6 experienced general surgeons. Cannulation was successfully carried out in 78.6% of the procedures, but it could not be performed in 21.4% of the procedures. In 21.1% of the procedures, precut was performed with needle-tip sphincterotomy. While the mean diameter of the cannulated choledoch was 13.51±4.9mm (5–35), the choledochal stone was found in 680 of these processes. The mean diameter was 12.98±4.55mm in 451 male patients whose choledochs were measured and 3.89±5.08 mm in 636 female patients. The diameter of the female patients was significantly larger than the male patients (p <0.02). In 536 procedures, a flat stent or stent with curved ends were used. In these procedures, the mean diameter of the choledochs was 14.89±5.5 mm (6–35). While stent was applied due to residual or unremovable stones in 381 patients, 155 patients had other pathologies. The diameter of the choledoch in the patients who underwent stenting was significantly larger than that of those without (p <0.01). In 25.5% of 404 patients undergoing ERCP with the pre-diagnosis of choledocholithiasis, choledochal stone was not detected during the procedure. As the age progressed, the diameter of the choledoch increased and it was found to be correlated with age (r: 0.302). While stone was detected in 72.9% of the patients who were older than 65 years, this rate was 60.5% for the patients below 65 years old. The difference was statistically significant (p <0.01). At the end of the procedures, mortality was observed in 3 patients.

Conclusion

With the increase of the age average in the general population, the frequency of the benign and malignant diseases of the hepatobiliary system is also increasing in parallel. First of all, ERCP, which has been used for diagnostic purpose, leads the minimally invasive approaches in the pathology of hepatobiliary system with the developments in technology. The management of patients can be carried out as a whole with endoscopic interventions, which are irreplaceable elements of general surgery practice, and ERCP. ERCP is a minimally invasive endoscopic procedure successfully performed by general surgeons. It should be considered to be added to the core training program that general surgeons, who constitute the main team managing the complications in terms of patient health and safety, must take.

TJS. 2018;34(Suppl-1):S346.

PP-0295 [Endoscopy (Gastroscopy, Colonoscopy, ERCP)]. Decubitus Ulcer Developing due to Bezoar and Bulbus Perforation Secondary to Bezoar Fragmentation: Case Report

Gökhan Pösteki ^1,^✉, Veysel Sarı ¹, Alican Güreşin ¹, Turgay Şimşek ¹, Sertaç Ata Güler ¹

A 55-year-old patient with a psychiatric disease was evaluated by the department of gastroenterology with the picture of gastric outlet obstruction and a bezoar on the bulbus at the entrance of the pylorus was detected. After the endoscopic fragmentation of the bezoar, the acute abdomen developed after the procedure. The patient whose CT revealed perforation was operated. In the peroperative endoscopy, it was noticed decubitus developed due to bezoar at the post-pyloric bulbus in the area where the bezoar was fragmented and there was a perforation from this point. The perforation area was repaired by the Graham technique. No postoperative complication developed. Although similar cases are found in the literature, we think that our case has a clinical presentation that can rarely be seen because the perforation becomes more obvious after bezoar fragmentation.

TJS. 2018;34(Suppl-1):S347.

PP-0296 [Endoscopy (Gastroscopy, Colonoscopy, ERCP)]. Treatment of Endoscopic Band Ligation in Cirrhosis-Associated Esophageal Variceal Hemorrhage: Single Center Experience

Yasir Musa Kesgin ^1,^✉, Osman Köneş ¹, Cevher Akarsu ¹, Mehmet Karabulut ¹, Mehmet Abdussamet Bozkurt ¹, Nuri Alper Şahbaz ¹, Kemal Tekeşin ², Mehmet Emin Güneş ¹

Objective

Esophageal variceal hemorrhage due to portal hypertension is among the most important complications of cirrhosis. Endoscopic band ligation is one of the most important options in the treatment of these bleedings. In this study, it was aimed to present the results of patients who underwent band ligation due to esophageal variceal hemorrhage in a single center. This retrospective study was conducted in Bakırköy Dr. Sadi Konuk Training and Research Hospital in the department of general surgery. Sixty-four patients who were found to have acute esophageal variceal hemorrhage and performed endoscopic band ligation between January 2010 and 2018 were evaluated.

Content of Video

Endoscopic band ligation technique applied in patients with acute esophageal variceal bleeding.

Conclusion

Esophageal variceal bleeding can lead to life-threatening consequences in patients with portal hypertension due to cirrhosis. 28.1% of the patients were Child A, 60.9% were Child B and 10.9% were Child C. The Meld score was <9 in 9.4% of the patients, between 10 and 19 in 79.7%, and between 20 and 29 in 10,9%. Endoscopic treatment is an optimal treatment method in the acute treatment of varices causing abundant and persistent hemorrhage. The average band number applied in our study was 2.7 (1–9). Mortality developed in 7.8% of the cases. Endoscopic band ligation therapy patiently performed by experienced hands is a minimally invasive and life-saving method.

TJS. 2018;34(Suppl-1):S347.

PP-0297 [Endoscopy (Gastroscopy, Colonoscopy, ERCP)]. A Rare Case: Percutaneous Endoscopic Gastrostomy Dislocation

Altan Aydın ^1,^✉, Şaban Uysal ¹

Percutaneous Endoscopic Gastrostomy (PEG) can be briefly described as tube insertion for feeding from the abdominal wall to the stomach in patients who cannot be fed orally for various reasons. It can primarily be considered especially for patients requiring nutrition support for a time longer than 4 weeks. The tube can be inserted mainly using the Pull and Push method. The possibility of complications in the pull technique is higher. Feeding can begin 12 hours after the tube insertion. The procedure may have various complications such as wound site infection, abdominal wall hemorrhage, periostomal leakage, intraperitoneal hemorrhage and aspiration. Although the mortality rate varies in various studies, it is between 1% and 3% on average. The skin to be dry after wound healing is important in terms of avoiding maceration and infection. For this reason, the wound should be cleaned with antiseptic at certain intervals and after bathing the patient.

Various complications can be prevented if the tube is early removed as soon as patient does not need to be fed through a PEG tube. In our case report, the patient was 82 years old and had DM and Alzheimer’s disease. The patient had been inserted PEG for nutrition one year ago and fed through it for 8 months. The catheter had not been removed despite the fact that the catheter had not been needed any more. The patient consulted to our center because of the complaints of nausea and vomiting going on for the last 1 month. We planned to remove the catheter. While removing, it was observed that the catheter came out of the stomach and under the skin. Therefore, although it is very helpful for nutrition, when the PEG catheter is not needed, it should be removed early.

TJS. 2018;34(Suppl-1):S348.

PP-0299 [Hernia Surgery]. Secret Enemy of Advanced Aged Women: Obturator Hernia

Akile Zengin ^1,^✉, Sezgin Zeren ¹, Bercis İmge Uçar ¹, Mehmet Korkmaz ²

Introduction

Obturator hernia is the protrusion of the intraperitoneal or extraperitoneal organs into the obturator duct. Because women’s pelvis is wider, the risk of obturator hernia is 6–9 times higher than in men. Most of the obturator hernias become symptomatic when intestinal obstruction develops. Although there are studies indicating increased diagnostic value of the ultrasonography (USG), it is known that computed tomography (CT) is superior to USG and herniography in the establishment of preoperative diagnosis. Its treatment is the surgery. Surgical approaches in obturator hernia include inguinal, retropubic, and transperitoneal methods. On the other hand, laparoscopic approach is not recommended for all obturator hernias because it is difficult for the surgeon to evaluate the viability of the bowel and for resection. In this article, we present three obturator hernia cases operated in our clinic for reminding that this condition should be kept in mind in the differential diagnosis of elderly female patients.

Case

Case 1

A 75-year-old multiparous patient was brought to the hospital due to the complaint of nausea and vomiting ongoing for 2 days. In the direct abdominal radiography in standing position, air-fluid levels were observed. The CT revealed a finding consistent with obturator hernia on the left side. The patient was taken into an operation. In the operation performed with sub-umbilical median incision, the 5-cm strangulated jejunum loop in the left obturator canal was removed from the canal. Because the patient had no viability and was gangrenous, resection and anastomosis were performed. The hernia defect was repaired with a prolene mesh. The patient was discharged on the postoperative 8th day.

Case 2

A 83-year-old female patient was admitted due to the complaints of abdominal pain, nausea, and vomiting ongoing for 4 days. She had history of multiple labor, decompensated liver cirrhosis, hypothyroidism, and COPD. In the CT, obturator hernia was detected on the right side and she was operated. In the operation performed with subumbilical median incision, the 10-cm strangulated ileum loop was removed from the right obturator canal. Anastomosis was performed after resection and hernia defect was repaired. The patient could not be extubated because of her COPD disorder and she died on the postoperative 8th day.

Case 3

A 78-year-old female patient complained of vomiting and abdominal pain intermittently ongoing for 2 days. She had a history of multiple birth, osteoporosis, and COPD. The patient with right obturator hernia in the CT was operated. In the operation performed with subumbilical medin incision, it was observed that the inside of the abdomen was full of stool. The 5-cm strangulated ileum loop in the right obturator canal was removed. There was a perforation in the intestinal loop at the 15 cm proximal area of the strangulated ileum loop. Resection and anastomosis were performed for the strangulated loop, the perforated intestinal loop was applied primary repair, and the hernia defect was primarily repaired. The patient with postoperative respiratory insufficiency died on the postoperative 22nd day.

Conclusion

In older women, decreased preperitoneal fat tissue around the obturator vessels or atrophy prepares a ground for the development of obturator hernia. Therefore, the obturator hernia in the age group is called “little old lady’s hernia.” Conditions that increase intraabdominal pressure, such as advanced age, weight loss, constipation and COPD, and the presence of intraabdominal acid are the other risk factors. When obturator hernia causes compression on the obturator nerve, the Howship-Romberg sign appears. Because the mass is concealed under the pectineal muscle in obturator hernia, it is difficult to palpate it. In the presence of non-specific leg pain or intermittent abdominal pain in the elderly and thin women, obturator hernia should be remembered in the differential diagnosis. In addition to anamnesis and physical examination, imaging techniques have a leading role in diagnosing. Whatever surgical approach we choose, the most important thing is intervention on time.

TJS. 2018;34(Suppl-1):S348–S349.

PP-0300 [Hernia Surgery]. The Effect of Onlay and Inlay Patch Applications on Recurrence in Incisional Hernia Repair

Turan Acar ¹, Nihan Acar ¹, Yunus Sür ¹, Tuğba Balkaya ^1,^✉, Mehmet Hacıyanlı ¹, Erdinç Kamer ¹, Kemal Atahan ¹, Hüdai Genç ¹

Objective

The selection of incision type, way of incision closure, and suture material that is used are important factors to prevent the development of hernia. Our goal should be to apply the best method that will lead to the least recurrence with the best technique. Surgical options include primary repair and open or laparoscopic repair with mesh. Repair with mesh can be performed as onlay, sublay, and inlay according to the area where the repair mesh is to be laid. In this retrospective study, it was aimed to compare the recurrence rates in patients who underwent hernia repair with onlay or inlay technique due to incisional hernia.

Material and Method

In this retrospective study, 185 patients operated due to incisional hernia in our clinic between January 2012 and October 2017 were included. The patients were divided into two groups, as those undergoing onlay hernia repair (Group 1) and those undergoing inlay hernia repair (Group 2). In both groups, prolene mesh with the same features was used.

Results

Incisional hernia repair was performed in a total of 185 patients, including 121 patients in Group 1 and 64 patients in Group 2. There was a statistically significant difference between the groups in terms of body mass index (BMI), duration of hospital stay, wound site infection, mesh rejection, postoperative ileus and necrosis. This difference was found to be due to higher rates in the patient group undergoing inlay repair.

Conclusion

We suggest that onlay technique will be more appropriate than inlay technique if we only use prolene mesh because both recurrence and postoperative morbidity rates are lower.

TJS. 2018;34(Suppl-1):S349.

PP-0301 [Hernia Surgery]. The Effect of Non-Mesh Repair on Recurrence in Femoral Hernias

Nihan Acar ¹, Turan Acar ¹, Feyyaz Güngör ^1,^✉, Sercan Candan ¹, Ahmet Er ¹, Fatma Tatar ¹, Osman Nuri Dilek ¹

Objective

Results

Twenty (50%) of the 40 patients included in the study were treated with TAPP and 20 (50%) patients with the Lichtenstein technique. The mean age was 45.7 (24–62) years for the patients undergoing TAPP and 51.25 (21–66) years for the patients undergoing the Lichtenstein method. According to VAS, the pain average of the patients in the TAPP group was 1.9 at the 1st hour, 2.9 at the 3rd hour, 2.5 at the 6th hour, 2.2 at the 12th hour, 1.5 at the 24th hour, 0.6 in the 1st week and 0.2 in the 2nd week. On the other hand, in the Liechtenstein group, these scores were 3.1 at the 3rd hour, 3.9 at the 6th hour, 3.8 at the 12th hour, 3.2 at the 24th hour, 1.5 in the first week and 0.8 in the second week. Of the patients in the TAPP group, 18 (90%) stated that they were able to carry out their daily activities easily at the end of the first week, whereas 13 (65%) of the patients in the Lichtenstein group stated that they were able to do their daily activities. In the postoperative period, no complication occurred in the patients in the TAPP group. In the Lichtenstein group, an approximately 3 cm hematoma was observed in one patient on the first postoperative day and it was drained.

Conclusion

Although there were no statistically significant differences in terms of early postoperative complications in patients who underwent TAPP and Lichtenstein techniques due to inguinal hernia, we found that TAPP repair technique was more costly but better in terms of pain especially in the early period, analgesic requirement, duration of hospital stay, and early return to work and daily activities.

TJS. 2018;34(Suppl-1):S351.

PP-0304 [Hernia Surgery]. Paratesticular Leiomyosarcoma Accompanying to Strangulated Inguinal Hernia

Birol Ağca ^1,^✉, Yalın İşcan ¹, Timuçin Aydın ¹, Aytaç Şahin ¹, Adnan Somay ¹, Ahmet Çakmak ¹, Kemal Memişoğlu ¹

Sarcomas arising from spermatic cord are rare malignant tumors that constitute 2.1% of soft tissue sarcomas and that are seen in the genitourinary system at the rate of 1–2%. A 74-year-old male patient was admitted to our emergency unit with the complaints of inguinal pain and swelling going on for the last 3 days. In the physical examination, an approximately 5x5 cm hard non-reducible mass in the right inguinal region and right inguinal hernia were detected. The computed tomography revealed a large hernia sac in the right inguinal region and a 77x55 mm mass inside it. The patient was performed radical orchiectomy and hernia repair. In the pathological evaluation of the mass, the diagnosis of paratesticular leiomyosarcoma was established. Postoperative local recurrence or distant metastasis was not observed in the 7th month. In conclusion, although paratesticular leiomyosarcomas are rarely encountered, they should be kept in mind in the elderly patient group, especially with inguinal mass.

TJS. 2018;34(Suppl-1):S351.

PP-0305 [Hernia Surgery]. Our Experience of Inguinal Hernia Repair with Local Anesthesia in Patients with High ASA Score

Serhat Meriç ¹, Orkhan Valiyev ^1,^✉, Nihat Buğdaycı ¹, Erkan Yavuz ¹, Riza Kutanis ¹

Objective

The incidence of inguinal hernias and comorbid disease rate increase with age. If elective inguinal hernia repairs are performed under general or regional anesthesia in these patients, monitorization is required in the postoperative intensive care unit due to high ASA scores. Because of the high occupancy rates of the intensive care units and limited capacity in our country, suitable conditions for these patients cannot be provided and their surgeries are delayed. In our study, it was aimed to investigate the reliability of inguinal hernia repair with local anesthesia in patients with high ASA scores.

Material and Methods

The data of patients who underwent elective surgery with the diagnosis of inguinal hernia in the Department of General Surgery at Health Sciences University, Bağcılar Health Application and Research Center between May 2017 and January 2018 were evaluated retrospectively. The study included 32 patients having unilateral non-scrotal inguinal hernia without recurrence, having high ASA scores due to comorbid diseases, and requiring monitorization under the conditions of intensive care in the application of general or regional anesthesia. All patients underwent unilateral hernia repair with the Lichtenstein method under ilioinguinal-hypogastric nerve block and local infiltration. Patients’ demographic characteristics, comorbidities, ASA scores, duration of hospital stay, and complications were recorded.

Results

The mean age of the patients was 67.8±14.1 years and the female/male ratio was 2/30. Twenty-nine patients were ASA III and 3 patients were ASA IV. The mean duration of hospital stay was 16.3±6.8 hours. The comorbidities were hypertension in 26 patients, coronary artery disease and congestive heart failure in 16 patients, COPD in 12 patients, DM in 9 patients, CRF in 4 patients (requiring hemodialysis), cardiac pacemaker due to rhythm disorder in 4 patients, and previous CVE in 2 patients. As a complication, subcutaneous hematoma was detected in 2 patients after operation. At the time of transition to general anesthesia and hospitalization, no second surgery was needed in any patient. Despite the insufficient time of follow-up, no recurrence was observed.

Conclusion

The inguinal hernia repair under local anesthesia in all age groups with high ASA score can be safely performed with low complication rates and without the need for intensive care follow-up.

TJS. 2018;34(Suppl-1):S351–S352.

PP-0306 [Hernia Surgery]. Intraperitoneal Ventralex Patch Applications in Ventral Hernia Repairs

Birol Ağca ^1,^✉, Yalın İşcan ¹, Ender Onur ¹, Ahmet Çakmak ¹, Kemal Memişoğlu ¹

Ventral hernias are among the common conditions in surgical practice and umbilical hernias are the most frequently encountered ones of them. The development of recurrence at the rates varying from 10% to 54% after the repair of ventral hernias with primary suture techniques (herniorrhaphy) have made patch repairs (hernioplasty) popular. In our clinic, a total of 71 patients were operated by using the Ventralex patch, one side of which was ePTFE and the other side was polypropylene and which could be administered intraperitoneally, between January 2015 and June 2017. Hernias larger than 3 cm were not included in the study. Small ventral hernias were repaired with open surgical method by intraperitoneal tension-free method. Of the patients, 40 were male and 31 were female, and the mean age was 47.5 (range 28–74) years. According to the ventral hernia typing, there were 46 cases with umbilical hernia (65%), 18 cases with paraumbilical hernia (26%), and 7 cases with trocar site hernia. All cases were operated under general anesthesia. Duration of operation, analgesic requirement, duration of hospitalization, postoperative complications, and recurrences were recorded. The mean duration of surgery was detected to be 35 min (range 22–60). All patients were applied analgesia on the first day after surgery and discharged one day after the operation. They were asked to come for the first control examination after 1 week and for the second control examination after 4 weeks. Minimal wound site infection was observed in two cases (2.8%). No recurrence developed in any case. In our study, we concluded that the Ventralex patch used in small ventral hernia cases that were operated with open technique is a prosthetic material that can safely be used owing to its advantages including low complication rate, ease of application and shorter hospitalization.

TJS. 2018;34(Suppl-1):S352–S353.

PP-0307 [Hernia Surgery]. Case Report: Amyand Hernia

Ozan Akıncı ^1,^✉, Yasin Tosun ¹, Burcu Aydınlı ¹, Abdullah Kağan Zengin ¹

Introduction

Amyand hernia, which was first introduced to literature by Cladius Amyand in 1735, is defined as the presence of an inflamed or non-inflamed appendix vermiformis in the inguinal hernia sac. Amyand hernias constitute about 1% of all inguinal hernias. They are more common on the right side due to the anatomical location of the appendix on the right side. The diagnosis is usually established during the operation. Its treatment is primarily based on surgical approach and the treatment may vary depending on appendix inflammation, surgical site contamination, age, and the size of the hernia defect.

Case

A 38-year-old male patient having a swelling in his right groin for 3 months was admitted to our clinic due to a pain in his right groin for 48 hours. In the physical examination of the patient, who was learned to have used methamphetamine in his anamnesis, an irreducible painful swelling in the right inguinal region and tenderness in the right lower quadrant were detected. He had no nausea and vomiting and he was able to defecate. In the laboratory analysis, leukocytosis(16,000 mm3) and elevated CRP (16mg/L) were found. The patient was operated under spinal anesthesia with the diagnosis of incarcerated inguinal hernia on the same day. When the hernia sac was opened, it was seen that there was an erected, inflamed appendix with necrotic distal area in the sac. Lichteinsten inguinal hernia repair was performed with appendectomy, high ligation and mesh. Pathologic examination result was consistent with gangrenous appendicitis. The patient was discharged on the first postoperative day with recovery.

Conclusion

Conclusion

The rate of postoperative complications is 1–3.5% in elective inguinal hernia repairs. They are usually observed as a result of blunt dissection of vas deferens and testicular vessels during surgery. Scrotal edema and hematoma are the most common complications of hernia repair. Scrotal necrotizing fasciitis is a rarer but mortal complication. Fournier’s gangrene (FG) is a rare bacterial infection that can be progressive and lethal, which manifests itself with the necrosis of the subcutaneous tissue and fascia in the perineal, genital or perianal regions. Fournier gangrene typically begins in the labium region in women and scrotum region in men, and rapidly spreads to the perineal, gluteal and abdominal regions. Necrosis rapidly spreading in the tissues often results in systemic sepsis, toxic shock syndrome, and multiple organ failure. The most commonly reported bacteria are Gram-positive aerobes such as enterococci and streptococci; Gram-negative aerobes such as E. coli and P. aeruginosa; and anaerobes such as Clostridium and Bacteroides. Early diagnosis and wide surgical debridement are very important in the treatment. The VAC, that is negative pressure, increases the local blood flow in the wound areas, provides a significant shrinkage, acceleration in the development of granulation tissue, and control of edema and wound secretion.

TJS. 2018;34(Suppl-1):S355.

PP-0311 [Hernia Surgery]. Management of Complications Associated With Abdominal Wall Defect Repair After Open Obesity Surgery: A Difficult Case

Elif Çolak ^1,^✉

Today, laparoscopic incisional hernia repair is preferred by many physicians due to less recurrence rate, less wound site infections and less tissue dissection. One of the most common complications of intraperitoneal patches used in laparoscopic incisional hernia repair is postoperative adhesions. In this study, we present a 62-year-old female patient requiring multiple hernia repair due to multiple abdominal wall defects after open obesity surgery. In the examination and abdominal tomography of the patient, who was performed open sleeve gastrectomy due to obesity 5 years ago and who had swelling on the abdominal wall 6 months after the operation, a 5 * 5 cm fascial defect was detected in the right lateral area of the laparotomy incision. The laparoscopic incisional hernia repair was performed to the patient with an intraperitoneal patch. The abdominal tomography, which was taken one year after the operation because of her continuing abdominal pain, revealed recurrence. The patient was applied onlay mesh repair with open surgery then. The patient, who had the complaint of leakage from the last surgical incision, was hospitalized and given antibiotherapy. However, since the leakage continued despite antibiotherapy, the patient was operated for the excision of the onlay mesh. It was seen during operation that the onlay mesh was infected and there was an intestinal fistula. The mesh was excised. End-to-end anastomosis was performed by resecting the intestinal loop adhered to the mesh. Because it was observed in the exploration that the intraperitoneal patch was adhered to the small intestine loops, adhesiolysis was applied. The fascial defect was primarily repaired. Vacuum-assisted drainage was applied to the patient with postoperative wound dehiscence. On the postoperative 35th day, the patient was discharged with surgical healing.

The rate of incisional hernia after open surgery, especially in obese patients, is quite high. Severe complications of the patch after incisional hernia repair can develop. As much as possible, open surgery should be avoided in obese patients.

TJS. 2018;34(Suppl-1):S355–S356.

PP-0312 [Hernia Surgery]. A New Method for Laparoscopic Repair of Inguinal Hernias: Mesh Preparation and Different Fixation Area

Kenan Büyükaşık ¹, Aziz Arı ¹, Özhan Albayrak ^1,^✉

Objective

Laparoscopic inguinal hernia repairs have become more popular than open repairs due to their advantages since 1992, when they were defined by Dulucq. The transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP) approaches have mainly been described for the repair. In these techniques, mesh fixation is usually done in the preperitoneal area with tact. This increases the cost and can cause certain complications, especially chronic pain. Based on our previous work, ‘A new method in the repair of femoroinguinal hernias by videolaparoscopic way (sakman method)’, we proposed a method eliminating classical mesh fixation areas and related complications but does not increase the recurrence rate and we analyzed the results in the light of the literature.

Material and Methods

Male patients with the ASA score of 1–2 and the diagnosis of inguinal and femoral hernia, who were between the ages of 18 and 80 years, were included in the study. Those who were not suitable for general anesthesia, those with medication or alcohol addiction and coagulopathy, those who had a history of previousl surgery were excluded from the study. The included patients were followed up peroperatively and until postoperative 24th month. The data were analyzed with the literature.

Surgical technique

The patients were operated with the 3-port classical TEP approach. We used the mesh prepared different from classical application and subcutaneous fixation area that we proposed.

Mesh preparation and application

The 15x15 cm polypropylene mesh was cut in the shape of T at a distance of 2.5 cm from the edge. The short legs were rolled and shaped as a plug, like a cigarette. One third of the plug of the mesh was folded on itself and fixed with a vicryl suture. Thus, a 10x15 cm mesh folded on its own with a 1/3 lateral plug was obtained. The end of the plug was fixed by gently approximating with vicryl suture and this suture was left long to be pulled under the skin. This mesh was left to the preperitoneal area from the camera port by adjusting the medial-lateral coordination of the plug according to the location of the defect. The vicryl suture on the top of the long plug was carefully extended towards the subcutaneous area from the hernia defect in the preperitoneal region with the help of a conventional laparoscopic instrument and removed from the skin with an about 1–2 mm incision on the skin. Thus, the spread of the mesh into the preperitoneal area by including the mycopectineal orifice was ensured provided that the plug was in the defect. The vicryl suture removed outside was fixed in the subcutaneous area.

Results

In patients applied the repair procedure with the ‘plug mesh and subcutaneous vicryl fixation’ technique that we developed, we obtained shorter duration of hospitalization, less postoperative analgesic requirement, decreased urinary retention, and seroma rates compared to other laparoscopic techniques described in the literature. There was also no significant difference in the time of return to normal activities and recurrence of hernia in 24-month follow-ups.

Conclusion

The ‘plug mesh and subcutaneous vicryl fixation’ technique that we developed in laparoscopic TEP inguinal hernia repair decreases the need for narcotic analgesia, duration of hospital stay, and development of urinary retention and seroma and additionally, causes no increase in the recurrence rate. Moreover, it is advantageous in terms of cost and it is a technique that can be preferred in suitable cases.

TJS. 2018;34(Suppl-1):S356.

PP-0313 [Hernia Surgery]. Case of Suprafascial Giant Hematoma Cyst Developing After Umbilical Hernia Repair

Aydın Öztürk ^1,^✉, Mehmet Yılmaz Akgün ¹

A 42-year-old female patient was admitted to our department because of swelling on the abdominal wall. The patient had been operated for umbilical hernia in an external center 5 years ago. Due to the development of recurrence, she was re-operated in the external center on May 2017 and then, she was re-admitted with a 17x10 cm cystic mass under the surgical site on June 2017. The cyst was followed up and the 15x12 cm cyst showed continuity in the control USG performed on August 2017. On September 2017, the cyst was excised. The pathological result was reported as a fibrin-containing pseudocyst. On January 2018, the patient consulted to our department and her general condition was good and vital findings were normal in the physical examination. There was a 20x20 cm mobile mass extending from the epigastric region to the subumbilical area in the abdomen wall, and not causing tenderness. The values of the complete blood count and biochemical parameters were normal. In the operated patient, the mass considered to be hematoma with a cystic septa having a total weight of 3360 g was totally removed. Absorbent drain was placed on the fascia under the skin. The patient was discharged with absorbent drains after observing the absence of postoperative decrease in hemogram. Postoperative hemorrhage in the abdominal wall hernias is a rarely encountered condition. Insufficient hemostasis control can cause this condition. In this case, it was seen that the small leakages that could not be noticed after the operation turned into a giant mass by forming a cyst wall over time. It is important that the absorbent drains should not be removed from the surgical site until the disappearance of fluid in the drains and abdominal corsets should be used for the purpose of compression.

TJS. 2018;34(Suppl-1):S356–S357.

PP-0314 [Hernia Surgery]. A Rare Hernia that is Commonly Diagnosed Intraoperatively: Amyand Hernia

Uğur Topal ^1,^✉, Mevlüt Harun Ağca ¹, Erdi Aydın ¹, İsmal Cem Eray ¹

Introduction

Although the inguinal hernia is a very common disease, Amyand Hernias, which are characterized by the presence of an appendix in the inguinal hernia sac, constitute approximately 1% of cases. Appendix in the inguinal hernia was first reported by Claudius Amyand in 1735. The preoperative diagnosis of the disease is very difficult. This rare clinical condition may cause changes in the peroperative surgical treatment options. In our case report, we wanted to draw attention to a rare type of hernia.

Case

A 67-year-old male patient was admitted to the outpatient clinic of general surgery with the complaints of swelling and sometimes cramp-like pain in the right groin, which were continuing for 3 years. In the physical examination, indirect inguinal hernia was detected in the right inguinal region. There was no finding in his abdominal examination. The patient was prepared for surgery after diagnosing the indication for surgery. The patient was administered general anesthesia and performed a skin incision over the right inguinal canal. The layers were passed and the spermatic cord was suspended over the pubic tubercle. The hernia sac was severely adhered to the surrounding tissues. Cremaster muscle fibers were dissected and hernia sac was isolated. A hard long mass was palpated in the sac besides the intestinal loops. Upon that, the hernia sac was opened and appendix vermiformis was seen in normal appearance. The appendix was reduced into the abdomen. Then, hernioplasty was performed and the operation was terminated. The patient was discharged on the 1st postoperative day without any problems.

Conclusion

The inguinal hernia is defined as the protrusion of a portion of abdominal organ or organs through the weak points of the abdominal wall together with the peritoneum. Although the pathophysiology of Amyand’s hernia is not clear yet, it is defined as a chronic process. Because patients generally present with strangulated hernia when the appendix is inflamed or perforated in the hernia sac, it is difficult to establish preoperative diagnosis. Treatment approaches in Amyand hernia are still controversial today. If the appendix is inflamed, appendectomy is applied. The application of appendectomy in the detection of normal appendix vermiformis in the sac is controversial because of the infection risk in routine hernia repairs. Another controversial issue is the use of prosthetic material for hernia repair. It has been reported that the placement of prosthetic material into the surgical site in adult patients with Amyand’s hernia will increase the risk of infection or the placement of patch is contraindicated in cases with perforated appendix. Amyand’s hernia, which is rarely encountered, should be kept in mind and general surgeons should have knowledge about the treatment and follow-up of this disease.

TJS. 2018;34(Suppl-1):S357.

PP-0315 [Hernia Surgery]. Is Recurrent Incisional Hernia an Obstacle for Laparoscopic Repair?

Koray Baş ^1,^✉, Orkun Subaşı ¹, Hilmi Yazıcı ¹, Savaş Yakan ¹

The incidence of incisional hernia, which is defined as abdominal wall hernias developing from the incision line of previous abdominal surgery for any reason, has been reported in an average rate of 10–15% and this rate increases up to 23% in the presence of postoperative wound infection. Obesity, smoking, advanced age, inappropriate use of surgical material or technique, and all factors that can lead to immunosuppression, and particularly infection, increase the risk of incisional hernia. While open technique is preferred by most of the centers in the incisional hernia repair at present, the use of laparoscopic incisional hernia repair is gradually increasing because of increased laparoscopic surgical experience, technological improvements in the laparoscopy systems, and easy access to patches suitable for intraabdominal usage and fixation devices. However, laparoscopic applications in recurrent hernia repair still remain in the background in surgical clinics.

In this report, we present a 55-year-old female patient who had undergone appendectomy with Mc Burney incision about 30 years ago and then 3 hernia repairs due to recurrent hernias on the same incision line and whose 4th hernia repair was performed laparoscopically.

In the abdominal computed tomography performed for the suspect of recurrence hernia in the incision line in the right lower quadrant, the hernia was observed to include a single sac. The intraperitoneal adhesions were dissolved with the help of one 10 mm and two 5 mm ports and an energy device. The omental tissue in the hernia was taken into the abdomen. After doing necessary measurements, serosal surfaces and two-sided patch were laid in the hernia area and the patch was circumferentially fixed to the anterior abdominal wall with fixation sutures of the 4 quadrants and then absorbable fixation device. No drain was used.

During the preparation of the patient and the surgical procedure, the guideline of the SAGES (Society of American Gastrointestinal and Endoscopic Surgeons) for laparoscopic ventral hernia repair published on June 2016 was considered. The patient was started oral intake at the 6th postoperative hour and she was discharged on the 2nd postoperative day. In centers with surgeons educated and experienced on minimally invasive surgical field, we think that recurrent incisional hernias can be safely treated with laparoscopic methods as in this case and chronic pain and cosmotic problems associated with open surgery will decrease and quality of life will increase.

TJS. 2018;34(Suppl-1):S357–S358.

PP-0316 [Hernia Surgery]. Umbilical Trocar Site Hernias Developing After Laparoscopic Cholecystectomy

Mehmet Torun ^1,^✉, Hakan Özdemir ¹

Objective

The primary treatment of symptomatic cholelithiasis is laparoscopic cholecystectomy. It has lower rate of postoperative complications than open cholecystectomy and it is a more comfortable operation for the patient. The trocar site hernias are uncommon disorders after laparoscopic cholecystectomy, but they may lead to conditions that may result in even bowel resection. In this study, it was aimed to retrospectively evaluate the hernias of the umbilical trocar entry site after laparoscopic cholecystectomy.

Material and Methods

The data of 18 patients who were operated due to the development of hernia in the umbilical port site after laparoscopic cholecystectomy between 2013 and 2017 were retrospectively evaluated.

Results

It was learned from the anamneses of the patients that they underwent laparoscopic cholecystectomy operations in different centers. All 18 patients complained of pain in the umbilical region. Two patients were firstly examined in the emergency service and operated due to incarcerated hernia. Sixteen patients were electively operated. Of the patients, 61.1% (n=11) were female and 38.1% (n=7) were male. Their mean age was 46.06 (33–60) years. The mean body mass index (BMI) was detected to be 34.4 (27–42). The patients noticed the hernia sac at trocar entry site at a mean time of 22.72 (11–38) months. The mean time from the recognition of hernia until the surgery was 34.06 (12–51) months and the mean fascial defect size was 30.94 (18–50) millimeters. Despite the higher number of female patients, no statistical correlation was found between sex and herniation. Three patients (16.6%) had leakage from the umbilicus trocar site at the postoperative first week, but they were not given any antibiotherapy.

Conclusion

Hernia development after laparoscopic cholecystectomy is often noticed in the postoperative 2nd year and patients wait for the surgery decision approximately for 3 years. Growth of hernia sac and increase in pain are thought to affect this situation. It is thought that the umbilical trocar entry site is risky for the development of hernia particularly in patients with high BMI and careful repair of the fascial defect in the umbilical region will reduce the risk of hernia.

TJS. 2018;34(Suppl-1):S358–S359.

PP-0317 [Hernia Surgery]. The Relationship of Our Results with Experience in Patients Undergoing TEP

Gülten Çiçek Okuyan ^1,^✉, Mehmet Talu ¹, Ali Sürmelioğlu ¹, Metin Tilki ¹

Objective

We aimed to evaluate inguinal hernia patients undergoing TEP in our clinic between February 2012 and December 2017 in terms of complications and recurrence and to demonstrate the importance of experience.

Material and Methods

Standard technique was applied by a single surgeon. Exploration was performed by inserting one 10 mm infraumbilical port and two 5 mm ports without using balloon. Prolene mesh in the size of 10*13 cm was fixed with tacker. The patients were evaluated in terms of their ages, sexes, duration of surgery, hernia type, duration of hospitalization, peroperative and postoperative complications, conversion to open surgery, and recurrence parameters.

Results

Between February 2012 and December 2017, a total of 148 laparoscopic TEPs were performed to 111 patients. The age range was 20–81 years, 10 of the patients were female and 91 were male. There were 37 bilateral hernias and 74 unilateral hernias, and 94 of them were indirect and 64 were direct. The duration of the operation varied from 35 minutes to 124 minutes, and the patients were discharged on the first postoperative day on average. The peroperative complications were bleeding from the port in one patient, opening of the peritoneum in 20 patients, and conversion to open surgery in 8 patients. The postoperative complications were pain in 5 patients, which continued mostly for 3 months, seroma in 4 patients, and recurrence in 4 patients.

Conclusion

One of the most important challenges of the TEP technique is to work in a small area and not to be accustomed to anatomy. Working on the accurate plane and paying attention to specific anatomical points are important parameters. There are publications reporting the learning curve in 80 cases or 20–50 cases. We saw that the duration of the surgery decreased as experience increased. While the rate of peritoneal opening was reported as 11% on average in the publications, it was found to be 18% in our cases. Inferior epigastric vessel injuries were reported as 0–3% and organ injuries as 0,1% in literature, but they were not seen in our patients. While the development rate of seroma was reported between 1.9 and 11%, it was 3.6% in our study. Seroma formation was found to be associated with major defect. Pain was reported as 12.4% in open surgery and 4.5% in laparoscopic surgery and we observed as 4.5%. While conversion to open surgery was accepted at the rate of 1–10%, it was found as 7.2% in our cases. The reasons for conversion to open surgery are inability to fully reveal the anatomy (drastically reducing working area with the opening of the peritoneum, entering the wrong plan, etc.) and irreducible hernia sac. Recurrence is an important problem seen after inguinal hernia repairs. Recurrence, which was reported to be at the rate of 1–4% on average, it developed in 3.6% of our cases in the first year. This demonstrates the importance of experience, in other words learning curve.

In conclusion, we tried to reveal the relationship between experience and outcomes in total extraperitoneal hernia repair by demonstrating that parameters such as complication, conversion to open surgery and recurrence were more frequently observed within the first year.

TJS. 2018;34(Suppl-1):S359.

PP-0318 [Hernia Surgery]. Our One-Year T.A.P.P. Experience in Inguinal Hernia Repair

Semra Demirli Atıcı ^1,^✉, Emran Kuzey Avcı ¹, Halit Batuhan Demir ¹, Can Arıcan ¹, Mehmet Üstün ¹, Levent Uğurlu ¹, Cengiz Aydın ¹

Objective

We see that the use of laparoscopic procedures in inguinal hernia repair is gradually increasing and becoming widespread along with developing technology. Compared to open surgery, laparoscopic inguinal hernia repair has advantages such as lower risk of postoperative pain and infection, earlier return to the daily activities, and better cosmetic results. There are two commonly used methods in laparoscopic inguinal hernia repair. One of them is total extraperitoneal preperitoneal (TEP) hernia repair and the other is trans-abdominal preperitoneal (TAPP) hernia repair. In this report, it was aimed to present patients admitted to İzmir Tepecik Training and Research Hospital between 2017 and 2018 for inguinal hernia and performed TAPP with their demographic characteristics.

Material and Methods

The patients undergoing TAPP due to elective inguinal hernia in the department of general surgery between 2017 and 2018 were retrospectively analyzed in terms of age, gender, duration of operation, hospitalization and postoperative complications.

Results

Of the 46 patients included in the study, 3 were female (6.53%), 43 were male (93.47%), and the mean age was 46.2 years (age range: 20–77 years). In the preoperative physical examinations of the patients, it was found that 26 patients had right inguinal hernia (56.5%), 10 patients had left inguinal hernia (21.7%), and 10 patients had bilateral (21.7%) inguinal hernia and they were operated. The mean duration of operation was 107 minutes and this time was 92 minutes in unilateral hernia repair. Only in one patient, the surgical technique was switched to open technique due to technical insufficiency, and the operations of remaining 45 patients were completed laparoscopically. The patients were mobilized at the postoperative 6th hour as a standard approach, their foley catheters were removed, and they were started oral intake. The mean duration of hospitalization was detected as 1.2 days. No complication or recurrence was observed in the follow-up of postoperative patients.

Conclusion

The most important advantages of laparoscopic hernia operations include less need for postoperative analgesia, earlier return to daily activities, ability to perform repair in bilateral hernias at the same session, and good cosmesis. The prolonged surgical period and high cost with general anesthesia still remain to be disadvantages.

TJS. 2018;34(Suppl-1):S359–S360.

PP-0319 [Hernia Surgery]. Perforated Appendicitis Mimicking Incarcerated Inguinal Hernia

PP-0325 [Hernia Surgery]. Retrospective Comparison of Titanium and Polypropylene Meshes in Patients Undergoing Anterior Onlay Mesh Hernioplasty with the Diagnosis of Ventral Hernia

Çağrı Akalın ^1,^✉

Objective

In the anterior approach to ventral hernioplasty operations, there is no standard use of patch. In this study, titanium (Ti mesh, light, 35 g/m2) and polypropylene (Prolene mesh, heavy, 80 g/m2) patches were examined in patients who underwent anterior onlay mesh hernioplasty with the diagnosis of ventral hernia and the analysis of data was aimed.

Material and Methods

The data of 129 patients undergoing anterior onlay titanium and polypropylene mesh hernioplasty for the diagnosis of ventral hernia in the General Surgery Department of Ordu University Training and Research Hospital between May 1, 2014 and May 1, 2017 were retrospectively examined.

Results

Patients with ventral hernia were performed hernioplasty with onlay titanium and polypropylene mesh. Of these patients, 88 were applied polypropylene mesh and 41 were applied titanium mesh. While no recurrence and mesh reaction was observed in both groups in the post-operative period, there was no statistically significant difference between the groups in terms of hospitalization, infection, hematoma, wound site infection, and seroma (p> 0.05).

Conclusion

The use of patch in ventral hernia operations have almost become standard and the range of patches has increased with developing technology. The patches used in the hernia operations are classified among themselves and in our study, patches having different contents with the standards of light and heavy patches were compared. Of the used patches, the titanium one was light weighted and polypropylene one was heavy weighted. In our study, there was no statistically significant difference in the postoperative outcomes between two groups for whom these patches were used (p>0,05).

TJS. 2018;34(Suppl-1):S363–S364.

PP-0326 [Hernia Surgery]. Spontaneous Ruptured Direct Inguinal Hernia and Small Bowel Meso Separation

Mehmet Nuri Koşar ¹, Yaşar Çöpelci ^1,^✉, Onur Özener ¹, Murat Kağan Bilge ¹, Hülya Evrim Özak ¹

Introduction

It is not a common complication of hernia that the direct inguinal hernia spontaneously ruptures from the skin and the eviscerated small intestines are separated from their meso. In the literature, there are such spontaneous rupture of femoral hernia, recurrent inguinal hernias, or incisional hernias, but no primary direct inguinal hernia has been reported. For cases of incisional hernia with spontaneous rupture in Poland and ruptured femoral hernia in Singapore have been reported. In this study, a direct inguinal hernia case with spontaneous rupture, which has not been reported previously in the literature, is presented.

Case

A 44-year-old female patient was admitted to the emergency unit in Antalya Training and Research Hospital with the complaints of rupture in the right groin and the protrusion of the small intestine. The patient was examined in the emergency service. It was learned from the anamnesis of the patient, who appeared very weak, that she had inguinal swelling for a long time and that her skin was torn due to severe cough on the day of the event and bleeding occurred in association with the protruded intestines. The patient and her relatives were questioned in detail for possible trauma or from legal aspect. It was understood that the event was spontaneous. In the physical examination, a 2 cm well-circumscribed skin opening in the right inguinal region and an about 1 meter necrotic small intestine segment separated from its meso were observed. The patient was operated urgently. The small intestine segment separated from the meso was resected and end-to-end enteroenterostomy was performed. The opening area in the right inguinal area was sutured. The patient, whose oral intake was initiated on the postoperative 3rd day, was discharged on the 5th day with healing. When the patient completed the postoperative 3rd month without any problems in the follow-ups, she was electively operated for right direct inguinal hernia and mesh herniorrhaphy was carried out. She was discharged without complications.

Conclusion

Inguinal hernias constitute 75% of all hernias. They are seen in a 25 times higher rate in men than in women and 2/3 of inguinal hernias are indirect hernias. Direct inguinal hernias are also encountered 10 times more frequently in males. Spontaneous rupture is theoretically possible in all types of hernias, but generally reported in incisional hernias. Spontaneous rupture can occur in situations such as constipation, coughing, straining, and heavy lifting, which increase the intraabdominal pressure. Other factors that may cause the rupture are the corsets or clothes used by the patient, which can cause squeezing or crushing. The difference of this case is that the patient was female and weak and the hernia was direct and developed spontaneous rupture. No similar case has been reported in the literature. As a result, it should not be forgotten that the hernia, either direct or incisional, is a disease that must be treated electively before the development of complications. In this study, we presented a case of inguinal hernia that was spontaneously ruptured and resection of small intestine segment after separation from its meso, which can be seen very rarely.

TJS. 2018;34(Suppl-1):S364.

PP-0327 [Hernia Surgery]. Acute Intestinal Obstruction Case Secondary to Left Paraduodenal Hernia: Case Report

Ersin Kılıç ^1,^✉, Sertaç Ata Güler ¹, Ömer Yavuz ¹, Turgay Şimşek ¹, Nuh Zafer Cantürk ¹

Paraduodenal hernias are the most common type of internal abdominal herniation and they are a rare cause of acute intestinal obstruction. The left paraduodenal hernia is 3 times more common than the right paraduodenal hernia. While it is rarely defined in the preoperative period, its diagnosis can be made by abdominal imaging performed during the symptomatic period. Delays in diagnosis and surgical treatment can cause high morbidity and mortality. In this study, a patient who was admitted due to the complaints of nausea, vomiting and abdominal pain, operated with internal herniation pre-diagnosed in the abdominal computed tomography, and peroperatively found to have left paraduodenal hernia was presented.

TJS. 2018;34(Suppl-1):S364.

PP-0328 [Hernia Surgery]. Foreign Body-Induced Perforation in Incarcerated Incisional Hernia: A Case Report

Ersin Kılıç ^1,^✉, Sertaç Ata Güler ¹, Gökhan Pösteki ¹, Ömer Yavuz ¹, Nihat Zafer Utkan ¹

The perforation of the gastrointestinal system due to ingested foreign bodies may manifest itself with different clinical pictures, and the correct diagnosis is rarely established preoperatively. In our case, foreign body-induced (chicken bone) perforation without strangulation was detected in a patient operated with the pre-diagnosis of small intestine perforation secondary to incarcerated incisional hernia. It should not be forgotten that if a possible foreign body in the incarcerated bowel segment cannot progress due to angulation in the tract, it may cause ulceration and perforation on the intestinal wall. Computed tomographies of patients should be interpreted carefully considering that there may be foreign bodies in the herniated area.

TJS. 2018;34(Suppl-1):S365.

PP-0329 [Hernia Surgery]. A Rare Case: Left Paraduodenal Hernia

Ahmet Yazıcı ¹, Adem Aktaş ¹, Mehmet Uluşahin ^2,^✉, Sercan Büyükakıncak ¹

Introduction

Paraduodenal hernia (PH) is the most common type of internal herniation. It appears more often on the left side. In this article, a case of left paraduodenal hernia (LPH) will be presented.

Case

A 47-year-old male patient was admitted to the emergency service with the complaint of abdominal pain ongoing for a day. The patient’s pain was intermittent. The complaints of nausea and vomiting also accompanied abdominal pain. It was learned that the last gas-stool discharge of the patient was 2 days ago and he had similar complaints for 10 years and they usually healed with symptomatic treatments. He had no history of a known additional problem, drug use or previous operation. Sensitivity and defense were detected in the umbilical region and left quadrants in the abdominal examination of the patient, but no significant distention was detected. There was no abnormality in the direct abdominal radiography in standing position. Blood values were not found to be pathological except for the value of leukocyte as 11800/μL. Although the abdominal computed tomography (CT) did not reveal a pathognomonic finding, suspicious signs were reported in terms of LPH. Emergency operation was recommended to the patient. In the laparotomy, approximately 50 cm small intestine loop was herniated form a defect near the Treitz ligmanet towards the retroperitoneum, there was no necrosis, and there was minimal dilatation in the intestinal loops. After the intestine loops were reduced to the abdomen, the hernia sac entry was sutured with absorbable suture. The oral intake of the patient was initiated on the 2nd postoperative day and he was discharged on the 4th day. No problems were encountered in his follow-ups.

Discussion

LPH is a condition that is usually caused by abnormal rotation of midgut. It is characterized by the entrance of intestine loops into the area known as Landzert fossa in the lateral area of the 4th part of the duodenum. Patients mostly consult with abdominal pain intermittently going on for a long time and the complaints of nausea, vomiting, and inability to defecate can also be reasons for admission. In physical examination, different findings depending on the degree of ileus and peritonitis can be encountered. In X-ray, air fluid levels and clustered intestine loops in the LPH can be seen. Abdominal computed tomography (CT) is usually successful at diagnosis, but the symptoms of LPH may be similar to those of many intraabdominal pathologies and this can lead to delayed diagnosis or misdiagnosis when not evaluated carefully. Despite imaging methods, LPH cases that can be diagnosed only by laparotomy are not rare. Laparoscopic or open method may be preferred for the treatment of LPH. Firstly, the intestine loops in the LPH sac are reduced into the abdomen. Primary repair of the sac entry is the most preferred method. The sac entry can be left by expanding or the hernia sac can be excised completely. If necrosis is present in the intestine loops, resection can be required and the morbidity and mortality rates of these patients are higher.

Conclusion

LPH is a rare cause of acute abdomen. The early diagnosis is very important for the life of the patient who are generally admitted with the picture of intestinal obstruction.

TJS. 2018;34(Suppl-1):S365.

PP-0330 [Hernia Surgery]. Laparoscopic Morgagni Hernia Repair in an Adult Patient

Süleyman Kalcan ^1,^✉, Muhammet Kadri Çolakoğlu ¹

Morgagni hernia was first described in 1769. It is a rare type of diaphragm hernia. It is congenital and it results from the inadequate junction of diaphragm. It is usually asymptomatic and more common in women. When it becomes symptomatic, it can cause acute abdomen findings such as obstruction. The most herniated organs are the omentum and the transverse colon. A 84-year-old male patient presented with the complaints of vomiting and abdominal pain to the emergency unit and he was found to have obstruction associated with Morgagni hernia. Diaphragmatic hernia repair was performed with dual mesh by laparoscopic method. The patient was discharged without any problems. No recurrence was observed in the thoracoabdominal computed tomography taken in the postoperative 6th month.

TJS. 2018;34(Suppl-1):S366.

PP-0331 [Hernia Surgery]. Our Experience of Laparoscopic Inguinal Hernia

Ahmet Ziya Balta ^1,^✉, Zafer Şenol ¹, İlker Sücüllü ¹, Süleyman Atalay ¹, Ayhan Öz ¹, Yavuz Kurt ¹

Objective

Inguinal hernia surgery is one of the most common elective operations in general surgery practice. The inguinal canal anatomy differs anteriorly and posteriorly. In the laparoscopic surgery performed with posterior approach, the closure of direct, indirect, and femoral hernia points displays difference compared to the open technique because myopectineal orifice is closed with patch. In this study, we will present our clinic’s experiment in laparoscopic inguinal hernia.

Material and Methods

Patients who were diagnosed with inguinal hernia and treated laparoscopically in the HSU Sultan Abdülhamid Han HARC Department of General Surgery between 2012 and 2017 were included in the study. Both extraperitoneal (TEP) and transabdominal (TAPP) approaches were used. A dissection balloon was used for TEP in cases administered general anesthesia. In both approaches, a supraumbilical 10 mm camera port and two 5 mm study ports were used. After the hernia sac was peritonealized, a 10 x 15 cm sized patch was fixed to the cooper ligament with a wire stapler to close the myopectineal orifice in the medial area and it was fixed to the transvesus abdominis muscle in the lateral area.

Results

Of the 58 patients in our study, 56 were male and 2 were female. 26 of these patients had right, 14 left and 18 bilateral inguinal hernia. In our cases, 3 of right inguinal hernia cases and 1 of left inguinal hernia cases were recurrent cases. The mean age of our patients was 34 (21–67) years and 83.2% of the cases were operated with TEP and 13.8% with TAPP method. The mean duration of surgeries was calculated as 62 min (45–110). In the postoperative period, seroma was detected in 3 patients and treated conservatively. There was no postoperative wound site infection. When the pain score was evaluated, the mean VAS score was evaluated as 2 (1–3). The mean duration of hospitalization after the operation was found to be 2 days (1–3). In the long-term follow-ups of the cases, recurrence was detected in 2 patients (3.4%) at the early period and treated with open surgery.

Conclusion

In the comparison of laparoscopic inguinal hernia surgery with conventional surgery, it appears as a preferred technique with similar recurrence rates and with the advantages of laparoscopy such as less pain and early return to work.

TJS. 2018;34(Suppl-1):S366–S367.

PP-0332 [Hernia Surgery]. Stenosis of Garre: Abdominal Strangulation in Reduced Inguinal Herni

Leyla Zeynep Tigrel ^1,^✉, Adil Koyuncu ¹, Mustafa Ertuğrul Yurtteri ¹, Ekrem Ferlengez ¹

Introduction

In recent years, conservative observation has been replacing surgery in the management of small-bowel obstruction. On the other hand, in obstruction patients without history of operation, surgical treatment has been prioritized. Therefore, the history of operation in the anamneses of patients is very important. In the retrospective studies by Garre, it was reported that narrowing of the intestinal lumen with ischemia and fibrosis developing with venous stasis in the incarcerated intestine segment caused delayed intestinal obstruction. In our study, a case of intestinal stenosis of Garre with bowel obstruction recurring after incarcerated inguinal hernia repair was presented.

Case

A 47-year-old male patient was admitted to the emergency unit due to incarcerated inguinal hernia that caused acute mechanical intestinal obstruction and an emergency operation was planned. In the operation, the 10cm small intestine segment was observed to be hyperemic and edematous, the peristaltism was preserved, and the intestinal color was improved after the application of warm compress. The segment was reduced into the abdomen. The inguinal hernia defect was repaired in accordance with the Lichtenstein technique. The patient was discharged on the 2nd postoperative day. On the postoperative 11th day, the patient was admitted to emergency service because of abdominal pain. The intravenous contrast-enhanced tomography of the abdomen revealed dilatation in the small intestine, minimal increase in ileum wall thickness, and free fluid. After the conservative follow-up, the obstruction of the patient was regressed and he was discharged after 4 days. On the postoperative 22nd day, the patient consulted again and he was recommended to be followed up in the outpatient clinic because of no obstruction. On the 28th postoperative day, he was re-admitted to the emergency unit with distention and defecation. He was hospitalized and diagnostic laparoscopy was performed. At the exploration, it was seen that the small intestine loops were dilated and edematous, and there was intraabdominal diffuse free fluid. Thickening and fibrotic changes were observed in the approximately 10 cm ileal bowel loop in the 30 cm proximal area of the ileocecal valve. With the 5cm incision made from the right lower quadrant, this intestine loop was removed outside the abdomen and resected. Intestinal continuity was provided by ileo-ileal anastomosis with stapler. The patient was discharged without any problems on the postoperative 7th day. The pathological examination of the resected intestinal segment was reported as narrowing of the intestinal lumen, ulceration, granulation tissue, mixed type inflammatory infiltration in serosal areas, and fibrosis.

Conclusion

Abdominal symptoms after strangulated inguinal hernia repair were first defined by Richter. In 1892, a benign fibrous stricture developing after the reduction of strangulated inguinal hernia was described by Garre et al. Histopathological studies have shown that necrosis develops in the intestinal wall in long-term ischemia and mucosal ulcerations and fibrosis develop in short-time ischemia. It is difficult to define the intestinal stenosis of Garre because of the different causes of obstruction such as postoperative adhesions, recurrence and patch migration. In our case, physical examination, blood tests and radiological examinations were inadequate for diagnosis and the diagnosis of the patient was established through diagnostic laparoscopy. It should not be forgotten that intestinal stenosis of Garre can also be seen in the non-operated and reduced cases of hernia.

TJS. 2018;34(Suppl-1):S367.

PP-0333 [Hernia Surgery]. Our Laparoscopic Ventral Hernia Experience

Eyüp Murat Yılmaz ^1,^✉, Ethem Bilgiç ², Mustafa Gökhan Ünsal ¹, Ahmet Ender Demirkıran ¹

Objective

A common complication of abdominal surgery is incisional hernia. Ventral hernias constitute approximately 5–6% of all abdominal wall hernias. Various techniques have been developed in the surgery of ventral hernia. The first laparoscopic ventral incisional hernia repair (LVHR) was reported by LeBlanc and Booth in 1993. In this study, we aimed to examine laparoscopic ventral hernia repairs in our clinic demographically.

Material and Methods

The study included laparoscopic ventral hernia cases in Adnan Menderes University between December 2014 and February 2017. The ethics committee approval was not obtained because it was included retrospective file scanning. Patients’ ages, sexes, hernia sizes, durations of hospital stay, complications, and recurrence follow-ups were recorded.

Surgical Technique

The abdomen was insufflated until the intraabdominal pressure value of 12 mmHg by entering from the right or left lateral region with 12 cm trocar with open vision under general anesthesia. Subsequently, two study trocars were inserted into the left and right lateral sides of this trocar to reveal the hernia defect. After forming strong fascia edges, dual mesh was inserted into the abdomen through the 12 cm trocar. It was fixed on the abdominal wall with an absorbable tacker and the operation was terminated.

Results

Forty-two patients were included in the study. Of them, 30 (71%) were female and 12 (29%) were male. 24 (57%) had recurrent ventral hernia. The mean age was calculated as 42±6.7 years. The average fascia defect size was calculated as 8 cm (min: 3 cm, max: 15 cm). The mean duration of hospital stay was 2.1 days. The mean duration of operation was 42 minutes. The patients started liquid food on the postoperative 1st day and normal food on the postoperative 2nd day. It was observed that drain was not used in any patient. One patient (2.3%) developed hematoma and 1 (2.3%) patient developed ileus. No other complications were observed. The mean duration of follow-up was 6.2 months and recurrence was observed in 2 (4.6%) patients.

Conclusion

The ventral hernia repair has many types and its recurrence rates with simple suture are reported to be high. In randomized controlled trials comparing laparoscopic and open ventral hernia repairs, recurrence and complication rates are reported to be lower in laparoscopic repair. In our study, these rates were found as 2–3%. Laparoscopic ventral hernia repair is a method that shortens the duration of operation and provides convenience for the surgeons especially in recurrent defects.

TJS. 2018;34(Suppl-1):S367–S368.

PP-0334 [Hernia Surgery]. A Rare Complication After Bilateral TEP Hernia Repair: Entire Body Emphysema

Twelve patients with inguinal hernia and cholelithiasis were included in the study. The diagnosis of cholelithiasis was established through ultrasonography. Simultaneous intervention was not planned in patients with acute cholecystitis. The patients were firstly performed graft inguinal hernia repair with the TEP procedure and then performed laparoscopic cholecystectomy operation. The patients were postoperatively evaluated in terms of the duration of operation, duration of hospital stay, and complications.

Results

The mean duration of surgery was 54 minutes (42–65 min), the mean duration of hospitalization was 1 day, and the mean number of trocars was 6. No wound site or graft infection developed in any patient. Four patients were found to have spontaneously regressing seroma at the postoperative 1st month control.

Conclusion

With acceptable duration of surgery and short duration of hospitalization, the synchronous application of laparoscopic TAP hernia repair and laparoscopic cholecystectomy is a promising safe procedure because it does not increase the risk of graft infection, which is one of the most frightening hernia repair complications, in association with non-impaired peritoneal integrity in the graft region.

TJS. 2018;34(Suppl-1):S373.

PP-0346 [Hernia Surgery]. Laparoscopic Repair of Recurrent Hiatal Hernia with GRAFT

Can Konca ^1,^✉, Burak Kutlu ¹, Mehmet Ali Koç ¹, Akın Fırat Kocaay ¹, Atıl Çakmak ¹

Gastroesophageal reflux is a common problem encountered worldwide. Gastroesophageal reflux surgery was first described by Rudolph Nissen in 1956 by performing 360 ° fundoplication with open technique. Later in 1963, André Toupet defined 270 ° fundoplication. With the improvement of minimally invasive surgical techniques, the first laparoscopic Nissen fundoplication was performed in 1991 and since then, laparoscopy has become the gold standard technique also in reflux surgery. In addition to the studies reporting that symptomatic recovery was provided at the rate of 90%–95% in a 10-year follow-up, recurrence despite fundoplication has been reported in patients varying from 3 to 30%. Compared to open surgery, laparoscopic approach has come advantages such as less intraabdominal adhesions, less postoperative pain, and shorter hospitalization time in recurrence cases. In anti-reflux surgery in which postoperative patient satisfaction is lower than other procedures, anti-reflux treatment is continued in approximately 62% of patients in the postoperative period. In this case, the morbidity associated with the surgery performed in patients becomes even more important. The causes of recurrence after antireflux surgery include the dehiscence of crus sutures due to tension, opening of fundoplication, and paraesophageal and sliding hernia. The primary underlying etiology of recurrence is reported as short esophagus in which adequate dissection has not been achieved and opening in inappropriate crus repair. In recurrent cases, dissection is more difficult and efficacy is lower, and morbidity is higher than in primary cases. For these reasons, tendency to open approach by many surgeons is observed in recurrence cases. In this case report presented as a video presentation, in a patient who underwent laparoscopic Nissen fundoplication with graft 10 years ago, recurrent hiatal hernia was detected in the endoscopy performed after the occurrence of similar symptoms that started in the postoperative 8th year and continued for 2 years. Recurrent hiatal hernia surgery was performed laparoscopically. In the intraoperative exploration, it was observed that the fundoplication was in good condition and there was no graft migration. Paraesophageal hernia was found to have developed from the edge of graft. The patient was performed hiatal hernia repair and a graft was placed into the area of repair. No intraoperative and postoperative complication developed in the patient. Because it is difficult to satisfy patients in antireflux surgery, the importance of morbidity and quality of life increase. Therefore, it should not be forgotten that primary repairs should be standardized as much as possible and laparoscopy should be given a chance in recurrence cases. This video presentation aims to raise awareness about the applicability of laparoscopy in recurrence cases.

TJS. 2018;34(Suppl-1):S373–S374.

PP-0347 [Hernia Surgery]. Comparison of Laparoscopic Total Extraperitoneal and Open Inguinal Hernia Repair Techniques

Süleyman Çağlar Ertekin ^1,^✉, Mümin Coşkun ², Yalçın Burak Kara ³, Tevfik Kıvılcım Uprak ², Vafi Atalay ², Şevket Cumhur Yeğen ²

Objective

Laparoscopic inguinal hernia surgery is a technique that is increasingly becoming widespread in recent years. In our study, laparoscopic total extraperitoneal repair (TEP) and open inguinal hernia repair techniques were compared for a period of 13 months.

Material and Methods

Patients who underwent laparoscopic TEP and open surgical repair (liechtenstein) surgery in our clinic between 2017 and 2018 were evaluated retrospectively. Of the 67 patients included in the study, 54 were followed up over a 12-month period. The patients were requested to come for control examinations in the outpatient clinic in the postoperative 1st, 3rd, 6th, 9th and 12th months postoperatively.

Conclusion

Of 54 patients included in the study, 17 (31%) were performed open surgical inguinal hernia repair and 37 (69%) were performed laparoscopic TEP repair. Recurrence was found in 1 of 17 patients in the open surgery group (5%) and in 1 of 37 patients in the laparoscopic TEP group (2.7%). Laparoscopic TEP repair is a procedure that can safely be applied in terms of recurrence rates in inguinal hernia repair.

TJS. 2018;34(Suppl-1):S374.

PP-0348 [Hernia Surgery]. A Complication of Lost Gallstones after Cholecystectomy: Incarcerated Indirect Inguinal Hernia

Kemal Eyvaz ^1,^✉, Salim Balin ², Serkan Güler ¹, Arif Aslaner ¹, Murat Kağan Bilge ¹, Tuğrul Çakır ¹

Introduction

During laparoscopic cholecystectomy, spilled gallstones are not an uncommon situation. In this study, we wanted to present a patient admitted to the emergency unit with incarcerated indirect inguinal hernia after missing gallstone after laparoscopic sac operation and forgotten metallic clip.

Case

A 62 year-old male patient had a history of laparoscopic cholecystectomy operation performed 2 years ago. The patient was admitted to the emergency unit due to irreducible swelling in the right groin, which occurred one hour ago. A painful irreducible mass was palpated in the right inguinal region in the examination. In superficial tissue ultrasonography, the result was consistent with incarcerated hernia. The patient was taken into the operation with the diagnosis of incarcerated inguinal hernia. In the operation performed with right inguinal incision, the indirect hernia sac and a hard foreign body inside it were palpated. When the sac was opened, gallstone and a metallic clip material used in the previous cholecystectomy were observed. Following the reduction of the hernia sac into the abdomen, the hernia repair was completed with prolene mesh.

Complications of laparoscopic cholecystectomy include complications associated with both laparoscopy and cholecystectomy. Because of the perforation of the gallbladder during laparoscopic cholecystomy, the distribution and disappearance of gallstones in the abdomen is more commonly encountered than in the conventional cholecystectomy and this rate varies between 1% and 20%. The perforation of the gallbladder generally occurs while removing from the liver bed and perforation sometimes occurs during removal outside the abdomen due to narrow trocar site. It has also been reported that lost gallstones cause the picture of abscess in the abdomen. As in our patient, the gallstone, from lost gallstones after cholecystectomy, entering into the present inguinal hernia sac and clips caused the foreign body reaction and they presented with incarcerated hernia because they triggered the inflammatory process here.

Conclusion

In this case, we recommend to remember that gallstones in the perforated sac and abdomen during laparoscopic cholecystectomy and also metallic clips can present with the picture of incarcerated hernia and gallstones and metallic clips should be removed in order to prevent possible complications in the abdomen during cholecystectomy.

TJS. 2018;34(Suppl-1):S374–S375.

PP-0349 [Hernia Surgery]. Comparison of the Results of Cases with Fixed and Non-Fixed Patch in Laparoscopic Total Extraperitoneal Hernia Repair

İsmail Cem Sormaz ^1,^✉, Levent Avtan ¹

Objective

Inguinal hernia repair is one of the most frequently performed surgical procedures. Transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP) approaches have been defined after beginning the current use of laparoscopy. Compared to open surgery, minimally invasive methods have become prominent owing to less pain and analgesic need in the early postoperative period, better cosmetic results, early return to work, and fewer wound site problems. However, its negative aspects such as higher costs and a longer learning curve should not be overlooked. One of the causes of postoperative pain is the staplers used to fix the patch. In our study, we compared the results of the cases with fixed and non-fixed patch in patients undergoing TEP.

Material and Methods

This study included 56 patients performed TEP due to inguinal hernia in our clinic between January 2016 and December 2017. Twenty-eight patients fixed patches were identified as Group 1 and 28 patients not fixed patch as Group 2. Patients’ demographic data, hernia locations, body mass index (BMI), surgical duration, length of hospital stay, pain assessments, and perioperative complications were compared.

Results

There was no difference between two groups in terms of demographic data, hernia locations, and body mass indices. Two groups were similar with regard to duration of surgery and duration of hospitalization. When pain assessment was performed before discharge (group 1, 1.37±0.7; group 2, 1.26±0.5, p=0.21) and at the first month controls (group 1, 1.15±0.5; group 2, 1.05±0.3; p=0.14), pain was found to be slightly higher in the patients of Group 1, but this difference was not statistically insignificant. There was no urinary retention in both groups. Seroma was detected in 2 patients in Group 1 and in 3 patients in Group 2 (p=0.4). There was no significant difference in terms of the mean follow-up time (group 1, 11.3±7.16, group 2, 10.8±8.1, p=0.2). During the follow-up period, no patient had infection, nerve damage and recurrence.

Conclusion

Recurrence, seroma, nerve injury and infection were not detected during follow-up, which shows that there is no difference between fixed and non-fixed patches. Considering the cost of the staples used for fixing and relatively lower pain at postoperative and 1st month controls, not fixing seem to be a good option. We think that these findings should be evaluated with further large case series and prospective randomized studies because of our few number of cases and short follow-up period.

TJS. 2018;34(Suppl-1):S375.

PP-0350 [Hernia Surgery]. Our 5-Year Laparoscopic Inguinal Hernia Repair Experience in Başkent University İstanbul Hospital

Emil Guseinov ^1,^✉, Hüseyin Yüce Bircan ¹, Gökçe Aylaz ¹, Serdar Ahmet Karaca ¹, Feza Yarbuğ Karakayalı ¹

One of the most common operations in daily surgical practice is the repair of the inguinal hernia. Our aim in this study is to share the data of laparoscopic total extraperitoneal inguinal hernia repair operations performed in the Department of General Surgery at Baskent University Istanbul Hospital. Patients undergoing laparoscopic surgery for the diagnosis of inguinal hernia in the Department of General Surgery at Baskent University Istanbul Hospital between January 2013 and January 2018 were analyzed retrospectively. A total of 136 patients that were performed laparoscopic total extraperitoneal hernia repair were included in the study. The mean age was 59.24 years. Minor complications such as seroma, epididymitis and hematoma were observed in the early postoperative period. There was no major complication or mortality. No recurrence and no chronic pain were observed in the follow-ups. Laparoscopic total extraperitoneal inguinal hernia repair is performed safely in our hospital.

TJS. 2018;34(Suppl-1):S375–S376.

PP-0351 [Hernia Surgery]. Ovary and Tuba in Indirect Inguinal Hernia Sac in a Case with Ectopic Kidney

Halil Afşin Taşdelen ^1,^✉, Banu Karapolat ¹, İzzettin Kahraman ¹

Introduction

It was aimed to present the herniation of left ovary and tuba in the left indirect hernia sac in a 42-year-old female patient having a known left ectopic kidney with pelvic localization.

Case

A 42-year-old female patient presented with the complaints of swelling and intermittent pain in the left groin, which started about 6 months ago. In the physical examination, an irreducible inguinal hernia was found in the left groin. In the ultrasonography, intraabdominal fatty tissue herniation into the left inguinal canal was observed and there was a 30x11 mm hypoechoic lesion which included small cystic areas and could not be distinguished from fat tissue in the hernia segment. It was also reported that pelvic MR was recommended for ovary-mesenteric fatty tissue differentiation. In the pelvic MR report, it was stated that left ectopic kidney with pelvic localization was observed, and the inguinal canal was wide (28 mm) and it included an approximately 42x23 mm hypointense lesion including millimetric hyperintense cystic areas in T1A and T2A, which was firstly thought to be ovary (because the left ovary was not in normal localization). The patient was operated under elective conditions. The hernia sac was opened, seeing it was the indirect hernia. It was observed that there was the left ovary and tuba inside the hernia sac and these structures formed a wall of the hernia sac. The excess part of the hernia sac was cut, the remaining peritoneum was closed and returned to the abdomen. Lichtenstein mesh hernia repair was performed with the polypropylene mesh. On the first postoperative day, the case was discharged without any problems.

Conclusion

In the inguinal hernias, hernia sac most commonly includes the omentum and small intestine. In adult patients, the presence of the ovary and tuba in inguinal hernia sac is very rare. This is more common in the pediatric age group. In women at reproductive age, who have the ovary in the inguinal hernia sac, urogenital malformations have also been reported. Our patient had a known left ectopic kidney with pelvic localization, which was reported in MR examination. Although rarely seen, exploration should be performed carefully considering that inguinal hernia sac may involve the ovary and tuba in adult women and further imaging studies, if necessary, should be used in terms of urogenital malformations.

TJS. 2018;34(Suppl-1):S376.

PP-0352 [Hernia Surgery]. Our Experience of Nuck Canal Cyst

Ali İşler ^1,^✉, Fatih Mehmet Yazar ¹, Ömer Faruk Boran ², Ahmet Necati Şanlı ¹, Murat Bakacak ³, İlhami Taner Kale ¹, Mehmet Fatih Yüzbaşıoğlu ¹, Ali Özkömeç ¹, Emrah Cengiz ⁴, Mehmet Sertkaya ⁵

Objective

The Nuck canal is a remnant of the peritoneum associated with a round ligament and it can rarely cause the development of cysts in women due to its non-closure. Its diagnosis can be overlooked since women’s pain in the inguinal region can frequently be confused with other causes because Nuck canal cyst is rarely encountered. In this article, we aimed to share our experience on the Nuck canal cysts.

Material and Methods

Patients over 18 years of age, who were admitted due to inguinal swelling and pain and operated for inguinal hernia and inguinal mass between January 2015 and December 20, were retrospectively evaluated. Only female patients were included in the study.

Results

Twenty female patients were operated for inguinal hernia. In 4 of the operated patients, additional radiological examinations were needed because the results of their physical examinations were not consistent with hernia. The sonographic examinations of the patients, whose ultrasonographic examinations revealed cystic lesions, were reported as the presence of cystic structures displaying continuity with tuba uterina. And, the patients were operated with the pre-diagnosis of Nuck canal cyst. The pathological findings of the materials were evaluated as findings consistent with cyst.

Conclusion

Nuck canal cysts are usually incidentally detected in inguinal hernia or inguinal lymph node excisions. When ultrasonography is required for the first time for suspicious inguinal hernia or palpable pathologies in the inguinal region, it is recommended to confirm the diagnosis by magnetic resonance imaging as a further examination. It should be kept in mind that Nuck canal cysts may be encountered in cases of inguinal region pathologies that cannot be definitely diagnosed.

TJS. 2018;34(Suppl-1):S376–S377.

PP-0353 [Hernia Surgery]. A Rare Case: Morgagni Hernia

Arif Burak Çekiç ¹, Mehmet Uluşahin ^1,^✉, Muhammed Selim Bodur ¹, Ali Güner ¹, Serdar Türkyılmaz ¹

Introduction

The development of the diaphragm occurs during the first trimester of the embryonic period. The problems experienced in this period may result in the formation of diaphragm hernias.

Case

A 52-year-old female patient was admitted to the emergency service with the complaints of abdominal pain, nausea and vomiting intermittently continuing for 3–4 months and exacerbating for the last two days. Except the use of drug for the diagnosis of schizophrenia, she had no history of any feature. In the physical examination (PE), epigastric tenderness and minimal abdominal distention were found. In the laboratory values, leukocyte count was 19000/μL, creatinine was 2 mg/dL, blood urea nitrogen was 150 mg/dL, and potassium was 2.8 mEq/L, and other values were within normal intervals. In the abdominal computed tomography (CT) performed without contrast agent due to high value of creatinine, it was observed that the stomach, small intestine, and mesenteric fat tissue were herniated from the defect in the anterior right diaphragm into the right hemithorax. The patient, whose symptoms were regressed and general condition was recovered after the nasogastric decompression, was followed-up medically and the operation was planned to be performed under semi-elective conditions. During follow-up, the general state and laboratory values of the patient returned to normal and she was operated. The surgery was laparoscopically started with a 10-mm camera port entered supraumbilically and one 12-mm and two 5-mm trocars inserted from the subcostal areas and the epigastric region. A 5x5 cm hernia defect was seen in the anterior part of the diaphragm with the small intestine, stomach, and omentum extending towards the thorax in it. Since the organs in the hernia sac could not be taken into the abdomen laparoscopically, laparotomy was performed with supraumbilical midline incision. The stomach, small intestine and omentum filling the right hemithorax in the hernia sac were pulled back into the abdomen. With sutures with the help of Reverdin needle, the posterior and anterior wall of the defect was fixed to the anterior wall of the abdomen and the defect was closed. Then, a 20 x 15 cm composite patch was placed and it was fixed on the posterior surface of the anterior abdominal wall and the diaphragm. In the postoperative period, the patient had no problem except atelectasis and she was discharged on the 7th day.

Conclusion

Morgagni hernia is usually seen in the childhood age group. In adulthood, it is generally asymptomatic except for admission with complications. It can be diagnosed incidentally in imaging techniques performed for different purposes. In cases of incarceration, respiratory symptoms and ileus may be seen according to the organs herniated into the hemithorax. Chest X-ray, direct abdominal x-rays, contrast-enhanced radiographs and CT are usually helpful in the diagnosis. Small intestines, omentum, stomach and colon can be found in the hernia sac. When it is diagnosed, it should be operated for the risk of incarceration. Emergency surgical intervention may be required in patients who develop incarceration. The operation can be performed with thoracic or abdominal approach. In recent years, laparoscopic surgery can also be performed in selected cases.

TJS. 2018;34(Suppl-1):S377–S378.

PP-0354 [Hernia Surgery]. Risk Factors in the Development of Incisional Hernia

İbrahim Tayfun Şahiner ¹, Murat Kendirci ¹, Murathan Erkent ^1,^✉, Ramazan Topçu ¹, Settar Bostanoğlu ¹, Mete Dolapçı ¹

Objective

Incisional hernias are included among the anterior abdominal wall hernias. It is one of the most common problems encountered after surgical procedures performed in the abdomen. Their frequency is reported between 2% and 11%. Incisional hernias that can arise following abdominal surgical interventions can cause significant labor loss, morbidity, and even mortality and affect quality of life negatively. Therefore, we aimed to investigate risk factors in order to prevent the occurrence of incisional hernia.

Material and Methods

The data of 128 patients with incisional hernia, who were operated in our clinic between December 2013 and December 2017 were retrospectively analyzed. Parameters such as demographic data of the patients, initial surgical causes, body mass indices, comorbidities, and the development of surgical site infection (SSI) after the first operation were examined.

Results

Of the patients, 24.2% (n: 31) were male and 75.8% (n: 97) were female. The initial surgical causes were gastrectomy in 3.9% (n: 5), colectomy in 7% (n: 9), peptic ulcer perforation in 3.9% (n: 5), trauma in 17.2% (n: 22) (liver and spleen injuries), open cholecystectomy in 10.2% (n:13), laparoscopic cholecystectomy (trocar site hernia) in 3.9% (n: 5), and others in 53.9% (n: 69) (gynecologic surgeries, laparotomy due to bride ileus). When the body mass indices (BMI) of the patients were examined, 3.9%

In adults, Morgagni hernia is an asymptomatic diaphragmatic hernia unless it is complicated. In symptomatic cases, symptoms range from acute abdomen to acute respiratory distress and they may be related to different systems. In conclusion, we recommend that this rare pathology should be kept in mind in patients admitted with the complaints of acute abdomen, particularly when accompanied by respiratory problems, and the incidentally detected cases should be operated before they become complicated.

TJS. 2018;34(Suppl-1):S380.

PP-0358 [Hernia Surgery]. A Rare Case; Mesh Reaction Developing after 16 Years

Nesime İnci Eryılmaz ^1,^✉, Serdar Açar ¹, Ahmet Contarlı ¹, Bekir Sarıcık ¹, Ömer Rıdvan Tarhan ¹

Introduction

Hernias occurring in surgical incision sites are called incisional hernia. The place, shape and closure of the incision are important in the prevention of the development of the incisional hernia. Mesh can be preferred as the closure method in selected cases. Nowadays, synthetic and non-synthetic meshes are available. There are no definite truths about advantages and disadvantages over each other. There are complications associated with the application of mesh. In this case, we will present a mesh reaction that developed after 16 years.

Case

A 75-year-old female patient was admitted to the emergency service with the complaint of abdominal pain continuing for 3 days. In addition to abdominal pain, she had nausea-vomiting, and loss of appetite. She had a history of previous surgery for hydatid cyst and incisional hernia approximately 16 years ago. In the physical examination, sensitivity and rebound was detected in the lower right quadrant of the abdomen. In addition, there was an about 7x8 cm well-circumscribed palpable fixed mass at the level of umbilicus. The patient stated that the palpable structure was present for 3–4 months. There was no abnormal value in the laboratory analysis except elevated CRP (85) and white blood cell (15,300). There was no obvious finding in the direct abdominal radiography in standing position. In the ultrasonography (USG), the appendix was 9.5 mm and there was a 5x7 cm mass on the anterior wall of the abdomen. The result of computed tomography (CT) also supported USG. The patient was taken into operation with the pre-diagnosis of acute appendicitis and a mass on the anterior wall of the abdomen. In the laparotomy performed under general anesthesia, once the skin-subcutaneous region was opened, a hard dark-colored foreign body was encountered. It was released considering that it was the mesh placed in the previous surgery. Then, the mesh was opened and an approximately 8x9 cm hard massive lesion with organized surrounding, which was consistent with hematoma, was observed under it. The granulated tissue was excised and the abdomen was entered. The appendix was observed to be hyperemic erectile. Appendectomy was performed. The patient was accepted as a contaminated case and the open wound was not closed, and the operation was terminated. The result of the pathology was consistent with partially organized hematoma and appendicitis. In the postoperative period, the patient was discharged with recovery.

Conclusion

Meshes are medical support products used to consolidate related tissues and provide tissue integrity in hernia repair. Nowadays, synthetic and non-synthetic meshes are used. We can also classify meshes as absorbable and nonabsorbable. Complications such as recurrence, seroma formation, infection, pain, fistula development, and mesh reaction are observed depending on the material used for repair. The use of mesh in hernia treatment does not change the rate of wound infection. Deep mesh reaction with late onset is seen in a small number and it is an unexpected complication. In our case, there was no symptom related to mesh and it was detected as a result of analyses performed for simultaneous acute appendicitis. In conclusion, late-stage mesh reaction is a rare condition and the only treatment of this infection is to remove the mesh.

TJS. 2018;34(Suppl-1):S380–S381.

PP-0359 [Hernia Surgery]. Paraovarian Cyst in the Inguinal Hernia Sac: Case Report

Hikmet Pehlevan Özel ^1,^✉, Yasin Erkuş ¹, Akın Bostanoğlu ¹, Yasir Keçelioğlu ¹, Sevgi Yıldırım Alta ²

Introduction

Inguinal hernias are commonly encountered surgical pathologies and they may require emergency surgical intervention due to incarceration strangulation. In this study, a patient operated in the emergency surgery clinic due to left incarcerated inguinal hernia was presented. A direct inguinal hernia with a fallopian tube in the hernia sac accompanied by paraovarian cyst is a very rare case.

Case

A 57-year-old female patient was admitted to the emergency service because of abdominal pain and swelling in the left inguinal region. The patient without nausea and vomiting, with normal gas-stool discharge and with reduced hernia on the left side ongoing for the last 3–4 years presented with the complaint of swelling on the left groin for about 8 hours. In the physical examination, an immobile mass incarceration of about 5 cm in diameter was found in the left inguinal region. In the USG performed for evaluating organ pathologies in the patient whose laboratory parameters were normal, an immobile cystic mass, which did not look like bowel, was detected. Therefore, computed tomography was taken and its result was reported as “A 60x45 mm cystic lesion in the hernia sac in the left inguinal region, uterus and its attachments are deviated anteriorly to the left. Thus, the herniation of ovarian cyst was also considered in the differential diagnosis “. Because the incarceration and pain of the patient continued for a time longer than 8 hours, an operation was decided. It the exploration, a direct hernia sac with a left fallopian tube inside it, and an about 6 cm paraovarian cyst and small intestine loops were found. The blood supply of the intestine loops were normal, there was no sign of ischemia, it was mobile. The fallopian tube was found to be edematous and hemorrhagic. Approximately 6 cm diametered paraovarian cyst was detected on the left and the left ovary was normal. Upon that, left salpingectomy and paraovarian cyst excision were performed. The posterior wall was then repaired and the repair was completed by laying the mesh. And the operation was terminated. The patient was discharged on the second postoperative day without any complication.

Conclusion

The majority of abdominal wall defects are inguinal hernias, with an incidence of 1.9% in females. Of the inguinal hernias seen in women, 67% are indirect hernias, 14% are direct hernias, and approximately 20% are femoral hernias. While the organs that are commonly herniated are the omentum and intestines, and rarely appendix, Meckel diverticulum, bladder, stomach, ovary, fallopian tubes and even uterus can be detected in the hernia sac. The frequency of ovary and fallopian tubes is 2.9%. When the literature is examined, the presence of paraovarian cyst accompanying the fallopian tube is seen only in a few cases. With this very rare case, we would like to emphasize that rare causes should be considered in patients detected to have inguinal hernia.

TJS. 2018;34(Suppl-1):S381.

PP-0360 [Hernia Surgery]. Clinical Results of Laparoscopic Total Extraperitoneal Herniorrhaphy Treatment in Recurrent Inguinal Hernias

Mehmet Zafer Sabuncuoğlu ^1,^✉, Ayfer Şen ¹, Serdar Açar ¹, Nesime İnci Eryılmaz ¹

Objective

The lifelong risk rate of inguinal hernia is 27% in men and 3% in women and the recurrence rate of these hernias is reported to be 11% in men and 3% in women. The aim of this study is to demonstrate the clinical outcomes and recurrence rates of the TEP method in the treatment of recurrent inguinal hernias.

Material and Methods

In our clinic, TEP herniorrhaphy is performed by using 3 trocar ports (one 10 mm and two 5 mm) and by fixing the anatomically suitable sized mesh with tacker, and skin incisions are closed with 3.0 prolene primary suture.

Results

A total of 189 inguinal hernia repairs were performed through TEP method in our clinic. In 76 of them, TEP repair was applied for bilateral inguinal hernia and in 9 of them, for recurrence inguinal hernia. The mean age of recurrent inguinal hernias treated with TEP herniorrhaphy method was 53 years. Of the patients, 5 were operated once, 2 were operated twice, 1 was operated three times, and 1 was operated four times due to inguinal hernia. Right TEP herniorrhaphy was performed in 3 patients, left TEP herniorrhaphy in 3 patients, and bilateral TEP herniorrhaphy in 3 patients. All patients came to the outpatient clinic between the 1st and 13th months.

Conclusion

TEP should be preferred particularly in recurrence cases with multiple anterior approach because it has lower recurrence rate and advantages of laparoscopy due to the use of preperitoneal area without tissue damage in these cases.

TJS. 2018;34(Suppl-1):S381–S382.

PP-0361 [Hernia Surgery]. The First Finding of Ovarian Carcinoma: Sister Mary Joseph’s Nodule Mimicking Umbilical Hernia

Serdar Açar ^1,^✉, Nesime İnci Eryılmaz ¹, Mahmut Bülbül ¹

Introduction

Umbilical metastases are defined as ‘Sister Mary Joseph’s nodule’ (SMJN). Although rarely seen, it generally occurs secondary to gastrointestinal and gynecologic malignancies. In this case, we aimed to present a Sister Mary Joseph’s nodule, which was an ovarian carcinoma metastasis mimicking umbilical hernia, and to draw attention to this rarely encountered condition.

Case

A 70-year-old female patient presented with a complaint of abdominal pain. In the physical examination, there was an approximately 2x3 cm palpable defect (mass?) in the umbilicus and the umbilicus was in the necrotic appearance. There was no other positive finding. In the laboratory values of the patient, no abnormality was found. The patient was taken into operation due to the pre-diagnosis of umbilical hernia. Following the cleaning of the region under general anesthesia, the skin and subcutaneous area were passed with smile incision at the 3 cm under the umbilicus and the umbilicus was completely removed. Hernia sac could not be found. In the umbilicus, a partially necrotic tumoral material was observed and completely excised, and it was sent to the department of pathology for evaluation. After the bleeding control, the layers were closed according to the rules and the operation was terminated after dressing. The patient’s pathology report was as follows; “Adenocarcinoma metastasis under the skin and as a result of immunohistochemical staining, CK7, PAX8 positive, ER 100% strong positive, PgR 10–20% positive, p53 100% positive. The female genital system, particularly the ovary, should be examined. It suggests high-grade serous carcinoma”. Upon this report, the patient was referred to the gynecological oncology unit after discharge. After the elective surgery performed by the gynecological oncology team, the result of pathological evaluation was reported as high-grade serous carcinoma.

Conclusion

Metastases localized in the umbilicus are called ‘Sister Mary Joseph’s nodule’ (SMJN). It has been reported in literature that SMJN, which is very rarely seen in gynecological malignancies, generally originates from gastrointestinal and gynecological malignancies. In the literature, some case series on SMJN arising from the tumors of stomach, colon, ovary, pancreas and, more rarely, uterus, cervix, gallbladder, and small bowel have been published. In this case report, we presented a rare case of ovarian carcinoma showing umbilical metastasis, which can mimic umbilical hernia, in order to draw attention to this rare condition and to contribute to our colleagues.

TJS. 2018;34(Suppl-1):S382.

The herniation of a portion of the bladder into the inguinal canal is encountered at the rate of 3–5% in all inguinal hernias. In general, it is asymptomatic, but it can cause serious complications such as bladder necrosis and obstructive uropathy.

TJS. 2018;34(Suppl-1):S384.

PP-0365 [Hernia Surgery]. Laparoscopic Incisional Hernia Experience in the First 50 Cases

Mehmet Zafer Sabuncuoğlu ^1,^✉, Melih Can Gül ¹, Ayfer Şen ¹, Ahmet Contarlı ¹

We aimed to present our experience of laparoscopic incisional hernia repair in our study. After the first laparoscopic hernia repair was performed in 1993, it was started to be used owing to the short duration of hospitalization and its aesthetic superiority. In this study, 50 laparoscopic incisional hernia cases in SDU Department of General Surgery were retrospectively evaluated. The patients were taken into operation by applying nasogastric and bladder catheter under general anesthesia without bowel preparation. In all patients, GORE dual mesh with adhesion barrier was used. The mesh was fixed with a double-row 5 mm protack by exceeding hernia defect for 4 cm. The follow-up period was 3–48 months in the 50 patients that were evaluated. Postoperative pain scores, complication rates and length of hospital stay were evaluated in the laparoscopic repair group. Wound site complication was 0% in laparoscopic repair group and mortality was not observed. In 5 patients, intestinal injuries occurring during dissection were repaired laparoscopically. The incisional defect was between 3 and 15 cm. the mean age was 52 years and the mean duration of operation was 67.25±19.23 minutes. The mean duration of hospitalization was 1.3 days. Two patients had chronic pain ongoing for 6 months, but pain was not detected at follow-up controls. In one patient, a recurrence due to a mesh tear from a 1 cm defect was detected and it was treated with open repair.

According to the result of our study, even in obese patients and large hernias, laparoscopic incisional hernia repair can safely be performed as a very good alternative to open surgery, when performed in experienced centers, with shorter durations of operation and hospital stay, higher patient satisfaction, and lower complication rates.

TJS. 2018;34(Suppl-1):S384–S385.

PP-0366 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Our Experience of Revascularization with Synthetic Tube Graft in Mesenteric Ischemia

Miraç Barış Erzincan ^1,^✉, Ömer Arda Çetinkaya ¹, Hakan Uncu ¹, İskender Alaçayır ¹

Objective

In mesenteric ischemia, which is common particularly in arteriosclerosis patients over 65 years of age, diagnosis is too late, treatment is very difficult and mortality is still very high. In the literature, there are a few published cases of mesenteric ischemia patients treated with open vascular interventions and no consensus has been reached on the number of vessels to be performed reconstruction, graft selection and the preference for antegrade/retrograde applications.

Material and Methods

In the present study, we report 5 patients who were performed aorta-superior mesenteric single bypass by using a polytetrafluoroethylene (PTFE) tube graft over a four-year period. Antegrade approach was preferred in 4 patients and retrograde approach in 1 patient. This study did not include patients who were performed bypass with saphenous vein and Y grafts.

Discussion

The mean age of the patients, three of whom were female and two were male, was 50,2 years. The main symptoms of the patients presenting with acute/subacute clinical picture were abdominal pain and postprandial nausea and vomiting. All patients had a history of weight loss. The diagnosis was established with digital subtraction angiography (DSA) in 3 cases and with computed tomography (CT) in 2 patients under emergency conditions. The superior mesenteric artery was found to be completely obstructed in three patients and severely obstructed in two patients. Because of the absence of other options in these patients, aorta-superior mesenteric bypass was performed with a 7 mm PTFE graft synthetic tube graft. Three patients with irreversible changes in the intestines, who consulted later, were performed jejunostomy and colostomy following bowel resection. One patient who was taken into the intensive care unit as intubated died from septic shock on the following day. Two of the patients undergoing ostomy died from electrolyte imbalance and multiple organ failure 6 months and 19 months after the operation, respectively. The surgical mortality was 20% and late mortality was 40%. One patient with reversible bowel ischemic findings has been followed up for 3 years and another for 5 years, and their grafts are observed to be open in control DSA examinations.

Conclusion

We prefer endovascular interventions as the first choice in patients without severe calcification in mesenteric ischemia and with obstructed short segment. However, in situations where this is not possible and especially in emergency conditions, bypass surgeries with open technique are still life-saving in our desperation. As in our patients, high success rates can be achieved if early intervention can be done when the intestinal ischemia is reversible.

TJS. 2018;34(Suppl-1):S385.

PP-0367 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. ‘Burned-out’ Seminomatous Testicular Tumor Presenting as Retroperitoneal Metastasis, Case Report

Semra Demirli Atıcı ^1,^✉, Halit Batuhan Demir ¹, Yasemin Kırmızı ¹, Dilek Kuzukıran ²

The term “burned-out” refers to the testicular tumor that is detected with metastasis to the retroperitoneal, mediastinum, supraclavicular, cervical and axillary lymph nodes and that is completely or partially regressed spontaneously. It is different form primary extragonadal testicular tumors and it is encountered more rarely. In this case report, we planned to present a case with unknown primary, presenting with a mass in the retroperitoneal region and being detected to have a “burned-out” testicular tumor. A 34-year-old male patient was examined at various centers due to a complaint of abdominal pain radiating to his back for 3 months. He had no history of previous operation except for left nephrectomy due to nephrolithiasis at the age of 8 years or any chronic disease. All abdominal CT and PET-CT imagings performed in external centers revealed a 4.4x4.0 cm mass lesion (SUVmax: 19.0) located in the retroperitoneal region in the neighborhood of the right kidney caudal region and closely related to the inferior vena cava and duodenum, and increased 18FDG uptake in the areas consistent with lymph nodes (SUVmax: 18.2) in the paracaval, interaortacaval and right main iliac regions in the abdomen, the largest of which was 1.8cm in diameter at the level of the iliac bifurcation. Diagnostic biopsy under the guidance of interventional radiology was performed for three times in the patient. Because the fine needle aspiration biopsy was consistent with malignancy but tissue diagnosis could not be established, the primary tumor focus could not be detected. Retroperitoneal mass excision, paraaortic and paracaval lymph node dissection were performed in the patient. Microscopic examination of mass excision material revealed a tumoral tissue consisting of atypical cells as solid islets and alveolar structures separating by fibrous septas including lymphocytes. In immunohistochemical analyses, PLAP and CD117 (+), PANCK rare (+), HCG rare (+) and AFP (−) were detected. Lymphovascular invasion and necrosis were not detected in the tumor. Histopathological evaluation was reported as germ cell tumor (seminoma) and (6/10) metastatic lymph nodes. The patient who had no complication in the postoperative follow-up was directed to the urology department with pathology result for follow-up. Right radical orchiectomy was performed by the Department of Urology and chemotherapy was started by the Department of Medical Oncology. Retroperitoneal germ cell tumors should be considered as metastasis of the testicular focus until proven otherwise. Treatment for extragonadal germ cell tumors is systemic chemotherapy. Chemotherapy is highly effective in the treatment of metastatic nonseminomatous germ cell tumors but not in primary testicular tumors due to the blood-testis barrier. Following the effective treatment of extragonadal germ cell tumors, the presence of persistent residual malignant tumor in the testis is well documented with various series. Even in metastatic cases, surgical excision of the primary focus in the testis is recommended. It is recommended to remove the testis even if there is only intratubular germ cell neoplasm in the testis biopsies. As in our case, orchiectomy should be performed before the initiation of chemotherapy in order to provide a full cure. In the literature, it is stated that if the testis is normal in two small series, there is no need to perform surgery. However, these two studies have a few cases. In conclusion, burned-out germ cell tumors should be in our mind in the cases of retroperitoneal mass and the patient should be assessed in detail. For providing a full cure, orchiectomy should be performed in the patient before starting chemotherapy.

TJS. 2018;34(Suppl-1):S385–S386.

PP-0368 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Are Gastrointestinal Stromal Tumors Really Asymptomatic?

Arif Emre ^1,^✉

Objective

Gastrointestinal stromal tumors incidentally detected during abdominal surgical interventions or after imaging methods can still cause serious morbidity and mortality. In this study, it was aimed to retrospectively evaluate the files of patients whose histopathological diagnoses were reported as gastrointestinal stromal tumors in our clinic and to investigate the possible symptoms of these patients before diagnosis.

Material and Methods

The data of this study were obtained by retrospectively scanning the files of the patients who underwent surgery in the department of general surgery at KSU. Of thes patients, those who were hospitalized and operated in the general surgery department between April 2012 and January 2017 and whose histopathological diagnoses were reported as gastrointestinal stromal tumor were included in the study. Data on patients’ demographic characteristics including age and gender, preoperative complaints at the time of admission, localization of the tumor at the time of admission, metastasis, local recurrence or mortality were obtained from the ENLIL system of the hospital and/or outpatient clinic recordings, and/or through interview the patients on phone. The records of the patients who died were retrospectively obtained through the electronic ENLIL HBYS system of the patient and national death notification system.

Discussion

The mean age of the male patients was 57.1±15.2 years and the mean age of the female patients was 51.3±15.3 years. The most common symptom at admission was abdominal pain with the rate of 46.2% and the others were weight loss, palpable abdominal mass, constipation, incontinence, and lower gastrointestinal system bleeding. Considering the tumor localizations in the patients, the ileum was the most common localization with the rate of 30.8% and the jejunum, intestinal meso and omentum, rectum, peritoneum, stomach, and pancreas were other involvement localizations. In the patients, CD117 positivity was 92.3%, CD34 positivity was 50%, actin positivity was 69.2%, and desmin positivity was 15.4%.

Conclusion

Although gastrointestinal stromal tumors are generally known as asymptomatic tumors, they actually manifest symptoms in every patient. However, as these symptoms are seen in many diseases, they are often ignored and the tumor is not recognized and incidentally detected by patients or physicians. The prognosis is generally good for tumors in the low-risk group. This tumor is unresectable especially in the moderate and high-risk groups or it can present with metastases in advanced stages.

TJS. 2018;34(Suppl-1):S386.

PP-0369 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Evaluation of Diagnosis and Treatment of Midgut Volvulus in an Adult Patient in the Light of Literature: Case Report

Ufuk Coşkunkan ¹, Onur Sakallı ^1,^✉, Ümit Geçgel ¹

Congenital midgut malrotation is a complex gastrointestinal anomaly that can cause midgut volvulus and gastrointestinal obstruction. While it often presents with symptoms in childhood, it may rarely become symptomatic in adulthood. In our case, a 32-year-old female patient consulted to our outpatient clinic due to the complaint of vomiting ongoing for 3 months. Midgut volvulus was diagnosed with abdominal tomography and Ladd’s procedure was performed. She was discharged on the postoperative 5th day. Midgut volvulus is a rotation anomaly of the middle intestine in intrauterine life. It results from the clockwise torsion of the middle intestine mesentery on the superior mesenteric artery axis. Adult patients may present with chronic unexplained abdominal discomfort, vomiting, abdominal pain increasing after meals or acute abdominal pain. These findings occur due to Ladd bands and volvulus, which cause acute or chronic intestinal obstructions. The diagnosis can be established with changes in the localization of the mesenteric vascular structures in the Doppler ultrasonography and with the swirl view of the mesenteric tissues in the abdominal tomography. During surgery, after the dissection of the Ladd bands, described as Ladd’s procedure, and the detorsion of the torsioned loops, the cecum is localized in the left lower quadrant and the the small intestines are placed in the right lower quadrant. Although midgut volvulus often presents with symptoms in childhood, it may rarely become asymptomatic until adulthood. It should be kept in mind as an uncommon pathology in patients evaluated in emergency or outpatient clinic conditions and the Ladd’s procedure, which is used for the treatment, should be known by general surgeons.

TJS. 2018;34(Suppl-1):S386–S387.

PP-0370 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Small Bowel Perforation Due to a Foreign Body

Hakan Öğücü ^1,^✉, Özgür Akmeşe ¹, Emre Turgut ¹, Ayberk Dursun ¹, Cengiz Aydın ¹

Introduction

Foreign bodies may rarely lead to intestinal perforation, intestinal obstruction and peritonitis. In the literature, 80% of the foreign bodies taken orally are reported to be defecated by completing the digestive system without causing any complication or morbidity. Although they are usually seen in children, they can be encountered in alcoholic and mentally handicapped individuals, or elderly patients with dental prosthesis and needy individuals. The most frequently swallowed foreign bodies are the materials such as fish bones, bone fragments, or pins. In this study, two cases admitted to the emergency unit with intestinal perforation due to foreign body were presented.

Case 1

A 78-year-old female patient with known histories of DM, HT, and CAD was admitted to the emergency unit with the complaints of diffuse abdominal pain, nausea and vomiting going on for two days. There was widespread tenderness, defense and rebound in the abdomen in the physical examination. There was no significant pathology except leucocytosis in the laboratory tests. The abdominal computed tomography images showed an appearance consistent with foreign body in the lumen at the small intestine level and millimetric free air densities around the intestine. The patient was taken to the emergency operation with these findings. In the operation, the foreign body (chicken bone) causing perforation in two localizations in the jejunum at about 80cm from the treitz ligament was observed. Segmental small bowel resection and end-to-end anastomosis were performed to cover the perforation areas. The patient was followed up postoperatively. The patient, who did not develop any complication during the follow-up and tolerated oral intake, was discharged on the 6th postoperative day by healing.

Case 2

A 34-year-old female patient with mental retardation was admitted to the emergency runit with the complaints of nausea, vomiting, and abdominal pain continuing for 3 days. In the physical examination, there was extensive tenderness, defense and rebound in the abdomen. Leukocytosis was found in the laboratory analysis. The patient was performed abdominal computed tomography based on these findings. The tomography images revealed an appearance consistent with the foreign body causing obstruction in the small intestine loops and diffuse intraabdominal free fluid. The patient was taken to emergency operation with these findings. In operation, it was seen that there was full-layer perforation area at 90 cm from the treitz in the small intestine loop and complete obstruction of the lumen due to the foreign body (plastic material) in the small intestine at the 110 cm from the treitz. The 30 cm small intestine segment between the 90th and 110th centimeters was resected and endto-end anastomosis was performed. The patient was postoperatively followed up in the clinic. The patient, who did not develop any complication during the follow-up and tolerated oral intake, was discharged on the 4th postoperative day with healing.

Conclusion

Although gastrointestinal complications associated with foreign bodies are not common in adults, they should be included among the prediagnoses that should be remembered especially in elderly, needy or mentally retarded patients admitted to the emergency unit. In suspected cases, the sensitivity of tomography in diagnosis is very high. Enterotomy, primary repair and resection anastomosis in the presence of more than one perforation are the treatment methods that are preferred.

TJS. 2018;34(Suppl-1):S387–S388.

PP-0371 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Crohn’s Disease Presenting with Gastroduodenal Region Involvement: A Case Report

Süleyman Utku Çelik ^1,^✉, Nihad Nazarzade ¹, Mustafa Anıl Turhan ¹, Acar Tüzüner ¹

Introduction

Crohn’s disease is one of the two major chronic idiopathic inflammatory diseases of the gastrointestinal system. This disease can involve all parts of the gastrointestinal system, from the oral mucosa to the anus. While it especially affects the terminal ileum and proximal colon, gastroduodenal involvement can also be seen rarely (0.5–4%). In this study, a patient diagnosed with Crohn’s disease in the duodenum and the treatment plan was shared as a case report.

Case

A 24-year-old male patient was admitted to our clinic with the complaints of bloating, epigastric pain, nausea and vomiting existing for about a year. The patient had no history of any pathology except for peptic ulcer developing on the ground of

H. pylori. There was no finding except epigastric tenderness in the abdomen in his physical examination. Perianal examination revealed two external fistula orifices. His vital signs at the time of admission were within normal intervals. Pylorus and an apparent narrowness in the first part of the duodenum were detected in the endoscopy. In the esophagus-stomach-duodenum radiography, it was observed that the opaque material passed into the duodenum in a small quantity and slowly. The thoracoabdomino-pelvic computed tomography showed diffuse wall thickening in the 1st and 2nd parts of the duodenum, and multiple abscesses in the sizes of 1–1.5 cm around the first part. In addition, several fistula tracts were observed in the anal canal. The present findings and investigations were evaluated to be consistent with Crohn’s disease and the Whipple procedure was applied to the patient. In the histopathological examination of the specimen, changes showing Crohn’s disease (full-thickness wall involvement, focal abscess formations in the intestinal wall, etc.) were detected in the duodenum. The patient Medical treatment for Crohn’s disease was planned for the patient considering the recommendations of the gastroenterology department and he was discharged with healing on the 9th postoperative day.

Conclusion

Crohn’s disease affects the gastroduodenal region of the intestinal system at the rate of 0.5–4%. In approximately 1/3 of these patients, involvement of the terminal ileum and colon can occur at the advanced stage despite the absence of small intestine and colon involvement at the time of diagnosis. Neighbor organ involvement is a common picture and involvement of the antrum, pylorus and proximal duodenum is observed in approximately 60% of patients. Gastroduodenal Crohn’s disease is seen equally in men and women. Approximately 75% of the cases are encountered in the 3rd and 4th decades. Endoscopic

biopsy is the gold standard for diagnosis and the esophagus-stomach-duodenum passage radiography is an important test, especially in the presence of stricture. Proton pump inhibitors and steroid treatment significantly reduce the symptoms in cases without complication in the treatment. Although conservative treatment modalities such as balloon dilatation and stenting seem to be the most appropriate therapeutic approaches, surgical treatment (stricturoplasty, gastrojejunostomy and gastroduodenectomy) is inevitable in some patients. In the treatment of the presented case, the Whipple procedure was preferred due to the presence of widespread involvement beginning from the pylorus and advanced stricture and also by considering the patient’s being young and having no comorbidities. Today, the optimal approach to Crohn’s disease with gastroduodenal involvement is conservative medical treatment. However, patient-based evaluation should always be performed and surgical options should be kept in mind in some patients.

TJS. 2018;34(Suppl-1):S388.

PP-0373 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Coexistence of Adenocarcinoma, Gastrointestinal Stromal Tumor and Schwannoma in the Stomach, A Rare Case Report

Ömer Yalkın ^1,^✉, Serdar Çulcu ¹, Ferit Aydın ¹, Fatih Aslan ¹, Ali Ekrem Ünal ¹

Adenocarcinoma is the most common histologic type of gastric tumors. Gastric schwannoma is a fusiform-cell mesenchymal submucosal tumor. It most commonly localizes in the stomach in the gastrointestinal system and represents 02% of all gastric tumors. Gastrointestinal stromal tumor constitutes 1% of all gastrointestinal system malignancies and 60–70% of them are located in the stomach. The coexistence of three synchronous tumors of different histological types is quite rare. Our case was a 70-year-old male patient. The gastroscopy performed due to epigastric pain and weight loss revealed ulcerated lesion extending to the cardia in the small curvature.

The result of biopsy was reported as adenocarcinoma. The patient was performed total gastrectomy-Roux-en-y gastrojejunostomy. In the pathologic examination, it was reported that a synchronous 1cm diameter GIST and a 3.5cm diameter schwannoma were detected in addition to the known adenocarcinoma. We aimed to present the coexistence of synchronous adenocarcinoma, schwannoma and gastrointestinal stromal tumor, which is a rarely encountered condition.

TJS. 2018;34(Suppl-1):S388–S389.

PP-0374 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Malignant Solitary Fibrous Tumor in the Pelvic Area with Hypoglycemia: Doege-Potter Syndrome

Ebru Esen ^1,^✉, Ramazan Saygın Kerimoğlu ², Meryem İlkay Eren Karaniş ³, Osman Doğru ⁴

Solitary fibrous tumors (SFTs) are rarely seen spindle cell neoplasms and they are mostly benign. While SFT has been considered to originate only from the pleura previously, it has been shown that it also originates from various anatomical regions. Pelvic SFT is a rare but its malignant form is rarer. And, it is very difficult to diagnose it histopathologically. The clinical course of SFT with hypoglycemia is defined as Doege-Potter Syndrome. A 47-year-old male patient, who was operated in an external center for GIST and detected to have recurrent mass in the pelvic region in the follow-up, was referred to our clinic. The patient with type 2 DM had hypoglycemic attacks for the last 6 months and did not use antidiabetic drugs. In the blood tests performed to investigate the cause of hypoglycemia, the levels of growth hormone (GH) and IGF-1 were low and the levels of cortisol and insulin were normal. The computerized tomography revealed a 47x37mm mass in the left jejunal loops and multiple heterogenous solid masses, the largest of which was 67x60 mm, involving the common iliac vein of 156x129 mm, having an about 180 degree contact with the external iliac artery and being in the anterior area of the vertebrae at this level, along the iliac chain and in the right perirectal area. In the magnetic resonance imaging, it was reported that the mass was mildly hyperintense in T1A images and apparently hyperintense in T2A images and intense pathological contrast enhancement was observed following the IVGd injection. In the angio-CT, mass at the level of bifurcation and fatty planes between the VCI and right common iliac vein could not be selected (invasion?). The patient was operated based on these evaluations. In the operation, the left common iliac vein was resected with mass due to right internal iliac artery invasion and cytoreductive surgery was performed. In the histopathological examination, the surface of section was dirty yellow and a 23x20x13cm mass with local bleeding and necrotic appearance was evaluated. Microscopic examination of the mass revealed oval round nucleated pleomorphic cells with narrow cytoplasm, 7 mitoses in x10HPF, and local necrosis and bleeding areas. Vimentin, CD34, Bcl-2, and CD99 stainings were positive in immunohistochemical evaluation. In the light of these findings, the mass was pathologically diagnosed as malignant solitary fibrous tumor. Considering the blood tests performed for hypoglycemia and the improvement of hypoglycemia in the early postoperative period, it was decided that the patient had Doege-Potter Syndrome. In the early postoperative period, the patient was initiated antidiabetics due to high blood glucose levels. The patient was coumadinized for 3 months and then switched to LMWH. The patient was followed up for 8 months without the occurrence of hypoglycemia attack.

TJS. 2018;34(Suppl-1):S389.

PP-0375 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Jejunal Diverticulosis Complicated with Perforation; A Rare Etiology of Acute Abdomen

Ahmet Gökhan Saritaş ^1,^✉, Abdullah Ülkü ¹, Atılgan Tolga Akçam ¹

Introduction

Jejunal diverticulosis is a rare pathology with an incidence of 0.5–1% (1). The increased pressure in the small intestine lumen and the weakening of the wall are accused for the etiology (2). While most cases are asymptomatic, 30–40% of cases may become complicatedly symptomatic as chronic abdominal pain, malabsorption, hemorrhage, diverticulitis, obstruction, abscess formation, and rarely diverticular perforation (2–4). In this study, we aimed to present the rarely seen case of jejunal diverticulosis and diverticular perforation with the literature.

Case

A 36-year-old female patient was admitted to the emergency unit with the complaints of diffuse abdominal pain, nausea and vomiting. In the physical examination, she had diffuse defense, rebound and tenderness in all quadrants. The body temperature of the patient was 37,6’C, pulse was 114/min, BP was 110/80 mmHg, and WBC was 15,3. The computed tomography revealed clear free air around the liver, free fluid consistent with the intense collection, and edema in the mesentery. The patient was operated under emergency conditions. Eight diverticula, one of which had perforation, were observed on the mesenteric surface in the jejunum segment between the 50th and 90th cm from the Treitz ligament and there was intraabdominal bilious purulent fluid. Segmentary small bowel resection, side-to-side anastomosis, and intraabdominal irrigation were performed. The patient was discharged on the 7th postoperative day with recovery. In the pathology of the specimen, eight diverticula, the largest of which was 8 x 7 cm and the smallest was 4 x 3 cm, were detected and one diverticulum had a 4 mm perforation area. It was found that the diverticula were pseudodiverticular lesions including herniation of the mucosa and submucosa.

Conclusion

Acquired jejunoileal diverticulosis was first described by Sommering in 1794 as the herniation of the mucosa and the submucosa of the mesenteric side of the small bowel wall along the muscular layer (pseudodiverticulum). It is more commonly seen in advanced ages.1–5

Uncomplicated cases are usually asymptomatic. It may show symptoms such as nausea, vomiting, epigastric and periumbilical abdominal pain. Complications such as diverticulitis, bleeding, intestinal obstruction and perforation occur in 30% of patients with jejunal diverticulosis.2–6. Lobo et al. defined the most common complication requiring surgery as perforation in small bowel diverticulosis.6 The CT imaging is the best method for diagnosing complicated jejunal diverticulosis.7 Most of the complications of jejunoileal diverticulosis require surgical treatment. In the surgical treatment, simple diverticulum excision should not be performed due to the risks of postoperative intestinal leakage, sepsis and death.2–7 In the differential diagnosis of jejunal diverticulosis perforation, Crohn’s disease, small intestine neoplasm, foreign body trauma, and colon diverticulitis perforation should be considered.8 Jejunoileal diverticulosis is a rarely encountered disease that usually presents as asymptomatic or with non-specific findings and has life-threatening complications such as perforation, obstruction and bleeding. It should be considered in the etiology of acute abdomen.

TJS. 2018;34(Suppl-1):S390.

PP-0376 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Gastric Cancer in Pregnancy: Case Report

Conclusion

In addition to the benefit of follow-up of patients with open abdomen, it may cause an increase in mortality and morbidity. Once the causes of open abdomen are eliminated, the fascia must be closed as soon as possible to prevent complications such as fistula, fluid and protein, and loss of heat and electrolyte. Failure in closing the fascia may cause ventral hernia, which leads to significant morbidity and mortality. OANPTS prevents the internal organs to adhere the abdominal wall and it effectively removes the fluid in the abdominal cavity. Thus, it facilitates the mobilization of the fascia and plays an active role in the closure of the fascia. In our case, we performed OANPTS in the patient instead of opening temporary ileostomy after performing anastomosis and washing the abdomen. In this way, we removed the fluid in the abdomen and avoided re-opening the abdomen and performing anastomosis. This gave us the opportunity to control the anastomosis line in the abdominal re-exploration and to intervene when necessary. However, there was no pathology in the anastomosis line. Then, the abdomen was closed. It should be kept in mind that negative pressure treatment can be used instead of opening ostomy in cases requiring ileostomy due to abdominal infection.

TJS. 2018;34(Suppl-1):S392.

PP-0380 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Our Experience of Laparoscopic Gastrectomy in Our Clinic in the Last Two Years

Ömer Yalkın ^1,^✉, Ferit Aydın ¹, Serdar Çulcu ¹, Fatih Aslan ¹, Nurian Ohri ¹, Salim İlksen Başçeken ¹, Cemil Yüksel ¹, Salim Demirci ¹, Sancar Bayar ¹

In this study, the demographic data, durations of surgery, pathological reports, stages, and complications of 76 patients who were performed laparoscopic gastrectomy due to gastric adenocarcinoma in the Department of Surgical Oncology at Ankara University between the years of 2015 and 2017 were presented.

TJS. 2018;34(Suppl-1):S392–S393.

PP-0381 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Case of Ileus Due to Meckel’s Diverticulum Torsion

Erman Yekenkurul ^1,^✉, İsmet Özaydın ¹, Mehmet Fuat Çetin ¹, Ufuk Önsal ¹

Introduction

Meckel’s diverticulum (MD) is an embryological remnant resulting from the incomplete obliteration of the omphalomesenteric canal and it is the most common congenital anomaly of the gastrointestinal system. Of the patients, 3.7–6.42% are symptomatic. These symptoms are nonspecific symptoms such as nausea, vomiting and abdominal pain. In this article, a case of ileus developing due to rarely seen torsion of Meckel’s diverticulum in adult patient was presented.

Case

A 84-year-old male patient was admitted to the emergency service with abdominal pain, inability to defecate for two days, and vomiting. She had abdominal distention, diffuse tenderness and defense. He was hypotensive and tachycardic. In the blood analyses, white blood cell count was 12600/mm3 (lymphocyte 4,8%, neutrophile 87%), hemoglobin was 11,5 g/dl, CK was 568,5 U/L, CK-MB was 25,9 U/L, glucose was 160 mg/dl, total bilirubin was 2,57 mg/dl, direct bilirubin was 0,8 mg/dl, indirect bilirubin was 1,720 mg/dl, ALT was 15 U/L, AST was 57 U/L, ALP was 120 U/L, creatinin was 1,09 mg/dl, CRP was 9,70 mg/dl, and elektrolytes were normal. In the direct abdominal X-ray in standing position, dilated small intestine segments and air fluid levels were observed, but there was no free air. The abdominal tomography revealed diffuse fluid in the abdomen, free air in the rectum, an increase in calibration in the iliojejunal loops, and air-fluid levels. The patient was hospitalized with the pre-diagnoses of acute abdomen and intestinal obstruction. Fluid replacement was started by inserting a nasogastric catheter. Because there was no change in his findings, he was taken to the operation. When the abdomen was entered under general anesthesia, diffuse distension was observed in the small intestine and the entire abdomen was explored. The torsion of the meckel diverticulum was observed at the 120 cm proximal to the ileocecal valve. While there was diffuse distention in the segments of the diverticulum proximal, the segments in the distal area were normal. The torsion was corrected. Once vascularization of the ischemic bowel loops and peristaltic motion were seen, resection was not performed. The inside of the abdomen was washed with 1000 cc fluid and a drain was placed. The patient was discharged on the ninth postoperative day with recovery.

Conclusion

The majority of patients with Meckel’s diverticulum are asymptomatic. It is usually detected incidentally during surgical interventions performed for another reason or due to its complications. The complications of MD are bleeding, intestinal obstruction and diverticulitis. It occurs most frequently with obstruction and hemorrhage clinic in the adulthood and is often silent. The main mechanisms for MD, which can cause bowel obstruction, are volvulus, Littre’s hernia, intussusception, mesodiverticular band, stenosis secondary to diverticulitis, and Meckel’s diverticulum lithiasis. Torsion of MD is a rare complication of diverticulum, which present with the signs of obstruction and infection. Several cases have been reported in the literature. Our patient had one of these rare complications and he was performed emergency surgery. In the literature, segmental resection is recommended for such cases. However, in our case, the resection was abandoned because vascularization of the intestines was provided and the patient was discharged with improved condition. Meckel’s diverticulum should be considered in the differential diagnosis of patients with acute abdomen signs with small bowel obstruction.

TJS. 2018;34(Suppl-1):S393.

PP-0382 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Complications of Nissen and Redo Nissen Operations and Their Management

Mutlu Şahin ^1,^✉, Mehmet Saydam ¹, İbrahim Yılmaz ¹, Harun Karabacak ¹

Objective

Laparoscopic Nissen fundoplication surgery is the gold standard surgical method in cases of gastroesophageal reflux and hiatal hernia. Although laparoscopic antireflux surgery (LARS) is usually a safe procedure, serious and complicated complications can occur especially in recurrent cases.

Material and Methods

We retrospectively evaluated the early and late complications and their management after LARS operations performed in our clinic in 2017.

Results

Four of the 40 patients who underwent LARS (10%) developed early complications and 6 (15%) developed late complications. Postoperative ileus occurred in two patients (5%) as an early complication and their complaints were regressed with medical treatment and follow-up. One patient was hospitalized in the intensive care unit because of pulmonary complaints and decreased oxygen saturation on the first postoperative day. The complaints of the patients with atelectasis were regressed after 36 hours and they were discharged with recovery. One patient who underwent LARS for hiatal hernia 4 years ago was operated due to the diagnosis of recurrent gross hiatal hernia. After the redo Nissen operation, a possible esophageal leak was detected in the test performed with methylene blue on the postoperative 3rd day. Central venous catheterization was performed on the postoperative 4th day. TPN was initiated and supportive treatment was given for one week. However, although the content of the drain was around 40–50 cc per day, it was observed that the leak continued in the methylene test performed on the 12th day. In our clinic, 2–3 trials were performed to insert the feeding tube extending the jejunum by endoscopy, but in all of them, the feeding tube was returned to the stomach. On the 16th day, with the help of an experienced endoscopist, a feeding tube was placed to extend to the distal part of Treitz with consultation with the Department of Gastroenterology. The patient was fed with feeding tube until the postoperative 30th day. Because there was no lekage in the methylene test performed on the 30th day, oral intake of patient was started. In the barium graph taken due to the complaints of dysphagia and vomiting in the second month, stenosis was observed in the esophagogastric junction. The department of gastroenterology was consulted for balloon dilatation. It was observed in the endoscopy that balloon dilatation was not needed, but 3–4 linear notches were formed in the mucosa due to the reactional strictural appearance. The patient recovered rapidly after this procedure and normal diet was started in the postoperative 3rd month. Four patients (10%) had bloating and dyspepsia as late complications. The endoscopy revealed alkaline reflux gastritis in 3 patients and antral gastritis in the remaining one patient. In one patient who presented with dysphagia, there was no evidence of narrowing in the esophagogastric junction in the barium radiography. In one patient who complained of burning retrosternal, the endoscopy showed evidence of alkaline reflux gastritis. Medical treatment was planned for all of these patients and their complaints were significantly regressed.

Conclusion

Although LARS is defined as safe, the necessity of intervention and multidisciplinary approach by experienced surgeons is inevitable in coping with complications especially in recurrent cases.

TJS. 2018;34(Suppl-1):S394.

PP-0383 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. GIST Originating from the Jejunum and Causing Metastasis to the Rectum and Left Axilla

Halis Bağ ^1,^✉, Taner Coşkun ¹, Haldun Kar ¹, Aras Babayev ¹, Hüdai Genç ¹

Introduction

Gastrointestinal stromal tumors (GIST) constitute less than 1% of gastrointestinal tumors. They are the most common mesenchymal neoplasm of the gastrointestinal system. GISTs are usually found in the stomach or small intestine, but it may occur at any region along the gastrointestinal (GI) tract. They may rarely have extra GI involvement. Clinically, abdominal pain, ileus, jaundice and peritonitis can be seen. Tomography, usg, mr, endoscopy and eus are used for diagnosis. The definite diagnosis is established through biopsy. Its primary treatment is surgery. Tumor size and mitotic activity are the determinants of prognosis. These tumors can cause metastasis to the liver, GI and peritoneum. Metastases other than these are very rare. Treatment should be continued with chemotherapy (CT) in order to prevent recurrence and metastasis. In this case, a case of metastatic GIST undergoing radical surgery was presented.

Case

In the examination of the patient, who was admitted to the emergency service because of abdominal pain, there was no acute abdomen. A mass was palpated in the midline and left axilla of the abdomen. A mass was detected on the rectal examination of the patient who was suffering from constipation. Because the result of FNAB performed by the department of urology was reported as “Gastrointestinal Stromal Tumor”, the patient was referred to our department. The patient underwent colonoscopy. Its result was evaluated as “external compression with restricted expansion in the distal part of the rectum and at the level of sigmoid colon? The mucosa is normal”. Abdominal CT of the patient was reported as, “There is a solid mass lesion of approximately 10 cm in diameter with large necrosis areas, filling the area between the rectum and the bladder, considered to originate from the anterior wall of the rectum. The prostate gland and seminal vesicles cannot be separated from the mass. There is a second mass lesion about 7 cm in diameter which is thought to originate from the ileum at the midline and on the right of the pelvis entry. The patient was operated. In the exploration, a 15*15 cm GIST originating form the jejunum and involving the appendix was found at the distance of 200 cm from the ileocecal valve. Jejunum resection and anastomosis were performed by involving the tumor and the appendix. In the continuation of the exploration, a 20 * 20 cm mass arising from the 1/3 lower rectum and invading the prostate and seminal vesicles was palpated. It was decided to perform Miles operation. The anal canal was released and taken into the abdomen. A radical prostatectomy was performed by the urology team in such a way that the prostate and seminal vesicles remained within the mass. Colostomy was removed from the left lower quadrant of the abdomen. The mass in the left axilla was excised and sent to pathology. The patient was discharged uneventfully on the 10th postoperative day. The pathological evaluation revealed that the stromal tumor in the jejunum was the primary focu and the masses in the rectum and left axilla were metastatic. In addition, it was found that the metastatic mass in the rectum was invasive to the prostate and seminal vesicles. There were no problems in the surgical margins. The patient’s CT therapy and oncological follow-up are ongoing.

Conclusion

The primary treatment of GIST is surgery. When necessary, radical surgeries can be performed. It should be considered that there may be extraintestinal involvements. In oder to prevent recurrence and metastasis after surgery CT should be continued.

TJS. 2018;34(Suppl-1):S394–S395.

PP-0384 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Hiatal Hernia and Peptic Ulcer Perforation

TJS. 2018;34(Suppl-1):S397.

PP-0388 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. A Rare Case Report; Primary Retroperitoneal Serous Cystadenoma

Yeşim Akdeniz ^1,^✉, Yasin Alper Yıldız ¹, Ali Muhtaroğlu ¹, Enis Dikicier ², Emrah Akın ¹, Fatih Altıntoprak ², Belma Koçer ¹

Introduction

Primary retroperitoneal serous cyst adenomas are rare cystic lesions with unknown pathogenesis. Although the majority of tumors are benign, early diagnosis and resection are necessary to prevent malignant transformation, rupture and secondary infection. In this case, we aimed to present our patient who was operated with the pre-diagnosis of intraabdominal cystic mass, found to have peroperative retroperitoneal cystic mass, and reported to have serous cystadenoma in the pathological evaluation.

Case

A 39-year-old female patient was admitted to the outpatient clinic with the complaints of abdominal pain, nausea and constipation. The physical examination revealed mild distention in the abdomen and asymmetry in the inspection. A well-circumscribed formation not exceeding the midline was detected in the left side of the abdomen with palpation.

The contrast-enhanced computed tomography (iv) showed a 16x10 cm hypodense lesion with a content of liquid density in the left half of the abdomen, the margins of which could not be differentiated from the the lower pole of the left kidney and which caused compression and deviation in the neigboring bowel loops and had a contact with the psoas muscle in wide area (mesenteric cyst?). Following the completion of the preoperative preparations, the patient was taken to an operation, and a retroperitoneal cystic mass with a diameter of 20x15 cm that pushed the small bowel towards the right lower quadrant and did not exceed the midline of the abdomen was detected. The mass was excised. The postoperative pathology of the patient was reported as serous cystadenoma and her follow-ups are still going on.

Conclusion

Very few primary retroperitoneal cystic lesions have been reported in the literature. Most lesions are benign. They are mostly seen in women. They can remain asymptomatic until they reach a certain size and they are usually discovered when they reach very large sizes. In rare cases, these lesions may have malignancy potential. Complete excision of the cyst is recommended to prevent recurrence. The diagnosis of primary retroperitoneal serous cystadenoma should be considered in the differential diagnosis of all retroperitoneal cysts.

TJS. 2018;34(Suppl-1):S397–S398.

PP-0389 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. The Effect of Pycnogenol on Lymph Nodes in Peritoneal Adhesion Model, an Experimental Study

Ceren Canbey Göret ¹, Nuri Emrah Göret ², Aslı Kiraz ³, Ömer Faruk Özkan ^4,^✉, Muammer Karaayvaz ⁵

Objective

In this study, it was aimed to investigate the effectiveness of pycnogenol, also called pinus pinaster bark extract, the antioxidant, antimicrobial and anti-inflammatory effects of which were demonstrated on the prevention or reduction of intraabdominal adhesions causing serious complications in the literature. Moreover, it was also aimed to investigate the effect of immunohistochemically free oxygen radicals on the intraabdominal adhesions and the contribution of the reactive lymph nodes detected in this adhesive tissue that we sampled around the cecum.

Material and Methods

Twenty-seven Wistar Albino rats were divided into 3 groups (n=9): Group 1 (SHAM); only laparotomy, Group 2 (Control group: After laparotomy, punctate hemorrhage was created in the cecum with cecal abrasion and 2 cc fluid for each rat was applied intraperitoneally with physiological saline solution. In Group 3 (experimental group), after laparotomy, punctate hemorrhage was created in the cecum by cecal abrasion method and sterile pycnogenol derivative prepared by dilution with physiological saline solution from 10 mg/kg was administered intraperitoneally. Re-laparotomy was performed to all groups on the 7th day, and the peritoneal tissue around the cecum was sampled and the rats were sacrificed. Histopathological parameters were evaluated with Hematoxylin & Eosin, Masson Trichrome, Glutathione S-transferase, Glutathione Reductase, SSO, and Catalase.

Results

There was a statistically significant difference in inflammation, lymph node dimensions and immunohistochemically free oxygen radicals in the group given pycnogenol and these parameters were found to be increased. In terms of fibrosis, no statistically significant difference was found between the control and experiemental groups in both H & E and MT. (for fibrosis; Group 1 – 2: p value 0.001, Group 1 – 3: p value 0.001, Group 2 – 3 p value 0,730. (p<0.05). For inflammation: Group 1 – 2: p value 0.005, Group 1 – 3: p value 0.001, Group 2 – 3: p value 0,002 (p<0.05). For Masson Trikrom;Group 1 – 2: p value 0.001, Group 1 – 3 p value 0.001, Group 2 – 3 p value 0,996. (p<0.05). For lymph node size:Group 1 – 2: p value 0.003, Group 1 – 3; p value 0.001, Group 2 – 3; p value 0,024. (p<0.05). Total immünohistochemical free oxygen radicals; p 0.0001 (p<0.005). The number of lymph nodes;p 0.017 (p<0.005))

Conclusion

No positive result about that pycnogenol decreased intraabdominal adhesion was found, but it caused a severe inflammatory process in the tissue. There was also a significant increase in the size of the lymph nodes detected secondary to this inflammatory process. Additionally, in the immunohistochemical analysis performed to detect oxidative stress, it was determined that it increased free oxygen radicals in tissues.

This article has been accepted for publication in “Acta Cirurgica Brasileira”.

TJS. 2018;34(Suppl-1):S398–S399.

PP-0390 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Intestinal Mantle Cell Lymphoma Causing Ileoileal Invagination, A Case Report

Yeşim Akdeniz ^1,^✉, Merve Yiğit ¹, Burak Kamburoğlu ¹, Emre Gönüllü ¹, Fehmi Çelebi ¹

Introduction

Intestinal invaginations are frequently seen in children, especially under the age of 2 years, but rarely encountered in adults. Patients often present with abdominal pain, nausea, vomiting and ileus findings in the invaginations developing secondary to wall-induced intraluminal pathologies. In this article, we aimed to present our patient who was operated for intestinal invagination and pathologically reported to have as mantle cell lymphoma.

Case

A 32-year-old male patient was admitted to the emergency service with abdominal pain, nausea and vomiting. There was no defense and rebound in the physical examination. Nevertheless, he defined pain particularly in the lower abdominal quadrants. The value of Wbc was 12,7 K/uL and Hgb was 13,8 g/dl. In the intravenous contrast-enhanced computed tomography, there was a target finding consistent with invagination with an approximately 52 mm thickness and right paramedian localization in the distal ileal loops, blur in the omental fat planes in the neighborhood of the defined finding, and local air fluid levels in the distal ileal loops. The patient was operated after the completion of preoperative preparations. In the exploration, ileoileal invagination was detected at a distance of 20 cm from the ileocecal valve. When the invaginated area was reduced, an approximately 3x5 cm mass originating from the small intestine lumen, which was thought to cause invagination, was palpated. During the exploration, multiple intraluminal masses were palpated along the entire small bowel segment. In order to prevent tissue diagnosis and reinvagination, the 10-cm ileum segment having invagination was resected and end-to-end anastomosis with double folds was performed by hand. No other intraabdominal pathology was detected. On the postoperative 5th day, the patient was initiated regimen after the gas-stool discharge. He was discharged on the postoperative 7th day. The postoperative pathology was reported as mantle cell lymphoma. In the neck, axillary and inguinal USG of the patient, there were a large number of reactive lymph nodes with a short diameter of 8 mm in the bilateral upper cervical chain and in the axilla. In the bilateral inguinal region, 10.5x9.5 mm 6–7 LAPs without echogenic hilus were observed. Oncological treatment of the patient is ongoing.

Conclusion

Mantle cell lymphoma constitutes 3–10% of all non-Hodgkin’s lymphomas in the western societies and its annual incidence is 2–3/100.000. It is observed 2 times more frequently in males. It gains an aggressive characteristic defined by resistance to chemotherapy over time. The majority of the cases at the time of diagnosis are at advanced stage. Although rare, it can be seen as small intestine involvement causing invagination. For this reason, mantle cell lymphoma originating from the small intestine should be considered in patients was admitted to the emergency unit due to abdominal pain and found to have invagination in the radiological imaging.

TJS. 2018;34(Suppl-1):S399.

PP-0391 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. A Case of Phytobezoar Causing Ileum Obstruction

Mürşit Dincer ^1,^✉, Ümit Gür ¹, Ekrem Ferlengez ¹, Fazilet Erözgen ¹, Muzaffer Akıncı ¹

Introduction

Bezoar is the solidification of non-digestible food components in the gastrointestinal system. Phytobezoars occur due to undigested residues of plant fiber foods. Although they are most commonly seen in the stomach, they can rarely be seen in the small intestine. 0.4% – 4% of all gastrointestinal system obstructions are caused by bezoars. In this study, we presented a case of small bowel obstruction due to phytobezoar.

Case

A 55-year-old male patient presented with abdominal pain, nausea and vomiting. He had a history of laparotomy due to non-vehicle traffic accident and coronary bypass. The abdominal examination of the patient revealed diffuse tenderness and rebound. There was no abnormality in the laboratory values. Air-fluid levels at the small intestine level were observed on direct abdominal X-ray. The computed tomography revealed an image consistent with bezoar at the small intestine level. The patient was performed laparotomy. There was a bezoar causing obstruction at the level of ileum. Enterotomy, removal of bezoar, and primary repair were performed. The patient with no problem in the postoperative follow-ups was discharged with recommendations.

Conclusion

Phytobezoars occur as a result of frequent consumption of high-fiber foods and insufficient chewing. In addition to frequent consumption of fiber foods, impaired motility due to previous gastric surgeries has been considered to be responsible in the etiology. They usually do not present with symptoms unless they cause obstruction. Imaging methods such as endoscopy, ultrasound, are tomography are helpful in the diagnosis. The bezoars developing in the small intestine are usually at the level of the terminal ileum and the ileocecal valve. Surgical removal of bezoar is the most important method in the treatment as well as conservative or endoscopic approaches. Nasogastric decompression and prokinetic agents are used in the treatment of asymptomatic bezoars. Bezoars that do not respond to conservative treatment or that cannot be broken endoscopically are surgically removed. Bezoars should be kept in mind in the differential diagnosis of patients presenting with the complaints of nausea, vomiting, and abdominal pain or with the signs of obstruction. Appropriate training should be given to patients feeding with high fiber foods and having undergone gastric surgery and the formation of bezoar should be tried to be prevented.

TJS. 2018;34(Suppl-1):S399–S400.

PP-0392 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Esophageal MANEC: A Case Report

Anıl Koçman ^1,^✉, Erkan Hazar ¹, Fatih Dolu ¹, Hatice Özer ², Şule Karadayı ⁴, Naciye Özlem Saygılı Yönem ³, Kürşat Karadayı ¹

Introduction

In the classification of the World Health Organization 2010, gastrointestinal neuroendocrine tumors were classified as neuroendocrine tumor grade 1, neuroendocrine tumor grade 2, neuroendocrine carcinoma, mixed adenoneuroendocrine carcinoma, hyperplastic and neoplastic lesions. Esophageal mixed adenoneuroendocrine carcinomas (MANEC) are very rare cancers. These cancers generally displaying poor prognosis are mostly metastatic when they are detected. MANEC should contain at least 30% of each of the adenocarcinomatosis and neuroendocrine component. MANEC involves low and high-grade lesions. The neuroendocrine part may be well or poorly differentiated. In this study, it was aimed to present a patient with MANEC located in the middle part of the esophagus.

Case

A 57-year-old male patient presented with the complaint of swallowing difficulty gradually increasing in the last one year. It was learned from the anamnesis of the patient that he had weight loss and loss of appetite for the last few months. No abnormality was found in his history and the result of the physical examination was normal. In the esophagogastroscopy of the patient, whose laboratory values were within normal intervals, an ulcerative lesion was detected in the middle of the esophagus. The result of the pathological examination of the endoscopic biopsy was reported as a tumor displaying neuroendocrine differentiation. In the endoscopic ultrasonographic examination performed for staging, it was observed that the tumor invaded the submucosa. The positron emission tomography revealed that the mass was bordered by the esophagus and did not have distant metastasis. The patient underwent total esophagectomy with right thoracotomy, lymph node dissection of two areas, and cervical anastomosis with gastric transposition. The result of pathological examination was reported as MANEC. The tumor, the size of which was 8mm, was reported as T1b N0 M0 (surgical margins were negative and excised 40 lymph nodes were reactive) having Ki-67 index of 80%, less differentiated neuroendocrine component of 70%, and basaloid squamous component of 30%. In the postoperative period, the patient developed anastomosis leakage and he was followed up non-operatively. His fistula was closed spontaneously. After surgical treatment, chemotherapy was planned for the patient.

Conclusion

MANEC in the esophagus is a rare condition. The prognosis of these aggressive tumors is determined by the neuroendocrine part and they are mostly metastatic when detected. The surgical treatment is curative in rare cases diagnosed early.

TJS. 2018;34(Suppl-1):S400.

PP-0393 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Marginal Ulcer Perforation After SADI-S

Talar Vartanoğlu Aktokmakyan ^1,^✉, Nuri Okkabaz ¹, Serhat Meriç ¹, Yunus Emre Aktimur ¹, Fatih Çelebi ¹, Rıza Kutaniş ¹

Introduction

The Single Anastomosis Duodenoileal Bypass with Sleeve Gastrectomy (SADI-S), which is one of the contemporary surgical techniques, is a bariatric surgery technique and it is preferred in the treatment of obesity and diabetic patients. The data of long-term results and complications of this technique, which was defined in 2007, are just being included in the literature. In this report, we aimed to present a diabetic patient who had undergone SADI-S surgery 2 years ago and consulted to our emergency unit with marginal ulcer perforation.

Case

A 52-year-old male patient, who had been performed SADI-S procedure for the history of uncontrolled type II diabetes 2 years before, was admitted to our emergency clinic with the complaint of abdominal pain. There was no abnormality in the chest x-ray of the patient describing sudden onset of epigastric pain. Because of the presence of suspected free air image in the computed tomography performed due to clinical suspect, the decision of exploration was taken. When the abdomen was opened from the old incision line, a perforation area of 1.5 cm diameter was detected on the ground of marginal ulcer in the duodenoileal anastomosis and the Graham method was applied. The patient without any problem in the follow-ups was discharged on the 4th postoperative day with recovery.

Conclusion

While dominant symptoms such as chronic diarrhea and trace element deficiencies can be seen in patients with a history of previous SADI-S, delayed diagnosis may be prevented considering that marginal ulcer and associated perforations may develop.

TJS. 2018;34(Suppl-1):S400–S401.

PP-0394 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Intestinal Volvulus: A Report of 10 Cases

Server Sezgin Uludağ ^1,^✉, Çağan Aykurt ¹, Osman Şimşek ¹, Mehmet Velidedeoğlu ¹, Salih Pekmezci ¹

Objective

Intestinal volvulus is an emergency pathology requiring immediate surgical intervention, which results in death if intervened late. It is a condition in which necrosis and perforation may develop in association with hindered blood flow due to the torsion of the small intestine around its mesentery. In the etiology of intestinal volvulus, brides secondary to previous surgical operation, malignancies, long and narrow-angle mesentery, internal herniations, parasitic infections, high fiber foods eaten after a long meal interval, and primary intestinal volvulus are included.

Material and Methods

Ten patients treated in the Emergency Unit of Cerrahpaşa Medical Faculty between 2011 and 2018 were retrospectively evaluated. The patients were examined in terms of etiology, location, clinical findings, ASA scoring, and treatment strategies of volvulus.

Material and Methods

The files of the patients who underwent PEG procedure in Sivas Numune Hospital between January 2015 and January 2017 were retrospectively reviewed.

Results

During this period, 122 patients were treated with PEG. Of the patients, 69 (56.5%) were male and 53 (43.4%) were female. The patients were between the ages of 20 and 85 years and the median age was 61 years. Of them, 98 (80.3%) had cerebrovascular event, 21 (17.2%) had Alzheimer’s disease, and 3 (2.4%) had amyotrophic lateral sclerosis. The complications were infection around the catheter in 12 (9.8%) patients, leakage in 4 (3.2%) patients, and Buried-bumper syndrome in 2 (1.6%) patients.

Conclusion

PEG is one of the most suitable options for feeding when enteral feeding is not possible for any reason. In patients that can be performed PEG, it should be preferred for long-term enteral nutrition because of being more economic, having lower risk of complication, and having high efficacy.

TJS. 2018;34(Suppl-1):S403.

PP-0398 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. A Case of Acute Appendicitis Due to the Tip of the Appendix Left Long After After Appendectomy

Mustafa Uğur ¹, Ozan Utku Öztürk ^1,^✉, Hüseyin Çığın ¹, Akın Dedemoğlu ¹, Ersin Rasim Arslan ¹

Introduction

Common complications seen after appendectomy include wound site infection, abscess, stump leak, peritonitis, and ileus. Another rare complication is the development of acute appendicitis after appendectomy. Its incidence is 1 in 50000. The reason is that the appendix stump that is left long. In this article, we present a case of acute appendicitis due to the appendix tip left long after appendectomy.

Case

A 55-year-old male patient with abdominal pain was admitted to our clinic. It was learned from his anamnesis that he had undergone appendectomy in another center 1 year ago and he had been performed open abdomen treatment because of wound site infection and wound dehiscence after the procedure. The patient stated that his abdominal pain intermittently occurred after the operation, but the last attack was more severe. He did not have a history of any disease. In his physical examination, there was a sub- and supra-umbilical median incision scar. There was also a 10x15 cm fascial defect in this region. He had tenderness and defense in the lower right quadrant of the abdomen. The number of leukocytes was 16,000/mm3. Other complete blood count and biochemical values were normal. Abdominal ultrasonography and computed tomography showed no signs other than incisional hernia. The patient was operated for the diagnosis of acute abdomen. In the exploration, suture material of the stump was found in the area where appendectomy was applied. There was no problem in the stump. The 1.5 cm inflamed tip of the appendix with mesenteric veins one end of which were attached was seen just below the ileocecal junction. Appendectomy was performed. The patient, who did not develop any postoperative complication, was discharged on the 3rd day. The pathology result was reported as acute appendicitis.

Conclusion

The cause of acute appendicitis developing after appendectomy is inadequate appendectomy. The place of development has been classically reported as the stump of the appendix. In the literature, a case of acute appendicitis occurring due to leaving the tip of the appendix with the mesentery has been encountered. In this case, it was stated that right hemicolectomy was performed for a malignant polyp and the tip of the appendix with retrocecal localization was probably left. In our case, it was found that the tip of the appendix was left with its mesenteric vessels. The left part was in the retrocecal region at the posterior of the ileocecal junction. The patient’s old surgical report was carefully re-examined. The report indicated that the appendix had been perforated from the middle part, there had been adhesions in the right lower quadrant, and it had been difficult to reveal the appendix due to the accumulation of inflammatory materials.

Because of these difficulties, it was probably thought that the retrocecal area could not be fully explored. As a result, it was considered that the appendix was tied from a point near the tip, supposing that it was appendix mesentery, and the remaining appendiceal tissue remained alive because its mesenteric vessels were not cut.

In appendectomy patients with the findings of acute appendicitis, the retrocecal area should be carefully explored for inadequate appendectomy if no other reason was found in the operation.

TJS. 2018;34(Suppl-1):S403–S404.

PP-0399 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Robotic Gastrectomy Performed for Large GIST Located in the Lesser Curvature of the Stomach

Hayrullah Yıldırım ^1,^✉, Volkan Öter ¹, Mehmet Aziret ¹, Kerem Karaman ¹, Metin Ercan ¹

Despite the limitations in the literature for the laparoscopic surgery of gastrointestinal stromal tumor, the use of minimally invasive techniques is increasing day by day. Our aim in this case report is to demonstrate that the excision of GISTs in difficult areas such as small curvature can be applied with robotic surgery. In the literature, while large tumor excision in difficult regions such as pylorus and cardia has been reported, the robotic excision of 5 cm GIST in the lesser curvature is firstly presented.

A 44-year-old female patient presented with dyspepsia and bloating. The gastroscopy revealed a 2-cm lesion in the lesser curvature of the stomach, which caused an external compression on the stomach wall. In the computed tomography (CT), a 5 cm submucosal mass including cystic-necrotic foci was reported in the lesser curvature of the stomach. All parameters including tumor markers were found to be normal in the patient’s biochemistry evaluation. Basen on these findings, an operation was planned for the patient. In the operation room, the patient was given trandelenburg position and applied insufflation with the subumbilical incision to provide a pressure of 12 mm/hg. After the placement of a 12 mm trocar, the abdominal cavity was explored with a robotic optic camera. In the lesser curvature of the stomach, an approximately 5 cm mass without invasion to the surrounding organs and any evidence of dissemination was observed. Other trocars were placed. Firstly, the vascular structures of the greater curvature were transected and the gastrocolic ligament was cut in order to reach the omental bursa. Subsequently, the vascular structures of the small curvature were transected by preserving the latarjet nerve. The stomach wall was opened with the help of L-hook. The mass was excised with 1–2 cm intact gastric tissue by using the Ligasure device. The stomach wall was closed with a continuous weilock suture and then a 3/0 vicryl Albert-Lembert suture. The mass was taken out of the abdomen by umbilical incision with the help of endobag. A Jackson-Pratt drain was placed under the stomach and the operation was terminated. The patient was discharged after 5-day follow-up withut any complication. The patient’s condition was observed to be good at the 2nd week control. As a result of pathology, low-grade epitheloid type GIST with a diameter of 5.5 cm and no ulcer and necrosis was reported. The mitotic index of the tumor was 2/50 HPF and the surgical margins were at the closest distance of 0.5 cm to the tumor. In GIST surgery, minimally invasive techniques have taken a long way in the last 10 years. However, the risk of fragmentation of the large tumors with difficult localization has increased in laparoscopic surgery and gastrotomy is required for obtaining normal surgical margin. The field of vision provided by the Da Vinci robot system and the ease of intracorporeal dissection suture offer confidence in the surgery of large gastric GIST with difficult localization. However, there are limited studies on robotic surgery in the literature and it is emphasized that further studies are required. We think that our case contributes to the literature as it is about robotic gastrectomy of a 5.5 cm GIST located in the lesser curvature of the stomach. In conclusion, we suggest that the robotic excision of gastric GIST is safe and applicable even if it is large and poorly located.

TJS. 2018;34(Suppl-1):S404.

PP-0400 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Regional Seasonal and Gastronomic Phytobezoar Outbreak (A Black Sea Classic)

Bülent Koca ^1,^✉, Erol Kılıç ², İsmail Alper Tarım ³, Savaş Saim Yürüker ³

Introduction

Bezoars is the formation of a mass by non-digested foods in the stomach or small intestine. Bezoars are named according to their contents as phytobezoar, tricobezoar, lactobezoar, and pharmacobezoar. The most common type is phytobezoars. In our country, the Black Sea region is the region where phytobezoars are most commonly encountered because of its unique food consumption. The basic food accused for the formation of phytobezoar is a fruit that is called persimmon, which is consumed in the seasons of fall and winter. Consumption of this fruit causes the occurrence of serious number of bezoar cases and the general surgeons working in this region gain more experience in bezoar than those working in other regions. The aim of this study is to discuss the diagnosis and treatment of 21 phytobezoar cases treated in a bezoar season with our experience.

Case

Twenty-one patients (9 females and 12 males) aged between 24 and 78 years were treated for bezoar in the Bafra State Hospital between the dates of 01.11.2016 and 01.03.2017. Gastric localization was observed in13 patients, intestinal localization in 6 patients, both gastric and intestinal localization in one patient, and duodenal localization in one patient. Of 13 patients with gastric bezoar, 8 were diagnosed with endoscopy and 5 with CT. All 6 patients with intestinal localization were diagnosed with CT. Of the 13 patients with gastric bezoar, 8 were given cola regimen and bezoar was milked into the jejunum. One of the milked cases was re-operated due to ileus. Gastrotomy was performed in 10 cases and bezoar was removed. The duodenal bezoar was removed and treated with Heineke-Mikulicz pyloroplasty. Of the 6 patients with intestinal localization, 4 were treated with enterotomy and 2 cases were treated by milking the bezoar into the cecum.

Conclusion

Phytobezoar is a serious problem seen in the Black Sea Region due to seasonal eating habits. In our region, the etiology of intestinal obstruction is different from literature. The most common cause of intestinal obstruction in the Black Sea is bezoar. CT and endoscopy are very effective in diagnosis. Contrary to a significant part of the literature, the cola regime has no significant place in the treatment. The main treatment is surgery. The surgical procedure varies according to the case.

TJS. 2018;34(Suppl-1):S405.

PP-0401 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Our Laparoscopic Surgery Experience in Median Arcuate Syndrome

Mehmet Fatih Korkmaz ^1,^✉, Rumeysa Kevser Limandemirbağ ¹, Ahmet Bozdağ ¹, Koray Karabulut ¹

Objective

Median arcuate syndrome presents with a decrease in the blood flow due to the narrowing caused by the compression of the median arcuate ligament on the celiac truncus and the diaphragm left crus hypertrophy and associated symptoms. Its treatment is surgery. Its incidence has been reported to be between 2.3% and 10% in the world. We aimed to share our results on patients who were operated with the diagnosis of median arcuate syndrome and our laparoscopic approach to treatment.

Material and Methods

The data of the patients performed laparoscopic surgery due to the diagnosis of median arcuate syndrome in our clinic between January 2015 and December 2017 were retrospectively analyzed through patient files and hospital automation system.

Results

The total number of patients was 4, including 3 male and 1 female. The age range was 26 to 74 years and the median age was 42 years. Their complaints were abdominal pain, abdominal distention, and nausea. They had colic pain in the epigastric region immediately after eating and weight loss due to the fear of eating. They had history of recurrent gastroscopy and further investigations due to weight loss, and also history of symptomatic treatments. Dynamic contrast-enhanced tomography (CT) of the abdomen was used in the diagnosis. The CT images showed a 50%–90% narrowing due to the compression of the median arcuate ligament in the celiac truncus. All of the patients underwent laparoscopic surgery and no conversion to the open surgery occurred. The operation time was 64–113 min, and the median duration was 76 min. The patients were approached in the reverse Trendelenburg position. Two 11 mm and two 5 mm trocars were used. Nathanson retractor was used from the 5-mm trocar in the epigastric region. The hepatogastric ligament was cut and the diaphragm right crus was dissected. The muscles on the aorta were cut until the celiac truncus with the help of hook and ligasure. The left gastric, splenic and common hepatic arteries were viewed and preserved. The ligament and muscle fibers causing compression on the celiac truncus were cut. No drain was placed in any of the patients. In the postoperative control CTs, it was observed that the calibration of the celiac truncus was returned to normal. The patients were discharged on the 3rd postoperative day. The duration of follow-up was between 3 and 40 months. It was seen that the symptoms were almost healed, their eating habits were normalized, weight loss was stopped, and they returned to their normal weights.

Conclusion

We suggest that laparoscopic surgery is an effective and safe treatment for median arcuate ligament syndrome.

TJS. 2018;34(Suppl-1):S405–S406.

PP-0402 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Gastrointestinal System Bleeding Requiring Surgical Treatment and Surgical Procedures: Single-Center Data

Fatih Karaahmet ^1,^✉, Marlen Süleyman ², Koray Koşmaz ², Abdullah Durhan ², Rıfat Kuşabbi ², Ruçhan Bahadır Celep ², Murat Kekilli ¹

Objective

Acute gastrointestinal system (GIS) bleeding is a common cause of mortality and morbidity. While 85% of GIS bleedings stop spontaneously with endoscopic and conservative treatment approach, 15% require aggressive approach. The aim of this study was to investigate the rate of patients who underwent surgical treatment for GIS bleeding, the condition that led to the choice of surgical treatment, and what type of surgical treatment was performed.

Material and Methods

The patients admitted to the emergency unit with GIS bleeding and performed endoscopic and colonoscopic evaluation between January 2017 and December 2017 were scanned retrospectively. Of these patients, those that were applied surgical treatments were determined. The reasons for surgery and the types of surgical procedures were retrospectively investigated.

Results

Of 1056 patients with GIS bleeding who were admitted to the gastroenterology endoscopy unit during one year, 56 (5.34%) had lower GIS bleeding. A total of 2 (0.18%) patients who presented with GIS bleeding were performed surgical treatment because of uncontrolled bleeding by endoscopic treatment. One of these patients had bleeding secandary to the vasculitic small bowel involvement of Wegener granulomatosis and bleeding control was provided by endoscopy-surgery hybrid method in this case. After emptying the small intestine content from the Treitz’s ligament until the ileocecal valve, sequential clamping was performed at 40–50 cm intervals. Hemorrhage localization was detected in the proximal jejunum, and the lumen was entered with gastroscopy after applying enteretomy to the hemorhagic segment in the intestine. A large number of deep ulcer craters were detected in the proximal jejunum. The 20 cm intestinal segment was resected and end-to-end anastomosis was performed to control bleeding. In the other patient, GIS bleeding could not be controlled due to endoscopic intervention performed three times for gastric corpus Dieulafoy lesion. This patient was applied primary suture surgically and bleeding control was provided. General characteristics of patients, hemoglobin values and surgical techniques are given in the table.

Conclusion

The annual incidence of GIS bleedings is between 50 and 150 of 100,000 hospital admissions, and its mortality is still around 10% despite developments in diagnostic and therapeutic procedures and advanced life support. Surgical treatment should be considered for patients older than 60 years of age and having comorbidity and recurrent massive bleeding, those requiring more than 6 units of erythrocyte replacement within 24 hours, those being hemodynamically unstable, those undergoing unsuccessful endoscopic treatment, and those having ulcer with a high risk of re-bleeding. Only 0.18% of patients admitted to our hospital for GIS bleeding were treated surgically. Despite the developments in endoscopic treatment at present, multidisciplinary approach and surgical treatment is still needed in GIS bleedings.

TJS. 2018;34(Suppl-1):S406.

PP-0403 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Comparison of Efficiencies of Laparoscopic Transversus Abdominis Plane Block and Local Anesthesia at Trocar Site After Laparoscopic Appendectomy

İksan Taşdelen ^1,^✉, Ahmet Yalın İşcan ¹, Ali Cihan Bilgili ¹, Aziz Bora Karip ¹, Ender Onur ¹, Kemal Memişoğlu ¹

Objective

The most common operation performed in the general surgery practice is appendectomy. With the spread of laparoscopy, minimally invasive procedures have become more preferable and less pain, early mobilization, early return to work and better cosmetic results have been obtained in the postoperative period. A method for reducing postoperative pain is the ultrasound-guided transversus abdominis plane (TAP) block. The aim of this study was to compare the efficacy of local anesthetic (LA) infiltration in the trocar site with transversus abdominis plane block performed under direct laparoscopic view without using ultrasound in patients undergoing laparoscopic appendectomy for acute appendicitis.

Material and Methods

The patients who underwent laparoscopic appendectomy due to the diagnosis of appendicitis in the Department of General Surgery at Health Sciences University, Fatih Sultan Mehmet Education and Research Hospital between August 2017 and January 2018 were randomized into two groups. Group 1 was performed TAP block under laparoscopic view and Group 2 was performed LA infiltration in the trocar site. The pain levels of the patients were calculated by using visual analogue score (VAS) at the postoeprative 0th, 2nd, 6th, 12th and 24th hours. The duration of operation, postoperative nausea and vomiting complaints, the first times of gas-stool discharge, the first times of mobilization, duration of hospital stay, and the doses of nonsteroidal analgesic drugs and opioids were recorded and compared. The statistical analysis was performed using SPSS version 20.0 software. The p values below 0.05 were evaluated as statistically significant.

Results

There was no significant difference between the groups in terms of age, gender, BMI and ASA scores (p> 0.05). The VAS values recorded at 0th, 2nd, 6th, 12th and 24th hours were significantly lower in the TAP block group than in the trocar site group. The duration of hospital stay in the TAP block group was detected to be shorter (p: 0.002). Moreover, analgesic consumption in TAP block group was lower compared to the trocar site group (p: 0,023).

Conclusion

The TAP block method applied by surgeon during laparoscopic appendectomy is more effective than local anesthesia application in the trocar site. Due to decreased analgesic use, intestinal movements may be returned in the early period and this may shorten the length of hospitalization.

TJS. 2018;34(Suppl-1):S406–S407.

PP-0404 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Our Laparoscopic Experience in Gastric Tumors

Mehmet Fatih Korkmaz ^1,^✉, Ahmet Bozdağ ¹, Ertuğrul Şahin ¹, Rumeysa Kevser Liman Demirbağ ¹, Koray Karabulut ¹

Objective

Laparoscopic surgery has been used in gastric tumors at an increasing rate in recent years. In addition to the known advantages of minimally invasive surgery in selected cases, its oncologic results similar to open surgery have been reported. We aimed to share our perioperative experience and early oncologic outcomes in patients who underwent laparoscopic resection for gastric tumor in our clinic.

Material and Methods

Data of patients who were performed laparoscopic gastric resection with the diagnosis of stomach tumor in our clinic between January 2014 and December 2017 were retrospectively evaluated from hospital automation system.

Results

The number of patients undergoing laparoscopic surgery between the stated dates was 11. Five patients were male and 6 were female. Of the operated patients, 6 had gastrointestinal stromal tumor (GIST), 4 had adenocarcinoma, and one had polyp including in situ adenocarcinoma focus. The age range of the patients who were operated with the diagnosis of GIST was between 30 and 72 years and the median age was 48 years. The diameter of the tumor was between 2 cm and 15.5 cm and the median tumor diameter was 4 cm. All patients were performed laparoscopic wedge resection. There were no tumors in the surgical margins. No mortality or morbidity was observed. The age range of the patients with adenocarcinoma was 45–82 years and the median age was 63 years. While the tumor was in the antrum in 3 patients, it was located in the cardia in 1 patient. Laparoscopic radical distal subtotal gastrectomy was performed in those with distal localization. Intracorporeal suture and stapler were used in distal resections. In the patient who underwent total gastrectomy, resection was performed laparoscopically and anastomosis was carried out with the help of laparotomy and stapler. While the stage was T2 in one patient, it was T4 in the other 3 patients. The number of excised lymph nodes varied between 25 and 55 and the median number was 33. The number of lymph nodes in the patient with T4 tumor was 55 and 4 of them were positive. The other patients were N0. One patient developed an early port site herniation. Laparotomy and reduction were applied. This patient died on the 60th postoperative day with the diagnosis of respiratory insufficiency due to pneumonia. Laparoscopic wedge resection was performed in the case with in situ cancer. The surgical margins were clean. The duration of surgery was between 24 and 245 min and the median time was 48 min. The patients were approached in the reverse trendelenburg position. Five ports were used. Two 11 mm and three 5 mm trocars were used. Nathanson retractor was used from the 5-mm trocar in the epigastric region. The patients were discharged in 2–7 days. While 4 patients were placed drain on the anastomosis line, 7 patients were followed without drain. The drains were removed after beginning oral intake on the postoperative 3rd day. The follow-up period was 6–37 months and the median follow-up period was 21 months. No recurrence was observed during the follow-up period.

Conclusion

Although our series is limited, in order to benefit from the advantages of minimally invasive surgery in addition to oncologic results similar to open surgery, we suggest that laparoscopic surgery should be considered as a treatment method in gastric tumors in centers having experience in open stomach tumor surgery and intracorporeal anastomosis and skills in advanced laparoscopic surgery.

TJS. 2018;34(Suppl-1):S407–S408.

PP-0405 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Is Laparoscopic Approach Suitable for Cases Considered to be Stump Appendicitis?

Şevki Pedük ¹, Hayrullah Yıldırım ^1,^✉

Appendicitis is one of the most common causes of acute abdomen in our country and all over the world, which often requires emergency intervention. Stump appendicitis should be remembered in patients admitted to the emergency department with pain in the right lower quadrant pain and having old Mcburney incision scar. In this case, we aimed to explain the treatment of our patient with the diagnosis of stump appendicitis through laparoscopic approach. When patients with a history of appendectomy are admitted to the emergency unit due to pain in the right lower quadrant, the dilemma of surgeon can be inevitable. The inflammation developing in the residual appendix after incomplete appendectomy is called stump appendicitis and its incidence can be one in 50 thousand appendectomies. In our case, a 26-year-old male patient with right lower quadrant pain that started 12 hours ago had a history of appendectomy performed 6 years before. Abdominal examination showed an old Mcburney incision scar in the inspection. In the physical examination, right lower quadrant tenderness and voluntary defense were observed in the palpation. In laboratory tests, there was no significant finding except the white blood count of 12,200/mm3 and two-fold increase in the values of AST and ALT. In the ultrasonographic examination, a 6–7 mm appendicolith with an acoustic shadow in the right lower quadrant was seen and the appendix could not be detected. Computed tomography examination was reported as a 6 mm appendicolith in the neighborhood of the anterior region of the cecum in the right lower quadrant. In one patient, after the diagnosis of stump appendicitis was confirmed and the other pathologies were ruled out by inserting an optical port, stump appendicitis was clearly demonstrated by inserting two working ports. The minor vascular structures feeding the residual appendix tissue were ligated with the help of the energy device. The root of the appendix was closed with two polymer endoclips, and inflamed appendix and adhered fatty tissues were resected as fragments. Cecoplasty was performed with Endosuture. The patient was discharged after 3-day follow-up without any problem.

In conclusion, surgeons should be aware of stump appendicitis and keep it in mind for its etiology in patients undergoing appendectomy and having right lower quadrant pain. In cases causing dilemma in terms of exploration, laparoscopy can often be a diagnostic tool and it is possible to successfully complete the resection laparoscopically in selected cases. However, appendiceal root should be well visualized in every appendectomy operation and the appendix should be excised without leaving stump.

TJS. 2018;34(Suppl-1):S408.

PP-0406 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Ileus Associated with Multisegment Invagination Caused by Peutz-Jeghers Polyps: A Case Report

Deniz Esin Tekcan Şanlı ¹, Ahmet Necati Şanlı ^2,^✉, Ali İşler ², Arif Emre ², Mehmet Sertkaya ³

Peutz-Jeghers syndrome is an autosomal dominant disorder characterized by hamartomatous polyps and mucocutaneous pigmentation. Most of polyps are located in the small intestine and frequently cause jejuno-jejunal and jejuno-ileal intussusception in children.

While the spontaneous reduction of invagination caused by small polyps is possible, endoscopic or surgical treatment may be required for the large ones.

In this article, we aimed to present a 25-year-old female patient who was previously diagnosed with Peutz-Jeghers syndrome by the findings of physical examination and upper gastrointestinal system endoscopy and was admitted with the symptoms of ileus ongoing for 8 days.

TJS. 2018;34(Suppl-1):S408–S409.

PP-0407 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. A Rare Cause of Acute Abdomen in Adult Patients, Intestinal Invagination

Semra Demirli Atıcı ^1,^✉, Can Arıcan ¹, Emran Kuzey Avcı ¹, Murat Akalın ¹, Ali Kemal Kayapınar ¹, Bülent Çalık ¹, Gökhan Akbulut ¹

Invagination is a pathological condition that occurs mostly in pediatric patients but rarely in adult patients, and develops due to the progression of the intestinal proximal segment into the bowel loop. Patients are frequently admitted to the emergency unit with the complaints of gastrointestinal obstruction such as abdominal pain, nausea, vomiting, and inability to defecate. In this report, we presented a patient who was admitted to the emergency unit due to abdominal pain, whose physical examination result was consistent with acute abdomen, and who was detected to have intestinal invagination in the exploration. A 50-year-old male patient was admitted to the emergency department with the complaints of abdominal pain, nausea, vomiting, and inability to defecate going on for one week. He had a history of renal transplantation performed 15 years ago due to chronic renal failure and re-transplantation because of chronic rejection developing in the follow-ups and immunosuppressive therapy 5 months ago. His physical examination revealed defense in all quadrants of the abdomen. In the analyses, no additional pathology was found except for leukocytosis with neutrophil predominance. The patient who was observed to have a target sign appearance in the whole abdomen CT without contrast-enhancmeent, was taken to emergency operation with the pre-diagnosis of invagination. In the exploration, an image consistent with invagination at the 150th cm from the Treitz ligament was detected and segmental small bowel resection and end-to-end anastomosis were performed. The drain of the patient with gas-stool discharge was removed and he was discharged on the 5th day with healing. Invagination is a pathological condition that mostly occurs in pediatric patients, but rarely in adult patients, with a progression of the proximal segment of the intestine into the bowel loop in the distal area. Although the etiopathogenesis of invagination is not exactly known yet, it is thought that intralumen irritation or benign or malignant mass increases the intestinal peristaltism and causes invagination. In adult patients, it has a similar incidence in male and female patients and it is frequently seen between the 6th and 7th decades. Invaginations according to the localizations are put into five groups as enteric, ileocecal (ileocolic), colocolic, colorectal, and rectorectal. In a study conducted by Begos et al., it was detected that invaginations observed in adult patients arise from the small bowel at the rate of 64% and from the colon at the rate of 36%. It was reported that, of small bowel invaginations, 23% were due to idiopathic pathologies, 63% were due to benign pathologies, and 14% were due to malignant pathologies. Since invagination mostly develops due to benign causes in the pediatric age group, deinvagination is applied predominantly in the treatment. In the adult patient group, the potential for malignancy in the etiology of invagination should always be considered. Due to the presence of the risks of possible tumor perforation, intraluminal transplantation of the tumor, and anastomotic leakage in the deinvaginated edematous inflamed bowel loops, the primary treatment of invagination in the adults is surgery. Intestinal invagination should also be kept in mind in the differential diagnosis of patients consulting to the emergency unit with the symptoms of gastrointestinal obstruction and having the picture of acute abdomen. In adult patients, the possible underlying malignancy should be considered for invagination and surgical resection should be applied in its treatment.

TJS. 2018;34(Suppl-1):S409.

PP-0408 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Gastric Fluid CaIprotectin Values

Murat Çikot ¹, Bahadır Kartal ^1,^✉, Halil Aış ²

Objective

Calprotectin is a member of the S100 protein family. It is a calcium and zinc binding protein found in the cytoplasm of human neutrophil and monocyte. Calprotectin is released from activated neutrophils and acts as a marker of inflammation. Calprotectin has chemotactic factor activity as well as antimicrobial effect and proinflammatory cytokine functions. In this study, the aim was to investigate the usability of gastric fluid calprotectin value in the diagnosis of gastric cancer.

Material and Methods

Esophagogastroduodenoscopy was performed in patients with upper gastrointestinal system complaints between February and May 2004. Diagnostic biopsy and gastric fluid samples were obtained. According to the biopsy results, three different groups, each of which included 20 cases, were formed as: Normal (Group 1), gastric ulcer (Group 2), and gastric cancer (Group 3). Calprotectin values of gastric fluids were investigated through the micro-ELISA method.

Results

The mean gastric fluid calprotectin values were 16.96 ng/ml, 73.58 ng/ml and 143.07 ng/ml for Group 1, 2 and 3, respectively. After statistical comparisons among the groups, p values were found to be p=0.023, p=0.0001 and p=0.0001 between group 1-group 2, group 1- group 3, and group 2- group 3, respectively.

Conclusion

Calprotectin value increases in correlation with the intensity of inflammation and reaches the highest value with gastric cancer. Because gastric fluid calprotectin values are high in gastric cancer, the gastric fluid calprotectin value may be used as a screening test in early stage gastric cancers. In order to verify this hypothesis, researches should be conducted in larger case series.

TJS. 2018;34(Suppl-1):S409–S410.

PP-0409 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Our Experience in Gastric Cancer

Mehmet Baki Doğan ¹, Esin Kaplan ^1,^✉, Cihat Tatar ¹, Ali Emre Naycı ¹, Coşkun Çakır ¹, Aziz Arı ¹, Abdülkerim Özakay ¹, Serkan Sarı ¹, Feyzullah Ersöz ¹, Soykan Arıkan ¹

Gastric cancer is the fourth most common type of cancer across the world and it is on the third rank among the cancer-related deaths. The significant risk factors include helicobacter, smoked foods, pernicious anemia, previous gastric surgery, intestinal metaplasia, and genetic cancer syndromes. The 5-year survival rate is about 30% despite all aggressive treatments in cases. In this retrospective study, it was aimed to determine the prognoses of patients operated for gastric cancer according to the frequency of histological subtypes, the type of performed surgery, and lymph node profile. The data of 352 patients who underwent elective surgery for gastric cancer between January 2010 and December 2017 were retrospectively analyzed. Of the cases, 59 (16.7%) were female and 293 (83.3%) were male and the mean age was 62.2 years. Most of the tumors were located in the antrum. Total gastrectomy (TG) was performed in 254 (72.4%) patients, subtotal gastrectomy (STG) in 78 (22.4%) patients, wedge resection in 16 (4.5%) patients, and local excision in 2 (0.57) patients. In the intraoperative period, splenectomy was performed for splenic bleeding in 4 (1.13%) patients and for invasion in 3 (0.85%) patients. Segmentary transverse colon resection was performed for invasion in 2 (0.57%) cases. Eight (2, 26%) patients underwent distal esophagectomy for positive surgical margin. Due to invasion, one case (0.25%) was performed nephrectomy and one patient (0.25%) was applied surrenelectomy and distal pancreatectomy. Total gastrectomy was performed in 3 patients for remnant stomach ca. Completion gastrectomy was performed in 2 patients considering their pathological results. The mean number of affected lymph nodes in our patients was 20.9 in patients undergoing STG and 27.9 in patients undergoing TG. The number of metastasis detected in the excised lymph nodes was 4.7 on average in patients undergoing STG and 5.6 in patients undergoing TG. The mean survival was 26.1 months. Eleven patients died in the postoperative first month and 119 patients died in the postoperative first 5 years. The 5-year survival rate was 30.6%. The survival in mucinous adenocarcinoma and cohesive cell adenocarcinoma was detected to be quite short. Papillary adenocarcinoma and intestinal cell subtype had longer survival. The majority of our cases had stage 3 (62%) tumors. The best known treatment method for gastric cancer is curative resection. In the early and late results of the Dutch Gastric Cancer Research and Medical Research Council Survey, although morbidity and mortality rates after D1 and D2 LND were found to be significantly higher, it was reported that D2 lymphadenectomy displayed lower mortality associated with local, regional recurrence and gastric cancer than D1 lymphadenectomy. The authors concluded that D2 LND could be performed safely, and D2 was the recommended type of lymphadenectomy for resectable gastric cancer. Since 1960, the Japanese surgeons have made more aggressive interventions in gastric cancer surgery than in the Western countries and they have routinely applied D2 lymph node dissection in the treatment of gastric cancer. In our cases, approximately 25 lymph nodes were removed although the lymph node dissection type was not routinely indicated. In Japan and Korea, extensive endoscopic screening has led to the rate of patients with early gastric cancer to increase up to 50%. Pathological staging of the tumor in gastric cancer is important for the prediction of survival. In our cases, after the examination of the resection specimens, it was found that the advanced pathological stages (stage III, 62%) were more common. In our country, patients mostly consult at advanced stage because gastric cancer is not included in the cancer screening program and there are a few number of endoscopy centers. In order to perform minimally surgical interventions or endoscopic interventions more frequently, it is necessary to detect the cases at early stages with screening programs.

TJS. 2018;34(Suppl-1):S410.

PP-0410 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Patient with Peutz-Jeghers Syndrome Presenting with Inoperable Periampullary Tumor

Muhammer Ergenç ^1,^✉, Tevfik Kıvılcım Uprak ¹, Şevket Cumhur Yeğen ¹

Introduction

Peutz-Jeghers syndrome (PJS) is an autosomal dominant inherited genetic syndrome characterized by multiple hamartomatous polyps and mucocutaneous pigmentation in the gastrointestinal tract. In patients with Peutz-Jeghers syndrome, the risk of gastrointestinal and non-gastrointestinal malignancies is increased.

Case

The patient, who had complaints of weight loss, nausea and vomiting for about 2 months was admitted to the emergency service and then referred to the general surgery unit for further examination and treatment. The patient’s physical examination revealed no evidence of defense-rebound in the abdomen, palpable mass lesions in the periumbilical region were present, and hyperpigmented areas were observed on the lips. The patient had undergone laparotomy about 25 years ago and had no knowledge about the reason. In laboratory tests; WBC was 14200, HGB was 10,6, Creatine was 1,51, Albumin was 3,6, and Bilirubin was

N. A 10 cm mass at the head of the pancreas was detected in the tomography of the abdomen and the stomach was in a pitotic state. Upper gastrointestinal endoscopy showed polypoid appearance in the stomach fundus, pylorus could not be passed. The exploratory laparotomy was performed. At the head of the pancreas, all the retroperitoneal area filled with tumoral lesion was palpated. Implants on the gall bladder and hepatoduodenal ligaments were observed. Multiple invagination sites were observed in the small intestines and the polyps were palpated after being reduced. Multiple enterotomies were performed and polyps were excised. Gastrojejunostomy was performed on the patient due to duodenal obstruction secondary to lack of oral intake. The implants were biopsied and the operation was terminated. The patient who started the regimen on the postoperative 2nd day passed gas on the 3rd day. On the 4th day, the patient who started tolerating the regimen was discharged from the hospital. According to the patient’s pathology, the implants were reported to be compatible with mucinous adenocarcinoma and multiple hamartomatous small intestine polyps.

Conclusion

Introduction

Superior mesenteric artery syndrome, first described by the Austrian professor Card von Rokitansky in 1842, is the clinical symptom and findings resulting from the third part of the duodenum being trapped between the aorta and the superior mesenteric artery (SMA). It is seen when the angle between the abdominal aorta and SMA is 6 °–25 °. Loss of fat tissue, which is a different consequence of weight loss, and acute angulation of SMA are considered as etiological factors. SMA syndrome is also called Wilkie syndrome. The disease can be diagnosed by combining clinical and radiological findings. For treatment conservative or surgical interventions might be performed. In conservative treatment is it intended that the patient be nourished, gain weight and thus increase the fat tissue to prevent acute angulation. Surgical treatment is the by-pass or anastomosis techniques to provide a passage of jejunum passage.

Case

A 23-year-old male patient was admitted to the emergency room for a month of ongoing nausea, vomiting and pain in the epigastric region. The patient stated that he had been having eating problems for a long time and that he had lost about 6 kg of weight in the previous month. Nothing specific was identified in the patient’s laboratory findings. On the abdominal ultrasonography, moderate dilatation was observed in the first and second side of the stomach and duodenum. In the contrasted abdominal computed tomography scan, stenosis was observed in the third side of the duodenum. Endoscopy revealed continuous clearance in the pyloric duct along with advanced dilatation in the duodenum. In the contrasted abdominal tomography, external compression in the third part of the duodenum was, dilatation on the compression. Furthermore, it was observed that the third part of the duodenum was jammed between superior mesenteric artery and aorta. The patient whose complaints had been relieved with supportive care was scheduled for a follow-up.

Conclusion

Superior mesenteric artery syndrome is one of the difficult to diagnose syndromes. There are no pathognomonic findings in the patient’s history and examination. In most of the patients, symptoms such as vomiting, abstinence, premature satiety and upper abdominal pain are present. In patients with superior mesenteric artery syndrome, depending on the severity and cause of duodenal obstruction, there are complaints of long term and intermittent exacerbation of the abdominal pain. Our patient also was admitted to our unit with complaints of abdominal pain, nausea and vomiting. SMA syndrome rarely starts acutely and manifests itself as complete ileus development. In cases of acute mechanical intestinal obstruction, acute gastric dilation or bilious vomiting may present as a symptom of proximal small bowel obstruction. These clinical findings were also found in our patient’s history. Patients’ pain generally decreases with postural changes such as lying face downwards or on left decubitus, in order to increase the angle between SMA and aorta. Our patient also showed relaxation when lying face downwards. SMA syndrome should be considered in the differential diagnosis of patients with unknown complaints of nausea, vomiting and weight loss and congestion at the upper gastrointestinal system. Via the contrast enhanced upper abdominal CT, stenosis in the form of the external compression in the duodenum and in the passage imaging, the partial or complete occlusion in the third part of the duodenum are the findings that make the diagnosis possible. In cases where medical treatment is not successful, duodenojejunostomy is the most commonly used surgical method.

TJS. 2018;34(Suppl-1):S416.

PP-0419 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Presence of Konduitte Stapler Line Gap in Patients Undergoing Intrathoracic Gastric Conduit: Management of the Patient

Mehmet Yıldırım ^1,^✉, Savaş Yakan ², Erkan Oymacı ², Hilmi Yazıcı ²

Introduction

The main treatment Esophagus carcinoma is the tracheal continuum via esophagectomy and reconstruction. The main reconstructive organ is the stomach and this procedure is associated with high morbidity. Leakage from the gastric conduit stapler line causes mediastinitis and puts the patient’s life in danger and its treatment is still controversial. Since different treatments are suggested in this case, we aim to present the surgical management of this fatal condition.

Case

The patient was 59 years old and was admitted to our unit with dysphagia and retrosternal pain. Endoscopy revealed lower thoracic distal esophagus carcinoma. Adenocarcinoma was diagnosed as a result of endoscopic biopsy. The patient was performed Iwor-Lewis type (right thoracotomy, subcostal abdominal laparotomy, partial osophagogastrectomy, esophagogastrostomy with gastric conduit). The gastric tube was about 20 cm long and the esophagogastrostomy was performed with a 25 mm circular stapler. 75 mm cartridges were used in the construction of the gastric conduit. No additional serosal stitches were placed on the stapler line. Leakage test was performed with methylene blue in the postoperative period. The patient was started on oral food on the 6th day since no leakage had been detected. On the tenth day fever and dyspnea started. The bilious fluid was observed coming from the thorax tube. Emergency endoscopy was performed. A gap of 8 cm was detected on the stapler line in the stomach tube. During emergency thoracotomy, two leakage areas of 1 cm and 8 cm were detected. Stomach conduit was taken into the abdomen. The patient underwent cervical esophagostomy, esophagectomy with proximal gastric resection and nutritional gastrostomy. On the 5th day of re-thoracotomy, thoracotomy evantration was experienced. Continuous irrigation of the pleural space was performed. The patient died on the 16th day due to multiple organ failure.

Conclusion

Intrathoracic reconstruction is the main surgical option for distal esophageal tumors. Stomach tubing prepared in the reconstruction can be used. There is no data showing that reinforcement stitches placed on the stapler line prevent the leakage. Early endoscopy is useful and stents can be placed in the gaps below 2 cm. Surgical treatment should be performed in cases where nonstable and large defects are detected in gastric conduit.

TJS. 2018;34(Suppl-1):S416–S417.

PP-0420 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Unexpected Complications after Gastric Cancer Surgery

Sadık Emre Direk ^1,^✉, Ersan Semerci ¹, Abdullah Serin ¹

Objective

Anastomotic leakage after total gastrectomy causes high morbidity and mortality. Early detection and use of new operative techniques have a positive effect on mortality and morbidity. Discussion of the management of anastomosis leakage and pancreatic fistula in a patient who underwent total gastrectomy distal pancreatectomy and D2 dissection.

Material and Methods

Ulcerovegatan mass extending from the small curvature to the cardiovascular mass was revealed in the gastroscopy performed upon weight loss and dyspeptic complaints in a 62 year old male patient. Endoscopic bx: adenocarcinoma. Total gastrectomy + D2 lymph node dissection + distal pancreatectomy + splenectomy were performed on the patient. Postoperative Pathology report: Mucinous adenocarcinoma. Metastatic lymph nodes: 18, reactive lymph nodes: 23. It was evaluated as T3N3bM0 stage 3b. On the 6th postoperative day, the patient was operated on the development of tachycardia, tachypnea, dyspnea, fever, intestinal infiltration from the drain, and leakage from the closed segment of the tip-side esophagojejunostomy in fluoroscopy. Anastomotic leakage was closed with linear stapler and it was seen that since the end of the jejunal loop was adjacent to the edge of the pancreatic tissue and the tissue was exposed to pancreatic enzymes, the leakage was found to be fragile to be closed with the suture. Upon this, drains were placed in the place where the leakage was and near the pancreas tissue. Peroperative esophagascopy was performed and the esophagojejunostomy anastomosis line was found to be intact and the stent was placed to bypass the leakage, the guide wire was placed, feeding jejunostomy was performed and bilateral thoracic tube was placed. The next day, a stent was placed with the help of a guide wire to cover the anastomosis of the esophagojejunostomy endoscopically. The drainage in the right thorax tube, which was 200–300cc/ day serous until the 5th day, began to appear blurred, while there was nothing coming from the abdominal drains. Amylase (2541) from the fluid from the thorax tube was found to be high. Somatostatin was initiated and the pancreatic fistula was expected to be closed. During this period, the patient was fed through geogenicostomy. However, due to the amount coming from the right thorax tube they did not decrease, the patient was operated on the postoperative 20th day. Pancreas lodge and the previous operation site were seen to be quite fibrotic. This region was entered through transverse colon. The leakage in the trunk of the pancreas was controlled by prolene sutures. A drain was placed in that site. 250–300cc/day came from the drain in the first week. Then it decreased to an average of 15–20 cc daily. The drain was removed. The stent in the esophagus was removed 6 weeks after the date of insertion.

Results

Sixteen CD-1 male mice were used in the study. Subjects were randomly divided into two groups. Serosal abrasion in the cecum and excision of the parietal peritoneum excision from the right lower quadrant were performed in order to create an adhesion model. Group I (control group) was not performed an adhesion prevention method. In Group II (plasma group), APCP was applied for 60 seconds on the areas where an adhesion model had been formed. All the subjects were sacrificed on the postoperative 10th day. Macroscopic Knigtly and Linsky adhesion classifications were applied to the areas where adhesion model was formed in all subjects. The modeled areas were excised as a whole and sent to the pathology laboratory for evaluation of the microscopic Zühlke classification. Classification scores were evaluated with statistical analysis (Mann Whitney-U-test).

Results

The average scores of the Knightly, Linsky and Zühlke classifications of the cecum in Group I were 2.6; 2.1 and 2.6 respectively. In Group II, the average scores were 0.5; 1.1 and 1.3. Accordingly, the difference between Knightly and Zühlke classification scores was statistically significant in favor of Group II (p=0.015; p=0.018, respectively). In Group I, the average scores of the Knightly, Linsky and Zühlke classifications of the parietal peritoneum were 3.3; 3,8 and 3,4. The average scores of Group II were 1.6; 1.3 and 1.5. According to each of the 3 categories (Knightly, Linsky, Zühlke), the difference between the groups was significantly in favor of Group II (p=0.005; p<0.001; p<0.001, respectively).

Conclusion

In this study, it has been shown that APCP might be macroscopically and microscopically effective in preventing PA. A new field has emerged in which both APCP and PA can be investigated. The data obtained will guide the studies in this field.

TJS. 2018;34(Suppl-1):S419.

PP-0424 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Mesenteric Vein Thrombosis Secondary to Heterozygous Factor V Leiden, Prothrombin G20210A and Homozygous Methylene Thetrahydrofolate Reductase C677T

Danial Khabbazazar ^1,^✉, Erdinç Kamer ¹, Ahmet Atasever ¹, Atilla Örsel ¹, Mustafa Peşkersoy ¹

Introduction

Mesenteric vein thrombosis (MVT) is a rare cause of mesenteric ischemia and there are usually underlying predisposing factors. MVT is responsible for 5% to 15% of all cases of acute mesenteric ischemia. We presented the patient who was operated for mesenteric vein thrombosis secondary to Heterozygous Factor V Leiden, Prothrombin G20210A and Homozygous Methylene Thetrahydrofolate Reductase C677T.

Case

A 36-year-old male patient was admitted to the emergency service of our hospital due to abdominal pain that had been lasting for 2 days. He had complaints of nausea, vomiting and fever with widespread increasing abdominal pain that had started two days ago. Physical examination revealed hypoactive intestinal sounds and abdominal widespread tenderness, defense and rebound. It was detected that Leukocyte: 12540K/u and CRP: 8,96 mg/dL during the initial examination. Intravenous contrast-enhanced abdominal computed tomography (CT) examination showed ileal wall thickening, edema and minimal infiltration fluid in the surrounding mesenteric tissue. Surrounding mesenteric tissue was edematous. Filling defect that might be compatible with thrombus in the superior mesenteric vein was monitored. In the exploration, gangrene was present in all small bowel loops starting from 70 cm from treitz and remaining 20 cm from the ileocecal valve. Massive small intestine resection was performed. Terminal jejunostomy and ileostomy were performed. In the early postoperative period, low molecular weight heparin (LMWH) and paranteral nutrition were started. Short bowel syndrome diet was started on the 7th postoperative day. Tests were asked for possible hypercoagulability. The homozygote mutation was reported at MTHFR C677T and heterozygote was reported at factor 2 (prothrombin) and factor 5 leiden (G1691A). Protoin S (63.7%), protoin C (59%), Active protein C resistance ratio (1.6 Sn), anti-thrombin 3 antigen (73%), vitamin B12 and folate values were reported to be low. Homocysteine levels of 10.2 idmol/L, anticardiolipin and antiphospholipid were normal. After 5 days of LMWH treatment, oral warfarin treatment was bridged. The patient still remains in our unit on postoperative day 42.

Conclusion

Firstly, Elliot described MVT as a cause of mesenteric ischemia in 1895. 80% of these patients had an underlying predisposing factor (secondary MVT). The purpose of the initial MVT treatment is to find the underlying causes including protoin C, protein S and antithrombin deficiencies, recurrent abortus, anticardiolipin antibodies, platelet aggregation and abnormalities in hyperhomocysteinemia and provide a treatment. In a retrospective study conducted by Amitrano et al, in mesenteric patients the prevalence of thrombophilia genotypes (75%), Factor 5 leiden (25%), prothrombin G2021A (25%) and MTHFR prothrombotic defects (50%) is high. The presence of factor 5 leiden and prothrombin G2021A gene heterozygote combination variations increases the risk of venous thrombosis. In our patient, jejuno-ileostomy is planned due to the presence of a 70 cm intestinal loop and ileocecal valve.

As a result; MVTs are seen in 10%–15% of all mesenteric ischemia. Due to the MVT-induced mesenteric ischemia, we should perform limited resection. Secondary operations should be performed in a controlled way and we might consider that heterozygote factor V leiden, prothrombin G20210A and homozygote methylenetetra-hydropholate reductase C677T might be in the etiology. We believe that it is important to determine the hereditary risks.

TJS. 2018;34(Suppl-1):S420.

PP-0425 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. A Rare Mass of Small Intestine ‘’ Solitary Ganglioneuroma ‘’

Sami Benli ^1,^✉, Tufan Egeli ¹, Cem Terzi ¹, Burçin Tuna ², Özgül Sağol ²

Ganglioneuroma forms a subgroup of peripheral neurogenic tumors; it is defined as the tumor originating from neural crest and developing from neuroectodermal cells. It is divided into three subgroups as peripheral neurogenic tumors, neuroblastoma, ganglioneuroblastoma and ganglioneuroma according to the degree of neuroblastic differentiation, type, malignancy potential and schwann stroma development. Among these, ganglioneuroma is benign, often originating from sympathetic ganglion cells or adrenal medulla cells, rare, slow-growing tumors. Histologically, they are formed from ganglion cells, consisting schwann cells and fibrosis tissue. Although the most common sites have been reported as posterior mediastinum and retroperitoneal area, it is located at adrenal glands at 21%. Although rarely, it might also be seen in the mediastinum and retroperitoneal region at the same time, or in the parapharyngeal area, bone, gastrointestinal tract, supraclavicular region. In general, it is seen in the child age group and 2/3 of the cases are under 20 years old. Because of its slow growth, it is usually diagnosed in late adolescent ages; the symptoms usually result from the compression of the tumor on the surrounding tissue. Clinical findings such as chronic cough and shortness of breath can be seen. Neural compression, dorsal spinal scoliosis, although rarely increased secretion of catecholamine due to secretory activity and metabolic problems may also be encountered.

Intestinal ganglioneuromas are rare, benign neoplastic lesions characterized by specific pathological findings. In some patients, solitary lesions such as colonic polyps may be observed and in some, it may appear as multiple polyposis called ganglioneuromatosis in the colon and terminal ileum. In some patients, an increase in wall thickness can be seen as the infiltration of intestinal ganglioneuromatos cells in the bowel wall and proliferation in myenteric plexus. Intestinal ganglioneuromatos is mostly seen in the colon, terminal ileum and appendix in the intestinal system.

As a result of advanced tests, we present a patient whose pathology was reported as ileal ganglioneuroma and had right colectomy including the terminal ileum and who had a mass lesion located in the terminal ileum cecum and who was evaluated with abdominal pain and constipation.

TJS. 2018;34(Suppl-1):S420–S421.

PP-0426 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. A Friend That We Should Be Cautious Of: Persimmon

Altan Aydın ^1,^✉, Şaban Uysal ¹

Bezoars are the formations of non-digestible organic substance league in the gastrointestinal system. It is often seen in the stomach and small intestine. Depending on the variety of these non-digestible organic substances, there can be different varieties. Phytobezoar of plant origin; tricobezoar, especially in patients with psychiatric problems due to hair and hair eating habits; Pharmacobezoar due to the medication and those formed as a result of the milk powder used are called lactobezoar. Phytobezoars are the most common types of bezoar and in our country, foods that have high proportion of non-digestible fiber such as raisins, squash, leek, beet and Persimmon, also known as Trabzon hurması in our country, play an active role. Although the homeland of the persimmon is known as Far-East, it grows in Trabzon and Hatay in our country. Shibutal, which is abundant in raw and wild dates, is also a kind of wild date itself, is found in large amounts in persimmon. This substance becomes a gelatinous material which is difficult to dissolve when it reacts with gastric acid and causes a transition problem in the passage. The presence of previous gastric surgery and the presence of diseases causing gastroparesis are important risk factors for the formation of bezoars. It may be asymptomatic bezoars coincidentally detected during endoscopy. They can also cause life-threatening complications such as obstruction, perforation and bleeding. Treatment options include conservative methods such as endoscopic fragmentation and enzymatic thawing, but it usually requires surgical intervention. We present a 44-year-old male patient who presented to our unit with complaints of epigastric pain, nausea and vomiting 24 hours after eating about 1 kg of persimmon. Although it is a source of vitamin, mineral and antioxidant agent as well as cardiovascular, gastrointestinal and immune system friendly; we aimed to draw attention to the unfavorable situations that can be caused by the reckless consumption of persimmon. Our patient is a 44-year-old male patient with no history of additional disease and surgery. He was admitted to our unit with complaints of epigastric pain, nausea and vomiting. In the patient’s history, he had a history of eating persimmon 24 hours before on an empty stomach. The patient was taken to the endoscopy unit and was given fluid-electrolyte treatment and tried to be treated conservatively after a nasogastric catheter had been inserted. Since he was non-responsive to these methods, he was taken into the endoscopy unit. Endoscopy revealed giant phytobezoar in the stomach that caused ulceration in the stomach. Afterwards, the patient was taken into operation and gastrotomy was performed. After removing the bezoars, the stomach wall was repaired primarily. The patient was discharged with healing in the postoperative period. Therefore, although persimmon has many benefits; it shouldn’t be forgotten that it can form bezoars which can cause serious problems if consumed in excessive amounts and raw.

TJS. 2018;34(Suppl-1):S421.

PP-0427 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Gossipiboma (Restricted Internal Fistula)

Sadık Keşmer ^1,^✉, Kadir Yıldırım ², Ahmet Ragıp İyiyol ¹, Barış Candan ¹

Introduction

Gossipiboma is a foreign body reaction that develops from cotton material that is forgotten in the abdomen in surgical operations. It is one of the most medicolegally feared situation for surgeons. After the surgery, even the idea of forgotten foreign material is enough to disturb the surgeons. After abdominal operations, it can be seen in the range of 1/3000 to 1/5000. Considering the cases that are not reported due to legal problems, it would not be wrong to claim that these rates are higher. Although it can be seen in almost all major surgery branches, it is most commonly seen after general surgical operations. The most common foreign body which causes gossipiboma is the surgical tampon. Emergency surgery, obese patient, team change during surgery, prolongation of operation time increases the risk of gossipiboma.

Case

A 73-year-old male had been treated with Roux-en-Y anastomosis 6 months ago after total gastrectomy for gastric cancer. He presented himself to our outpatient unit due to intermittent abdominal pain, weight loss, anorexia and palpable stiffness in the left side of the abdomen. In the described area in USG, a hyperechoic shading appearance with a 47 mm diameter in posterior was detected and CT control was requested. CT was interpreted as a 4 * 3 cm diameter area with air densities and tubular foreign body density. The patient was planned for elective surgery due to gossipiboma.

In the laparotomy of the patient, it was observed that foreign body was surrounded by 3 intestine loops 20 cm distal from the ‘Y’ leg of the Roux-en-Y anastomosis and 50 cm from the intestine. When the lodge was opened, it was seen that 2 distal intestinal loops had lodge fistulas with surgical tampon. Although the proximal part didn’t have a fistula, ulceration and inflammation was present in the 10 cm area. In the unprotected proximal part and distal, anastomosis was performed and jejunum loops with fistulas were resected from 2 locations in 50 cm area. Postoperatively, the patient was started on a diet on the 4th day and was discharged after 7 days without any problem. During his 24-month follow-up, no problem was experienced in terms of gastric cancer and gossipiboma.

Conclusion

General surgical operations are more risky in terms of gossipiboma due to the high number of emergency interventions, long-term operations and the anatomical structure of the intraperitoneal cavity. The most common symptoms are pain, palpable mass in the abdomine, abscess and ileus. In the diagnosis, many radiological examinations can be used. Radiopaquelabeled tampons and pads are easy to detect peroperatively or postoperatively, but it may still be difficult to diagnose for nonradopoque pads that are still in use. Gossipiboma can be confused with cases such as tumor, complicated hematoma and hydatid cyst. Gossypiboma should definitely be considered in the differential diagnosis in patients with a history of previous surgery. Gossipiboma is an undesirable but avoidable condition. The main problem is how to avoid the problem rather than how to treat it. If detected, appropriate surgery should be performed as soon as possible to prevent mortality and morbidity.

TJS. 2018;34(Suppl-1):S421–S422.

PP-0428 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. The Effect of Vacuum-Assisted Closure (VAC) Application in Intraabdominal Sepsis on the Apache IV Score, Mannheim Peritonitis Index and Sofa Score

Murat Çikot ¹, Bahadır Kartal ^1,^✉

Objective

Vacuum-Assisted Closure (VAC) application is an open abdominal relaparotomy method used in intraabdominal sepsis since the late 1990s. This retrospective study was planned to evaluate the effect of VAC on apache IV score, Mannheim peritonitis index and sofa score.

Material and Methods

The data from the hospital database of 159 patients who underwent VAC between April 2010 and January 2017 were documented and their apache IV score, mannheim peritonitis index and sofa (Sequential Organ Failure Assessment Score) scores were found. VAC changes of the patients were performed every 72 hours and the data in the 1st, 2nd, 3rd, and 4th changes were documented. Patients who underwent VAC due to necrotizing fasciitis and Fournier’s gangrene were excluded from the study. ANOVA analysis was performed in repetitive measurements in order to determine changes in apache IV score, mannheim peritonitis index and sofa scores. P<0.05 was considered statistically significant. The analyses were performed with NCSS 11 (Number Cruncher Statistical System, 2017 Statistical Software) program.

Results

It has been found that VAC change has a decreasing effect on the values of apache IV score. It was determined that there was a significant difference between the 1st and 3rd changes (p=0.0001), between the 1st and 4th changes (p=0.0001), between the 2nd and 3rd changes (p=0.0001), between the 2nd and the 4th changes (p=0.0001) and between the 3rd and 4th changes (p=0.0001). VAC changes have been found to have a decreasing effect on mannheim peritonitis index measurement values.. It was determined that there was a significant difference between the 1st and 2nd changes (p=0.0001), between the 1st and 3rd changes (p=0.0001), between the 1st and 4th changes (p=0.0001), between the 2nd 3rd changes (p=0.0001), between the 2nd and 4th changes (p=0.0001), and between the 3rd and 4th changes (p=0.0001). When the effect of VAC change on sofa values was examined, it was determined that there was a significant difference between the 1st and 3rd changes (p=0.0001), between the 1st and 4th changes (p=0.0001), between the 2nd and 3rd changes (p=0.0001) and between the 2nd and 4th change (p=0.0001), There was no significant difference between the 1st and 2nd changes (p=1,00), and between the 3rd and 4th changes (p=0,079). Although there was no significant difference between the 1st and the 2nd changes and between the 3rd and 4th change, it was determined that there was a decrease in time compared to the average of the measurement values. However, this change was not statistically significant.

Conclusion

The positive effect of VAC application on apache IV score and mannheim peritonitis index was determined but no positive effect on sofa score was determined. In order to fight sepsis, long-term VAC should not be continued.

TJS. 2018;34(Suppl-1):S422.

PP-0429 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Giant Hiatal Hernia Associated with Gastric Schwannom

Sadig Sekiliyev ^1,^✉, Fazıl Sağlam ¹, Aziz Mahmudov ¹

A 72-year-old female patient was known to have a history of operation due to HT and endometrium CA. Her complaints were dyspepsia, pyrosis, and shortness of breath. Her hydro CT showed a smooth, homogeneous well-circumscribed lesion present in the stomach corpus with a 3.5x5 cm leiomioma. Her contrasted CT revealed a homogenous mass formation in leiomyoma-style benign nature with a size of 28x38 mm with subserous location in the hiatal hernias and large curvature of the stomach. According to the MRI, gastric sliding type hiatal hernia and leiomyoma forming area were present. In the Pet-CT, intense FDG uptake (suv max: 9,2) was first evaluated in favor of inflammatory processes (gastritis?) and, if necessary, endoscopic examination would be appropriate. According to the esophageal passage graph, a 3.5x5 cm filling defect was present in the stomach corpus. TM markers (CEA, CA 19-9 and CA-125) were in normal limits. As for surgery, laparoxopic nissen fundoplication + stomach wedge resection were performed. The patient was started water on the postoperative 2^nd day. On the 4^th postoperative day, the patient was started on a normal regimen. She was discharged on the 6^th postoperative day. According to the pathology, 4x4x3.5 cm in size spindle cell mesenchymal tumor was evaluated as schwannom.

TJS. 2018;34(Suppl-1):S422–S423.

PP-0430 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Crohn’s Disease with Atypical (Jejunum) Located Causing Massive GIS Bleeding (Case Report)

Sümeyra Emine Bölük ^1,^✉, İlker Sücüllü ¹, Yavuz Poyrazoğlu ¹, Adem Aslan ¹, Tuba Gülçelik ¹, Süleyman Atalay ¹, Ahmet Ziya Balta ¹, Yavuz Kurt ¹

Crohn’s disease is an inflammatory bowel disease characterized by granulomatous inflammation whose etiology is unclear, which can hold any region in the gastrointestinal tract from oral to anus. The aim of this study was to present a case of Crohn’s disease with jejunum located causing massive gastrointestinal bleeding.

A 64-year-old male patient who had had diarrhea and gastroenteritis for one month in the infectious diseases department, underwent gastroscopy and colonoscopy during the follow-up period and no pathological findings were observed. During this period, the patient was operated because of the suspicion of ileal invagination disease in his tomography and he was evaluated to have no invagination during the operation. He then was referred to the department of infectious diseases of our hospital. During the follow-up and treatment period, the patient was consulted by our clinic because of the development of abundant GIS bleeding. The patient with severe hematocesia had hypotension (70-30mm/hg) and tachycardia (120v/min). The complete blood analysis was Hb: 5 g/dl, Htc: 18. In the intensive care unit of our department, gastroscopy was performed under emergency conditions, there was plenty of blood in the stomach and aspiration was detected, but hemorrhage focus could not be detected. In spite of the resuscitation and replacement, the patient’s emergency operation was decided for the patient who had no improvement in his clinic, hemodynamics and laboratory values. Exploration revealed blood in the entire gastrointestinal tract and seroseal edema was present from the treitz ligament at the level of the jejunum. Jejunotomy was performed and endoscopic examination was performed from this area distally and proximally with the help of gastroscope. In the examination, it was seen that all of the jejunal mucosa were hyperemic and granular, there was leakage like active bleeding from all of the mucosa and multiple biopsies were taken. Empirical steroid treatment was started in the early postoperative period. The patient was started on empiric steroid treatment and his bleeding stopped during follow-up, and the necessary treatment was started since the pathology was consistent with inflammatory bowel disease. The patient was discharged with medical treatment.

Patients with Crohn’s disease usually present with symptoms such as abdominal pain, diarrhea, fatigue, fever, and weight loss, but although rarely they might also have GIS bleeding. In order for diagnosis, biopsies accompanied by endoscopy along with clinical evaluation are helpful. Medical treatment is the first choice. Although very rare, patients can be diagnosed during the operation as it happened in our case.

TJS. 2018;34(Suppl-1):S423.

PP-0431 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. A Rare Cause of Ileus in Adults: Midgut Volvulus

Can Arıcan ^1,^✉, Levent Uğurlu ¹, Hakan Öğücü ¹, Emran Kuzey Avcı ¹, Murat Akalin ¹, Cengiz Aydın ¹

Intestinal malrotation is more common in the neonatal period. It is seen in 0.2% of adults. This patient group is a unique problem for surgeons in terms of both diagnosis and treatment.

In this case report, we have presented an adult patient with midgut malrotation who applied to the emergency department of our hospital and our approach to this patient. 51 year old patient with no history of any known systemic disease and previous abdominal surgery, was admitted to our emergency department with complaints of extensive abdominal pain, distension, nausea and vomiting. The patient had no history of trauma and no history of travel. The patient had no weight loss and didn’t describe any changes in defecation habits.

The patient stated that when he had too much food, he usually experienced similar complaints.

On his physical examination, the patient was afebrile and hemodynamically stable. Abdominal distension was present and palpation showed diffuse tenderness. Normal colored stool was observed in rectal examination. No mass lesion was palpated. His hemogram examination showed wbc: 18,700/ul lipase: 134 U/L above normal values. Apart from these, hemogram and biochemistry laboratory test results were within normal limits. Standing direct abdominal radiographs showed air fluid levels at the small intestine level that were mostly localized in the right upper quadrant.

Abdominal CT: The duodenum was located in the 3rd part of the SMA anterior. Duodenum and proximal jejenum loops ended suddenly at the level of iliac bifurcation. The formations in the proximal of this area were dilated and the distal of the small intestine and colon loops were collapsed. At the deepest part among the intestinal loops, free fluid up to 1.5 cm was observed.

Patient’s oral was closed. IV hydration was started with 0.9% NaCl. A nasogastric catheter was inserted and a normal gastric content of 100 cc was observed. The patient was informed about the operation and was prepared for the operation. Treitz’s Ligament was not available in the exploration. It was observed that the small intestinal loops were completely under the Ladd’s band in a mass-like manner in the upper right-middle quadrant. This band extending from the duodenum to the cecum was removed. It was observed that the small bowel loops that herniated to this area were dilated. No necrosis was detected. No resection was needed. Right column was released. Appendectomy was performed. The right colon was taken on the left colon and fixed to the abdominal wall with silk sutures. Operation was terminated. In our case, duodenojejunal junction was on the right of the vertebral column in abdominal CT which was compatible with the literature. The clockwise malrotation of the mesentery root and the location of vascular structures, bowel pathologies were presented in detail. It was significant that our case was an adult with the rotation of the 270-degree mesenteric meso and without necrosis findings. In patients with non-specific abdominal complaints, the possibility of malrotation should not be underestimated.

TJS. 2018;34(Suppl-1):S424.

PP-0432 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Laparoscopic Minimally Invasive Surgery for Early Gastric Outlet Obstruction After Corrosive Agent Ingestion; Case Report

Ramazan Gündoğdu ^1,^✉, Zeki Özsoy ², Emin Daldal ², Özgür Yeniova ³, İsmail Okan ²

Introduction

Here, we present a case of laparoscopic gastroplasty applied to the patient who developed early gastric outlet obstruction after the intake of corrosive material.

Case

A 41-year-old male patient had an exposure of corrosive substance by accidentally drinking two sips of hydrochloric acid (15% HCL) at home. Afterwards, it was learned that he tried to relax by drinking milk, yogurt and vomiting. He was admitted to the emergency room 10 hours after the exposure. He did not have any positive findings except for oropharyngeal hyperemia in his clinic and there was nothing significant in his abdominal examination and imaging. The patient was hospitalized in our gastroenterology unit. After 24 hours, in his gastroscopy widespread exudate ulcers were detected in the distal esophageal. The patient, who tolerated oral intake on the 3rd day of his hospitalization, was discharged. The control gastroscopy performed on the 10th day of his exposure revealed that the ulcers on the esophagus were healed; an ulcer that almost completely obstructed the lumen in the antrum was detected. A gastroscopy was performed in the patient who presented to our hospital with nausea and vomiting 20 days after his discharge: Stenosis that hardly let the passing of the scope through the gastric outlet was observed. Repeated dilatations were performed with a 20-mm balloon. The patient was scheduled for operation in General Surgery unit due to vomiting after oral intake. In the laparoscopic exploration, the abdomen was cannulated and it was observed that fibrosis stenosis that was obstructing the lumen in prepiloric antrum. Intraoperative gastroscopy was performed. The stenosis of the prepiloric antrum was observed with the scope, but the distal part could not be passed. Suspender sutures were placed in the upper and lower part of the stenosis on the anterior surface of the stomach and a 5-cm gastrotomy was performed in the horizontal plane and fibrous stenosis was opened. Scope was taken distally from the proximal stomach with a laparoscopic grasper. In the gastroscopy that was completed via laparoscopic aid, gastrotomy was closed in the vertical plan following the observation that the passage was open. The patient who had started taking the regimen on the 1st postoperative day was discharged on the 6th day without any problems.

Conclusion

Corrosive substances cause different tissue damage depending on being acid or alkaline. The esophagogastroduadenoscopy is of great importance when evaluating the damage. It is thought that liquids such as water and milk, which are drunk for the purposes of dilution or neutralization after the intake of the corrosive substance can facilitate vomiting or increase heat by acid-alkaline reaction and increase esophageal damage. It was thought that the damage to the esophagus was more evident in our patient due to drinking milk and yogurt and vomiting with the help of the finger. The most common complication of corrosive substance ingestion is esophageal stenosis. Gastric complications are the most common late period occurrence of gastric outlet obstruction. In our case, gastric outlet obstruction developed in the early period. The most common treatment modality is periodic dilatation in patients who experience stenosis. The rate of success of dilatation in the literature is 60–80%. In our case, surgical intervention was planned for the patient who was not responsive to repeated dilatations.

We believe that the application of intraoperative gastroscopy for the evaluation of the passage and the lumen in the distal of stenosis in benign cases with gastric outlet obstruction due to corosive uptake is possible to increase the feasibility of minimally invasive methods and decrease possible postoperative complications. We conclude that laparoscopic gastroplasty as a minimally invasive surgery is a viable method in the treatment of gastric outlet obstruction after corrosive substance intake.

TJS. 2018;34(Suppl-1):S424–S425.

PP-0433 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Conservative Follow-up in Rare Distal Esophageal Microperforation After Endoscopy

Muhammet Fatih Keyif ¹, Semih Yaman ^1,^✉, Mustafa Şit ¹, Bahri Özer ¹, Oğuz Çatal ¹, Selçuk Köksal ¹, Elif Yalçın ¹, Özkan Kılınç ², Mehmet Hayri Erkol ¹

In the last two decades, endoscopic interventions for diagnostic and therapeutic purposes have been widely used in outpatient and inpatient gastroenterology units. Upper gastrointestinal endoscopy is a very reliable procedure, with an overall complication rate of 0.1% and a mortality rate of less than 0.05%. However, esophageal perforation is an important complication of upper GIS endoscopy. Our case was a 78-year-old male patient who had been having dysphagia and vomiting in the last year. Lately, he couldn’t eat solid food but only liquid food. After 6 months of vomiting 3 hours later after eating and even drinking water and weight loss of up to 20 kg, he presented himself to gastroenterology unit of our hospital. In his history, it was learned that he had previously undergone balloon dilatation for esophagus. Upon the diagnosis of achalasia-compatible mass was detected on barium X-ray and upper endoscopy, he was started to be followed up. The patient’s previous GIS endoscopy had revealed tertiary peristalsis, with the suspicion of achalasia, severe stenosis of the distal esophagus and proximal enlargement were observed. After the balloon dilatation, control endoscopy showed cardia edematous, mucosa at the distal esophagus was observed irregularly and biopsies were taken. Endoscopy was planned for re-control and dilation with spark plug was performed. Since it was a minimal laceration area, it was transferred to our general surgery unit. After the patient was admitted to the ward, an esophageal microperforation was observed in the PA AC and all abdomen + thorax CT. The conservative approach to esophageal perforation was well defined and an algorithm was established. Treatment is planned according to the etiology of non-perforating esophageal injuries and surgery is performed if the underlying disease requires one. Conservative treatment has a very specific selection criteria and can be applied to these patients. These criteria are early diagnosis, stable patient, minimal injury and minimal pleural or mediastinal contamination. Conservative treatment includes patient stabilization 48 hours after injury, total parenteral nutrition (TPN) and at least 7 days of broad-spectrum antibiotic treatment. As the general condition of the patient was good, conservative treatment and follow-up was decided in our case. After 7 days of follow-up, the patient was discharged with cure.

TJS. 2018;34(Suppl-1):S425.

PP-0434 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Clinical Approach in Giant Retroperitoneal Dedifferentiated Liposarcoma: A Case Report

The duration of hospitalization was longer in EN patients compared to ENIN group (18/12 days, p=0.032). Both groups were similar in terms of total morbidity and mortality rates (p>0.05).

Conclusion

Owing to some positive effects, immunonutrition and enteral nutrition as are shown in the literature, are used in surgical practice and malignant diseases increasingly. There are studies showing that there is positive or no effect on the use of immuno-nutrition in the malignancy surgery. In this prospective study, the perioperative use of enteral immunonutrition has been found to have a significant positive effect on the rates of infectious complications and anastomotic leakage and hospital stay. We think that the positive effects of immunonutrition result from determining the malnutrition level in the preoperative period and applying it at least 7 days peroperatively.

2016 National Surgery Congress

TJS. 2018;34(Suppl-1):S428.

PP-0439 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Disseminated Gastrointestinal Stromal Tumor: A Case Report

Onur Özener ^1,^✉, Ayşe Arduçoğlu Merter ¹, Burhan Mayir ¹, Serkan Ceylan ¹, Osman Zekai Öner ¹, Mehmet Tahir Oruç ¹

Introduction

Gastrointestinal stromal tumors (GIST) constitute 0.1–3% of all gastrointestinal tumors. These tumors originating from the interstitial Cajal cells located in the myenteric plexus in the gastrointestinal tract and regulating peristaltism show themselves with nonspecific clinical findings. In this report, we present a case of multiple gastrointestinal stromal tumors with clinical findings of neurofibromatis.

Material and Methods

This is a retrospective study of gastric cancer patients who underwent laparoscopic gastric resection in the General Surgery Unit in January 2017–December 2017. In this study, demographic characteristics of the patients, clinical features such as hospital stay and the pathologic features of the tumor were discussed.

Results

Laparoscopic surgery was performed in three patients diagnosed with gastric tumor in the General Surgery Unit between January 2017 and December 2017. All three of these patients were male. The first patient was 64 years old, the second patient was 65 and the third patient was 35 years old. Two of the patients had adenocarcinoma tumor and one was diagnosed with ring cell tumor. Pathology results were determined as T4aN3Mx, T3N1Mx, T3N2Mx. Negative surgical margins were reached in three patients after laparoscopic surgery. During the procedure, 5 ports were applied and in patients undergoing laparoscopic resection, the anastomoses were intracorporeal. The specimens were removed from the natural holes during the process. Furthermore, laparoscopic lymph node dissection was performed to the operated patients and 28, 26 and 44 lymph nodes were removed. The operation time of the patients was approximately 4.5–5 hours. The operation was completed without complications. In the post-operative period, the patients were started oral intake on the 4th and 5th days. All three patients adapted to oral feeding and did not develop any intolerance. Patients with normalized gastrointestinal activities were discharged within 7–10 days. There were no complications during post-operative period and hospitalization.

Conclusion

Laparoscopic surgical method for gastric cancer has become an increasingly preferred method. Although long operation time seems to be a disadvantage in laparoscopic gastric cancer surgery, it is thought that it will be preferred in gastric cancer patients considering the advantages such as comfort, decrease in post-operative wound site infection risk and shortening of hospitalization time.

TJS. 2018;34(Suppl-1):S430–S431.

PP-0443 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Treatment of Gastric Volvulus of Emergency Mesenteroaxial Type: A Case Report

Mehmet İlhan ^1,^✉, Burak Çelik ¹, Ali Fuat Kaan Gök ¹, Ahmet Kemalettin Koltka ², Mehmet Kayhan Günay ¹

Introduction

Stomach volvulus is a condition that occurs more than 180 degrees of rotation of the stomach and is diagnosed more frequently than ever before with advanced imaging methods and requires surgery. We aimed to present a case who had undergone surgery for ulcer perforation three years ago and who had gastric volvulus of mesenteroaxial type.

Case

A 42-year-old male patient was admitted to our emergency surgery unit with complaints of abdominal pain, nausea and vomiting. He expressed that he was vomiting everything he consumed, along with his abdominal widespread tension and feeling of bloating. On physical examination, there was no feature except for abdominal tenderness. There was no feature other than a mild increase in blood values of leukocytosis (WBC: 12.300) and acute phase reactants (Crp: 22). Chest x-ray revealed gastric fundus air extending to the mediastinum. In the abdominal computed tomography, the stomach was highly dilated and the appearance was compatible with gastric volvulus of the mesenteroaxial type. Left kidney was in the pelvis. In the gastroscopy, necrosis was detected in mesenteroaxial volvulus and mucosa but detorsion could not be performed. In the operation, mesenteroaxial volvulus was detected, detorsion was performed and gastropexy and hiatal hernia repair was performed. Peroperative gastroscopy revealed no complete necrosis in the gastric wall. The patient was discharged without any complication on the 10th day. There was no problem in the first postoperative control month.

Conclusion

Gastrointestinal intestinal volvulus is most commonly seen in the colon. Gastric volvulus is very rare clinical entity. These volvulus can be primary and secondary. The relaxation of ligamentous support structures of the stomach is thought to be the cause of volvulus. Stomach volvulus can be organoaxial, mesentereoaxial and mix. In our case, mesenteroaxial gastric volvulus was detected and detorsion was provided through surgery, gastropexy and hiatal hernia repair was performed. Gastric volvulus is rarely seen in surgical units and it is very difficult to diagnose since it doesn’t have an imaging test or laboratory examination with a high level of diagnosis. It should be kept in mind that clinical suspicion, differential diagnosis and urgent surgical intervention are required.

TJS. 2018;34(Suppl-1):S431.

PP-0444 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Incidentally Detected Gastric GIST: A Case Report

Sedat Tan ^1,^✉, Hilmi Yazıcı ¹, Erkan Oymacı ², Burak Dede ¹, Mehmet Yıldırım ²

Case

A 56-year-old female patient (BMI: 48) with type 2 diabetes mellitus and type 1 Gaucher disease was admitted to emergency unit with complaints of shortness of breath, weakness and melena. When her hemoglobin (Hgb) value was found as 5.6 gr/dL, she was hospitalized due to GIS bleeding. Three units of erythrocyte suspensions were given to the patient, and later in the upper gastrointestinal endoscopy, it was revealed that revealed findings were consistent with GAVE with active bleeding, and simultaneous argon plasma coagulation was performed. Endoscopy was performed again because of the decrease in Hgb on the second day after the procedure and bleeding from the same foci was observed again. Argon plasma coagulation was performed for the second time. The bleeding was controlled, but the patient was scheduled to undergo surgery one day after the second procedure, as the patient had recurrent bleeding and Hgb reduction (Hb: 6.7 gr/dl). After erythrocyte suspension transfusion, the patient was operated. It was observed that the liver was cirrhotic in nodular form during the operation. The patient underwent laparoscopic antrectomy and gastroenterostomy. No transfusion was needed in the postoperative follow-up and the patient was discharged on the 6th day without any problems. The pathology revealed erosive gastritis with increased mucosal vessels, and extensive intravascular thrombus.

Conclusion

GAVE, which is usually diagnosed with chronic iron deficiency anemia, is a rare cause of massive GIS bleeding. Because of the comorbidities accompanying the patient, surgery is performed with high morbidity and mortality in this patient group. However, surgery should be kept in mind in cases where endoscopic treatment methods cannot be used.

TJS. 2018;34(Suppl-1):S433.

PP-0447 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Rarely Seen Foregut Anomalies

Mustafa Yener Uzunoğlu ^1,^✉, Fatih Altintoprak ², Enis Dikicier ¹, Yasin Alper Yıldız ³, Ali Muhtaroğlu ³

Introduction

Foregut Cystic Developmental Anomalies (FCDA) are extremely rare gastrointestinal malformations, seen especially in gastric localization. FCDA is thought to occur due to the non-involution of primitive structures in intrauterine life. In this report, we present two cases who underwent surgical treatment for FCDA.

Case 1

A 26-year-old male patient presented with non-specific epigastric pain. Upper gastrointestinal endoscopy examination and biochemical parameters were evaluated as normal. In abdominal computed tomography (CT) examination; In the gastric fundus superior localization, a cystic lesion, 77x57 mm in size, showing peripheral thin septations and thought to be associated with gastric wall was detected. Robotic cyst excision was performed. The postoperative period was uneventful and the patient was discharged on the 4th day. Histopathological examination was evaluated as Gastric Foregut Duplication Cyst.

Case 2

A 34-year-old male patient presented with non-specific epigastric pain. Upper gastrointestinal endoscopy examination revealed a possible submucosal lesion in the large curvature localization of the stomach, which pushed the normal-looking mucosa towards the lumen. Endosonographic examination revealed a lesion of submucosa origin with anechoic cystic content of 20x20 mm. Abdominal CT showed a second lesion in the small curvature of gastric proximal region, a 4x3 cm in size and with similar internal features with endosonographically defined lesion. Robotic cyst excision and gastric wedge resection were performed. The postoperative period was uneventful and the patient was discharged on the 4th day. Histopathological examination revealed that 2 lesions were Gastritis Cystica Profunda.

Discussion

Gastric foregut duplication cyst is a rare anomaly and is usually symptomatic in the first years of life. Rarely, it can remain asymptomatic or cause non-specific complaints until adulthood. Often it is localized in the large curvature of the stomach. Endosonography, computed tomography and magnetic resonance imaging are used in the diagnosis. Although malignant degeneration is very rare, adenocarcinoma, squamous cell carcinoma or neuroendocrine carcinoma may develop in the cyst wall epithelium. Therefore, surgical resection is recommended. Gastritis cystica profunda is also a very rare anomaly and although the etiology is not known exactly, it has been accepted that cystic glands enter into the submucosal area and cause polypoid hyperplasia and cystic dilatation. Clinical complaints are generally non-specific. It is usually incidentally diagnosed with upper gastrointestinal endoscopy, computed tomography or magnetic resonance imaging. Although very rare, it has been reported to be predisposing to gastric adenocarcinoma, therefore surgical resection is used in the treatment. There is a possibility of recurrence and long-term follow-up is recommended.

Conclusion

PP-0453 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Mass in the Right Lower Quadrant; Retroperitoneal Localized Gastrointestinal Stromal Tumor

Muhammer Ergenç ^1,^✉, Tevfik Kıvılcım Uprak ¹, Şevket Cumhur Yeğen ¹

Introduction

Gastrointestinal stromal tumors (GIST) develop from Cajal cells, which are pacemaker cells responsible for the adjustment of peristalsis in the digestive tract. The prevalence is 7–15 per million. GISTs can be seen in all gastrointestinal tract, in order of frequency; stomach (60%), jejenum and ileum (30%), duodenum (5%) and colorectal (5%). Small intestine GISs may present with a small nodule or a giant tumoral mass. Although the clinical symptoms and signs are generally nonspecific, they may cause gastrointestinal bleeding, intestinal obstruction, pelvic mass, acute pain like appendicitis, tumor rupture and acute abdomen.

Case

A 58-year-old woman was admitted to the general surgery outpatient unit with a complaint of abdominal pain. Physical examination was unremarkable. In the abdominal USG, a well-defined hypervascular solid lesion 19x19x21 mm in size, in the right lower quadrant of the abdomen was observed; its origin could not be detected. Abdominal computed tomography showed a 21x23 mm lesion in the right lower quadrant adjacent to the psoas muscle. Laparoscopic exploration was performed. Retroperitoneal area was entered from the ileocecal region. Retroperitoneal area was opened and surrounding of the mass was cleaned and the lesion that was found to be ileum wall originated was resected via endostapler and the operation was terminated. The patient who was comfortable during the abdominal examination on the postop 1st day was started a diet and the patient was discharged. Pathology was reported as 3.5 cm in size, gastrointestinal stromal tumor, with spindle cell, in low risk group.

Conclusion

In patients presenting with a mass in the right lower quadrant, the ileal gist should be kept in mind. Laparoscopic mass excision can be performed safely.

TJS. 2018;34(Suppl-1):S437.

PP-0454 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Intestinal Lymphoma and Perforation

Tuğba Balkaya ^1,^✉, Fevzi Cengiz ¹, Serkan Karaıslı ¹, Halis Bağ ¹, Mustafa Peşkersoy ¹

Introduction

Lymphomas are not very common in the gastrointestinal tract, but small bowel involvement is rare. After adenocarcinoma and carcinoid they are the 3rd most commonly seen tumors in the small intestine. Lymphomas with small intestine involvement may cause symptoms such as bleeding, abdominal pain, abdominal pain, palpated mass, obstruction depending on the segment localization. We aimed to present a case of perforation secondary to the involvement of the primary small bowel lymphoma.

Case

A 59-year-old male patient presented to the emergency department with abdominal pain. He had been diagnosed with non-Hodgkin Lymphoma 2 months ago and had intestinal originated malignant tumor but he wasn’t receiving any oncologic treatment for lymphoma. Physical examination revealed widespread defenses and rebounds. Leukocytosis and intraabdominal free air were detected in the examinations. Abdominal tomography showed minimal dimensional progression in the mass lesion and a free air appearance in the abdomen. The patient was immediately taken into operation. In the operation, it was observed that it invaded the abdominal anterior wall, caused intestinal malrotation, was approximately 200 cm from the terminal ileum and perforated in this area. The small intestine was partially and mass was totally excised. Histopathological examination of the mass revealed diffuse large cell lymphoma. The patient was discharged from the hospital on the postoperative 18th day, and referred to the hematology polyclinic for oncologic treatment.

Conclusion

Small bowel lymphomas are rarely seen and account for 1–4% of all lymphomas. Although gastrointestinal lymphomas are mostly seen in the stomach, small intestines and colon follow the stomach. Primary gastrointestinal lymphoma was first described by Billroth and is usually the histopathologic type non-Hodking lymphoma. Abdominal pain, weight loss, nausea and vomiting are common symptoms. Although perforation is seen in 20–25% of patients, tumor cells are seen more frequently in patients receiving chemotherapy due to necrosis. If perforation is present in patients diagnosed with lymphoma, the perforation secondary to lymphoma should be considered.

TJS. 2018;34(Suppl-1):S437–S438.

PP-0455 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. A Case of Esophageal Ulcer due to Tetracycline Use

Dilek Yekenkurul ¹, Muzaffer Haldun Çolak ², Erman Yekenkurul ^3,^✉

Introduction

Esophagitis is the most common cause of esophageal diseases characterized by retrosternal pain, odynophagia and dysphagia. Drug-induced esophagitis is the occurrence of ulcers or damage to the esophageal mucosa due to the use of various drugs. More than 650 drug-induced esophagitis cases and over 30 responsible drugs have been reported worldwide. Approximately 50% of the responsible drugs are tetracycline, doxycycline and clindamycin. The prevalence of esophagitis and esophageal ulceration has increased due to the widespread use of tetracyclines in genital infections. Here we present a case of drug-induced esophageal ulcers who did not know what to look for when taking their medication, so they used tetracycline with a small amount of water every day before bedtime.

Case

A 29-year-old female patient presented with retrosternal pain and burning. The patient, who did not have a chronic disease, presented to the gynecologist and obstetrician with vaginal discharge one week ago. She was started on tetracycline 4x500 mg tb with pelvic inflammatory disease diagnosis and was using it for seven days. She also stated that she had been taking especially the night dose right before going to bed with a small amount of water. She was admitted to the general surgery outpatient unit for painful ingestion, difficulty swallowing, retrosternal pain after ingestion and burning. Laboratory findings and examination revealed no pathology. The patient was hospitalized with the diagnosis of esophagitis. Tetracycline treatment and oral intake were discontinued and parenteral nutrition was started. Upper gastrointestinal system endoscopy revealed ulcerative lesions surrounding the lumen in the middle part of the esophagus and biopsy was performed. Sucralfate and proton pump inhibitor were given as treatment. Infectious diseases department were consulted for pelvic inflammatory disease and maintenance antibiotics were not needed. After 10 days of follow-up, the patient was discharged with normal endoscopy, no complaints, no complications and the pathology consistent with ulcer.

Discussion

Mehmet Zeki Öğüt ^1,^✉, Arife Simsek ¹, Mahmut Burak Kılcı ¹, Hüseyin Kocaaslan ¹, Cengiz Ara ¹

Introduction

Mesenteric lipomas are rare and frequently asymptomatic. They are usually complicated when they are symptomatic. In this study, a case of giant mesenteric lipoma causing nausea, vomiting and abdominal pain is present since it blocked the passage through the compression on the intestine.

Case

A 26-year-old male patient presented with abdominal pain, nausea and vomiting after eating for 7 days. On examination, the abdomen was relaxed but a soft contoured mass extending over the umbilicus was palpated. Upon the detection of a 24x18 cm homogenous, with fat density well-circumscribed mass on the abdominal CT, surgery was scheduled. In the exploration, a 25 cm smooth lipomatous mass was detected in the mesenteric area which led to compression on approximately 40 cm of ileal loop, 20 cm proximal to ileocecal valve. The ileus was resected with the distorsioned ileal loop and the ileoileal anastomosis was performed. The patient was discharged without any problems on the postoperative day 7. The pathology of the mass was as mesenteric lipoma.

Conclusion

In the differential diagnosis of abdominal pain, mesenteric lipomas should be remembered and they should be remembered that their symptoms will change according to their location and size. When they are symptomatic, excision should be planned to prevent possible complications. The decision on whether or not the intestinal segment associated with mesenteric lipomas is included in the excision may vary from case to case.

TJS. 2018;34(Suppl-1):S440.

PP-0460 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Analysis of Cases Diagnosed with Small Intestine Adenocarcinoma

Nihal Aykun ^1,^✉, Orçun Yalav ¹, İsmail Cem Eray ¹, Kubilay Dalcı ¹, Ömer Alabaz ¹, Ahmet Rencüzoğulları ¹

Objective

In the literature, the oncological treatment of adenocarcinomas originating from the small intestine is limited. The aim of this study is to present the diagnosis, treatment and follow-up results of the patients whose pathological diagnosis was confirmed in our department.

Material and Methods

The patients who were admitted to our hospital with abdominal pain between 2010 and 2017 and were evaluated as small intestine adenocarcinomas as a result of either urgent or elective laparotomy were evaluated retrospectively.

Results

Of the 7 patients who were treated with the diagnosis of small bowel adenocarcinoma, 3 (42.8%) were female and 4 (57.2%) were male. The average age was 52 years (39–80). 5 (71.4%) of the cases were operated emergently (ileus) and 2 (28.6%) were electively. In one of 7 patients (14.2%), preoperative diagnosis of peutz jegher was present. In 2 patients (28.4%) the pathological examination revealed mucinous component. The median follow-up period was 2 years (1 month-6 years) and 1 had a mortal course and 1 had a local recurrence. In all patients, segmental resection was performed with lymph node dissection and 5-fluorouracil was given as adjuvant therapy.

Conclusion

Most cases of small bowel adenocarcinoma present with obstructive symptoms. It should be kept in mind in the differential diagnosis of ileus in emergency patients, especially in elderly patients. In the treatment of adenocarcinomas with small bowel origin, surgical resection and adjuvant therapy with extended lymphatic dissection are associated with positive oncologic outcomes.

TJS. 2018;34(Suppl-1):S440–S441.

PP-0461 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. A Case of Advanced Esophageal CA Masked by Goiter

Nesime İnci Eryılmaz ^1,^✉, Bekir Sarıcık ¹, Serdar Acar ¹, Ömer Rıdvan Tarhan ¹

Introduction

Although esophageal malignancies are rare cancers of the gastrointestinal tract, mortality is high. Life expectancy of patients diagnosed at an early stage is significantly increased. In this report, we present a patient who had swallowing difficulty for about 1 year and attributed this to the goitre which had been present for many years and diagnosed as advanced stage esophageal malignancy.

Case

A 81-year-old female patient was admitted to our outpatient department with the complaint of dysphagia. The patient had been under follow-up for many years due to toxic multinodular goitre and was taking thyromazole. In the physical examination, there was a palpable nodular swelling of approximately 5x6 cm on the anterior part of the neck. In the laboratory, thyroid hormones were observed as free T3 2.82 uIU/mL, free T4 1.23 uIU/mL and TSH 0.026 uIU/mL. There were no significant changes in her laboratory other than thyroid hormones. The patient was followed up for further examination and imaging. Neck computed tomogragphy (CT) was performed. Her CT was compatible with locally invasive oesophageal cancer with heterogeneous wall thickening, heterogeneously stained with contrast agent, which is probably indistinguishable conglomerated lymphadenopathy (LAP) from nerves, infiltrating mediastinal fat plans from the carinal level to superior half of the proximal esophagus. In continuity with lumen, among the brachycephalic vasculer structures on the left with prolongation and invasion/infiltration to the thyroid gland showing nodular guatrogen growth were observed. It was ınterpreted as “Diffuse mediastinal laps, pleural and parenchymal metastases were observed”. Intermittent mediastinal lap, pleural and parenchymal metastases were observed. Gastroscopy revealed a fragile, infiltrating and malignant appearance which did not allow the passage of the endoscopy at approximately 14–15 cm from the incisors. Radiation oncology follow-up was planned after surgical feeding tube gastrostomy. However, the patient was discharged on her own request.

Conclusion

Esophageal cancer accounts for approximately 7% of gastrointestinal system malignancies. It is ranked 6th in terms of cancer-related deaths. It is a tumor with curative treatment chance in patients diagnosed at early stage. In 25% of locally advanced tumors, distant metastasis is detected in the first 2 years. The most common sites of metastasis are lung, liver and bone. Esophageal carcinoma can be seen with dysphagia, odynophagia, weight loss, epigastric pain and aspiration pneumonia. The most common observed symptoms are weight loss and dysphagia. Similar findings are found in goiter patients. As it happened in our case, in case of synchronous two diseases, malignancy may be missed in the early period. As a result, although the difficulty of swallowing is a clinical manifestation of goiter disease, esophageal diseases which may be the underlying disease in elderly patients should be among the differential diagnoses.

TJS. 2018;34(Suppl-1):S441–S442.

PP-0462 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Mortal Complication of Incidental Meckel’s Diverticulum

Ceyhun Erdem ^1,^✉, Mustafa Tevfik Bülbül ², Bilal Turan ¹, Mustafa Hilkat Bilaloğlu ¹, İsa Karaca ¹, Ahmet Contarlı ¹, Yavuz Savaş Koca ¹, Bekir Sarıcık ¹, Mehmet Zafer Sabuncuoğlu ¹

Introduction

Meckel’s diverticulum is a true diverticulum that is located on the antimesenteric side of the ileum and contains all the layers of the intestinal wall. It results from the omphalomesenteric channel’s not being completely obliterated in the 5th–7th month of pregnancy. Meckel’s diverticulum is usually asymptomatic and is seen incidentally. It may can cause complications such as bleeding, stenosis, diverticulitis, invagination and perforation, and is symptomatic in these cases.

In this article, we aimed to present a patient who was operated for acute abdomen and whose meckel diverticulum was not resected and was perforated two months later.

Case

A 84-year-old male patient was admitted to our center with the complaint of abdominal pain, nausea and vomiting. The patient had tachycardia with 110, 130/70 blood pressure, 37.5 degrees of body temperature, and 95% saturation. In the laboratory parameters, WBC: 22.700/mL, Hb: 9.7 g/dL, CRE: 2.56 mg/dL, CRP: 152 mg/L. In physical examination; there was widespread tenderness and defense in the abdomen. The patient was diagnosed with acute abdomen findings. Laparoscopic surgery was performed. Upon the detection of widespread purulent fluid in the abdomen, open surgery was initiated. In the exploration, appearance compatible with a 4 cm meckel diverticulum 40 cm proximal of the cecum was incidentally detected. No perforation and other pathologies were found. Because the patient was thought to have primary peritonitis, resection was not performed in the meckel diverticulum due to the presence of intraabdominal infected fluid. Liquid therapy was scheduled for the patient with preoperative prerenal ABY clinic. Enterococcus faecium was produced in the abdominal fluid culture. The patient was discharged four days after the administration of piperacillin + tazobactam and flu-conazole since his laboratory and clinical findings were normal.

Two months later, the patient presented to our center with complaints of abdominal pain, nausea and vomiting. Tachycardia at 105, 130/70 BP, 38 degrees body temperature and 97% saturation were present. Laboratory parameters were WBC: 5900/mL, Hb: 11.6 g/dL, CRE: 2.18 mg/dL, CRP: 21 W mg/L. In his physical examination acute abdomen clinic was present. There was free air in his standing intraabdominal imaging and CT. The patient was operated due to acute abdomen and sepsis findings. In the exploration, it was observed that the meckel divergent seen in the previous operation was adhered to the anterior abdominal wall at the right inguinal region and perforated with a diameter of about 0.5 cm. There was an infected small intestine content in the abdomen. It was decided to perform a loop ileostomy after Meckel’s diverticulum excision. The loop that was performed Meckel’s diverticulum excision on was turned into anastomosis as loop ileostomy in the anterior right quadrant. He was treated with Piperacillin + tazobactam and his liquid treatment was regulated but his sepsis findings did not show regression and he died on 4th postoperative day.

Conclusion

Although the resection of symptomatic meckel diverticulum is widely accepted in the literature, the necessity of resection of asymptomatic meckel diverticulum that is incidentally identified is controversial. Although Meckel’s diverticulum is rare and mostly clinically silent; it may cause obstruction, hemorrhage, diverticulitis, invagination and perforation as it happened in our case. In conclusion, it should be kept in mind that Meckel’s diverticulum may cause mortality due to complications. In patients without resection, the development of acute abdomen should be warning sign for complications.

TJS. 2018;34(Suppl-1):S442.

PP-0463 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Drain is an Obstacle for the Recovery of Prolonged Gastrointestinal Fistulas

İsmail Hasırcı ^1,^✉, Adil Kartal ¹, Kemal Arslan ¹, Nergis Aksoy ¹, Murat Altınkaynak ¹

Introduction

Discussion on indications for use of drains in abdominal surgery continues today. It is stated that routine use of drain in laparoscopic cholecystectomy increases morbidity without a significant advantage. Drainage may delay the recovery of prolonged fistulas in the postoperative period. Keeping the drain in place, as discharge continues coming from the drain, may prevent the prolonged fistula from closing. The surgeon is afraid to take the drain out. The fistula becomes chronic.

Case

She presented with complaints of swallowing difficulties and weight loss. She had a Nissen Fundoplication surgery 11 months ago. During this time the patient lost 40 kg. She could only consume liquid. She was performed two balloon dilatation surgeries at the same institution. No results were obtained. Thoracic tomography revealed an advanced dilated appearance of the esophagus, air-fluid level in the lumen and appearance were consistent with food residue. In the esophagography, esophagus was markedly dilated. The first diagnosis was thought to be achalasia. The patient was operated. The esophagus was dilated in the abdomen. Hiatorafi and Nissen got disrupted. Cardiomyotomy was performed. At the distal part of cardiomyotomy, mini perforation (3–4 mm) was formed in the complete esophagus-stomach junction. It was repaired with 5/0 PDS and found that it did not pass the fluid. Toupet was performed. Stomach was dilated, pylorus was spastic. Vagus could not be found. It was thought that vaguses might have been cut in the previous surgery so Weinberg pyloroplasty was added. On the second postoperative day, the drain fluid was bilious. There was no Nazogastric. The discharge coming from the drain started to increase (250 mL/day). Nazogastric was removed. Oral intake started in that same week. The oral fluid was coming to the drain. Contrast-enhanced radiography showed contrast in the drain and stomach. TPN started. The patient was observed for three weeks. The drain was removed considering that the fistula tract was well developed. There was nothing coming from the drain. Contrast radiography revealed contrast in the stomach. Fistula path could not be displayed. The fistula got closed. Oral intake started. Nothing came out. No deposits were detected. The regime was increased. The patient had no problems on the 3rd day since the drain had been removed, the regime was increased to 3. The patient is in her 3rd postoperative month. She consumes every type of food. She gained 10kg.

Conclusion

The difficulty of swallowing in our patient had been probably attributed to hiatus hernia and Nissen fundoplication had been performed. The patient’s complaints had increased. The patient’s preoperative diagnosis was probably achalasia. In the reoperation, the procedures performed during the previous operation were disrupted and cardiomyotomy was performed. Nissen was changed into Toupet. Since Nissen could not be performed on the esophageal perforation that developed during cardiomyotomy and because the stomach was very adherent and the repair we performed was safe, front part of stomach section was not closed with perforation.

Our aim was to show that when certain fistulas were to become chronic, under certain conditions the drain was to be removed and the fistula would be closed. The drain itself ensured the continuation of the fistula. In order for the closure of the fistulas shortening the drain slightly would not be sufficient, the drain should be removed completely.

In patients with dysphagia, it should be considered that the problem might be achalasia. When performing cardiomyotomy in the achalasia, inflated myotomy should be avoided especially at the esophagus-stomach border. Conducting sutures on the opened mucosa is not enough. Omentoplasty or Dore surgery should be added. In prolonged GIS fistulas (lasting 15–20 days), drains may prevent the fistula from closing. In cases where the flow rate of the fistula does not exceed 300 cc/day, removing the drainage after the fistula path has matured will cause the fistula to close.

TJS. 2018;34(Suppl-1):S443.

PP-0464 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Investigation of Prokinetic Efficacy of Uterotonic Drugs (Experimental Study)

Ramazan Atalay ¹, Murat Çakır ¹, Mehmet Aykut Yıldırım ¹, Ahmet Tekin ¹, Mehmet Biçer ^1,^✉

Objective

Although there are many etiological factors in the development of gastroparesis, in our practice, post-operative gastroparesis is the most frequently encountered complication after surgical procedures. The efficacy of prokinetic agents such as metoclopramide in postoperative gastroparesis is currently known. In our study, we aimed to present that some drugs (oxytocin, methyl ergonovine and cloprostenol) which have contractile activity on uterus smooth muscles may have similar effects on smooth muscles of stomach.

Material and Methods

In the study, 5 groups were formed with 7 rats in each group. Group 1: Sham, Group 2: Metoclopramide, Group 3: Oxytocin, Group 4: Methyl Ergonovin and Group 5: Kloprostenol. After performing gastrectomy with laparotomy, the subjects were sacrificed. The stripler taken from the stomach fundus and prepared separately were taken to the isolated organ bath containing the modified krebs solution. Dose response curves were obtained by applying cumulative doses of the drugs in the groups and these findings were compared between the groups.

Results

After the evaluations, the contraction response was not observed in the smooth muscle of the stomach in the saline group, metoclopramide group and methyl ergonovine group. The relaxation response from the oxytocin group was observed. In the cloprostenol group, there was a continuous increase in contractile response after dose-dependent cumulative application.

Conclusion

Metoclopramide enhances proximal gastrointestinal motility primarily through the inhibition of dopamine D2 receptors and serotonin 5-HT4 receptor agonist and 5-HT3 receptor antagonist properties. In our study, the most frequently used metoclopramide as a prokinetic agent in the postoperative gastroparesis cases was the positive control group. However, we did not observe any contraction after metoclopramide application in the study of rat stomach fundus tissue in isolated organ bath. We thought that increased gastric emptying was performed by metoclopramide with different mechanisms.

This study was performed on 21 Wistar-Albino type rats, divided into 3 equal groups, at the Experimental Research Center of Fırat University. After midline laparotomy, the left colon was cut 2 cm above the pelvic peritoneum. For faecal contamination, the gaita in the lumen was smeared around the wound. Then, the abdomen was closed on two layers (fascia and skin) with 3/0 silks. After 1 day, the abdomen was reopened under general anesthesia. Before starting the colon anastomosis, the rats in the 1st group were rinsed with isotonic sodium chloride impregnated material and double-layer anastomosis was performed. In the second group, double-layer colon anastomosis was applied by cleaning the abdomen using metronidazole impregnated material. In the third group, an anastomosis was applied to the abdomen with chlorhexidine gluconate impregnated material. Tissue hydroxyproline level and anastomosis burst pressures were measured and histopathological evaluation was performed on the postoperative 10th day via relaparotomy. The average value of the anastomotic bursting pressure was highest in Group III (p<0.05 Group I–III, Group II–III). Tissue hydroxyproline level was highest in Group III (p<0.005 Group I–III, Group II–III). When histopathological findings were evaluated in three groups, there was no significant difference between Group II and Group III in terms of improvement score in intestinal tissue and there was a statistically significant difference between Group I and improvement scores in both groups (p<0.005). As a result, the use of material impregnated with antibacterial solution in peritonitis increased the safety of anastomosis in primary anastomosis.

TJS. 2018;34(Suppl-1):S448–S449.

PP-0475 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Meckel Diverticulum Perforation of the Ileus in a Patient with Sigmoid Colon Cancer

Ufuk Önsal ^1,^✉, Erman Yekenkurul ¹, Mehmet Yaşar ¹

Meckel’s diverticulum is the most common congenital anomaly of the gastrointestinal tract and is a true diverticulum. While there may be life-threatening complications such as bleeding and obstruction in childhood, it can rarely be detected during imaging or laparotomy in adults. In adults, very rare complications are observed and can cause serious life-threatening health problems. In this case, a case of meckel diverticulum perforation with sigmoid colon cancer has been presented.

A 62-year-old male patient presented to the emergency department with extensive abdominal pain, swelling in the abdomen and inability to remove gas-stool for 3 days. The patient had undergone medical treatment with the diagnosis of advanced sigmoid colon cancer. He had abdominal distention, defense, rebound tenderness in all abdominal quadrants and in his rectal palpation ampullary was empty. As a result of blood tests and imaging methods, laparotomy was performed for emergency diagnostic purposes with the preliminary diagnosis of intestinal perforation. In the operation, widespread enteric content was observed in the abdomen, meckel diverticulum perforation was observed in the ileum. 6mml mass that did not allow passage in sigmoid colon was seen. Ileum segmenter resection was performed and ileostomy was opened and abdominal lavage was performed. The patient was discharged on the post-op 4th day. Meckel’s diverticulum usually becomes symptomatic before the age of 2 years. The most common complication before the age of 20 years is bleeding and the most common complication over 40 years of age is obstruction. Diverticulitis is one of the most common complications and occurs as a result of obstruction generally with fecaloid. The treatment approach in symptomatic cases is surgery. In asymptomatic cases, Soltero performed surgery very rarely, while Schlicke and Johnston proposed the removal of the randomly observed Meckel Dicerticulum. In cases of intestinal obstruction, perforation is usually expected in the cecum, while meckel diverticulum is also a risk factor for perforation. Excision of the meckel diverticulum, which is incidentally detected during laparotomy, can be considered.

TJS. 2018;34(Suppl-1):S449.

PP-0476 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Comparison of the Effects of Longitudinal Gastrojejunostomy Surgery on Malabsorption in Rats with Short Bowel (Experimental Study)

Sinan Arıcı ^1,^✉, Osman Bilgin Gülçiçek ², Aytaç Biricik ³, Erkan Yavuz ², Candaş Erçetin ², Hakan Yiğitbaş ², Fatih Çelebi ², Atilla Çelik ²

Objective

Short bowel syndrome (SBS) is a clinical condition characterized by malabsorption and subsequent malnutrition following extensive intestinal resection. TPB, which is the most important weapon used in its treatment, is not a treatment method that can be applied indefinitely due to its technical difficulties, its non-economic nature and its various complications. The aim of this study was to investigate the effect of longitudinal gastrojejunostomy on the histopathological and biochemical parameters in rats via massive intestine resection (80%).

Material and Methods

Our study was conducted Bağcılar Training and Research Hospital, Experimental Investigation and Skills Development Center (BREISDC) were performed. In our study, the average weight of 190–260gr (average 220 g.) 24 adult Wistar Hannover rats were used. 3 groups were formed in each group with 8 animals. Group 1: Sham group, Group 2: control group with formed short bowel syndrome, Group 3: group with formed short bowel-longitudinally jejunostomy group. Each subject was weighed and recorded preoperatively and on the postoperative 21st day. Relaparotomy was performed on the postoperative 21st day. Biochemical parameters (AST, ALT, calcium, magnesium, iron, albumin, glucagon like peptide-2, vitamin-B12) were measured by cardiac blood puncture (4–5 cc). Anastomosis line was resected, the development of intestinal metaplasia in terms of adaptation were taken for histopathological evaluation.

Conclusion

In this experimental study, weight loss was lower and GLP-2 value was measured higher in SBS rats with antiperistaltic, longitudinal gastrojejunostomy. In this respect, our study is a pilot study. Our study should be supported by advanced clinical studies.

TJS. 2018;34(Suppl-1):S449–S450.

PP-0477 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Inflammatory Fibroid Polyp-Induced Invagination: Two Case Reports

Mehmet Arif Usta ¹, Mehmet Uluşahin ^1,^✉, Serkan Tayar ¹, Muhammed Selim Bodur ¹, Arif Burak Çekiç ¹

Introduction

Although invagination is mainly seen in the pediatric age group, there are cases in the adult age group.

Case 1

A 33-year-old male patient was admitted to the emergency department with complaints of nausea and vomiting that started a few hours ago. The patient had been suffering from constipation and occasional abdominal pain for several months and therefore receiving palliative medical treatment. There was no history of additional disease, drug use history and operation other than hypertension. On physical examination (PE), there was tenderness around the umbilicus and right lower quadrant, and abdominal defense and distention. Laboratory values were within normal limits. Abdominal computed tomography (CT) revealed an invaginated bowel segment of 8 cm in the right lower quadrant and thought to be benign mass lesion of 41x33 mm in size on the edge. Urgent operation was planned. In the laparotomy, the proximal small intestines were dilated, and a mass of 4x3cm at 80 cm to the ileocecal region, and approximately 10 cm of small intestine loops was found to have invagination (Figure 1, 2). Segmentary small bowel resection and end-to-end anastomosis were performed. The patient started oral intake on the 3rd postoperative day and was discharged on the 5th postoperative day without any problems. The pathology result was reported as inflammatory fibroid polyp (IFP).

Case 2

A 77-year-old male patient presented to the emergency department with complaints of abdominal pain, nausea and vomiting which started a day ago. He had a history of HCV, arrhythmia and heart failure, and a history of drug use related to these diseases. It was learned that the patient had been operated for choledocholithiasis. There was tenderness around the umbilicus, defenses and abdominal distention. The laboratory values were CRP 5 mg/dl and leukocyte was 14330/mgL. Abdominal CT revealed a dilatation and air-fluid levels which reached 62 mm in the proximal small intestine segments and invaginated intestine loop in the 7 cm segment of the right lower quadrant of the abdomen. The operation was recommended to the patient. Laparotomy revealed a 5x4 cm mass at 50 cm from the ileocecal region and a 7–8 cm segment invagination, proximal dilatation of the proximal segment. The patient was recommended operation. Laparotomy revealed a 5x4 cm mass at 50 cm from the ileocecal region and that segment approximately with 7–8 cm was forming invagination, and proximal loops had dilatation. Segmental small bowel resection and end-to-end anastomosis were performed manually. After the operation, the patient was intubated and admitted to the intensive care unit. On the postoperative 1st day he was extubated and the second day he was taken to the service. Although he had respiratory problems in postoperative period, his general condition recovered. He started oral intake on the postoperative 5th day and was discharged on the 11th postoperative day. Pathology was reported as IFP.

Conclusion

Invagination may occur in the adult age group depending on the masses. One of these masses is IFP. Although IFP can be seen all over the gastrointestinal tract, stomach is the most common. Small intestine localized IFPs are frequently encountered, as is the case with the patients presented. It is a benign lesion of submucosal origin. Its etiology is unknown. They may cause gastrointestinal bleeding. They may cause ileus and invagination. Invagination and accompanying masses should be kept in mind in adult patients with ileus.

TJS. 2018;34(Suppl-1):S450–S451.

PP-0478 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Emergency Gastrectomy in Gastric Cancer: The Importance of R0 Resection

Serkan Karaıslı ^1,^✉, Emine Özlem Gür ¹, Oğuzhan Özşay ¹, Hüdai Genç ¹, Erdinç Kamer ¹, Cengiz Tavusbay ¹, Mehmet Haciyanlı ¹

Objective

Massive bleeding and perforation due to gastric cancer require urgent surgical intervention. However, the required major surgical procedure in emergency conditions is associated with high morbidity and mortality due to the fact that patients are usually older and their hemodynamics are not stable. In this article, we aimed to present the treatment and follow-up results of patients who underwent emergency gastrectomy for gastric cancer.

Material and Methods

The files of 18 patients who underwent emergency gastrectomy for gastric cancer-related hemorrhage and perforation at Izmir Katip Çelebi University Atatürk Training and Research Hospital General Surgery Clinic between January 2007 and January 2017 were evaluated retrospectively. The demographic characteristics of the patients, surgery and pathology data and surgical complications were recorded based on patient files and database information. Mortality data of the patients were screened by the population registration system as of February 2018. Demographic data, operation indications, operative data and pathology results were evaluated. Follow-up and survival time of the patients were recorded.

Results

The average age was 60.6±15.1 (27–86). 16 (88.8%) of the patients were male and 2 (11.2%) were female. The surgery indication in 12 (66.7%) patients was tumor bleeding, and tumor perforation in 6 (33.3%) patients. The procedure was total gastrectomy in 8 patients (44.4%) and distal in 10 (55.6%) patients. Pathology was reported to be neuroendocrine tumor in 1 (5.6%) patient, lymphoma in 1 (5.6%) patient and adenocarcinoma in 16 (88.8%) patients. In 7 (38.9%) of the patients, resection without resection (R0) was observed. The average tumor size was 8±3.7 (3–18) cm. Lymph node metastasis was seen in 13 (72.2%) of 16 (88.8%) patients who had lymph node dissection. While 7 (% 38.9) patients died in the perioperative period, the average survival time was 19±12.4 (5–51) months in 11 (61.1%) patients who were discharged. Average survival was 16.5±8.4 (1–29) months in patients who underwent R0 resection, and for patients undergoing R2 resection it was 3.66±5.02 (1–16) months (p<0.05).

Conclusion

Massive bleeding and perforation due to gastric cancer are the pathologies that require urgent surgery and with high perioperative mortality due to the general condition of the patient. However, R0 resection significantly improves survival compared to patients with residual tumor.

TJS. 2018;34(Suppl-1):S451.

PP-0479 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Rare Complication of Subtotal Gastrectomy: Remnant Stomach Cancer

Emine Özlem Gür ¹, Serkan Karaıslı ^1,^✉, Mehmet Haciyanlı ¹, Yusuf Kumkumoğlu ¹, Ahmet Er ¹, Kemal Atahan ¹, Osman Nuri Dilek ¹

Objective

Remnant gastric cancer (RGC) is a gastric cancer that develops in patients at least 2 years after undergoing subtotal gastrectomy for benign or malignant reasons. In this article, we aimed to present the treatment and follow-up results of patients who underwent gastrectomy for remnant gastric cancer.

Material and Methods

The files of 14 patients who were operated for RGC at İzmir Katip Çelebi University Atatürk Training and Research Hospital General Surgery Department between January 2007 and January 2017 were retrospectively analyzed. The demographic characteristics, operation and pathology data of the patients were recorded based on patient files and hospital database information. The mortality data of the patients were screened from the population registration system as of February 2018. Demographic data, operation indications, operative data and pathology results were evaluated. Follow-up and survival time of the patients were recorded.

Results

The average age was 65.85±9 (50–82). Twelve (85.8%) of the patients were male and 2 (14.2%) were female. Malignancy was in the gastroenterostomy line in 9 (64.2%) of the patients and in 5 (35.8%) of the proximal stomach. Three patients (21.4%) had a history of subtotal gastric resection for gastric cancer and 11 (78.6%) patients had a history of previous peptic ulcer surgery. The initial postoperative RMC emergence time was 32.5±18 (2–54) years. The average tumor size was found to be 4.1±2 (1.5–8) cm. 7 patients (50%) had lymph node metastasis. Perioperative mortality was seen in 2 (14.2%) patients, while the average survival time for 12 patients who were discharged was 26.1±15.8 months.

Conclusion

In patients with a history of subtotal gastric resection or with a known history, malignant tumors can be seen, especially in the gastroenterostomy line. In this respect, it is important for routine endoscopic screening, detection of patients in the risk group and detection of RMC at an early stage even after many years of known gastric surgery.

TJS. 2018;34(Suppl-1):S451.

PP-0480 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Late and Fatal Complication of the Nissen Fundoplication: Gastric Volvulus

Alpaslan Sarı ^1,^✉, Gökhan Pösteki ¹, Alican Güreşin ¹, Saffet Çınar ¹, Sertaç Ata Güler ¹

Organoaxial gastric volvulus is a rare complication following gastric operations. A 47-year-old female patient underwent Nissen fundoplication for Hill Grade 4 Hiatal hernia and gastroesophageal reflux. Gastric volvulus was detected in the postoperative 5th month in the patient who presented with acute abdomen. Exploration was performed. The patient had an organoaxial stomach rotation and the stomach was going totally necrosis. After total gastrectomy, the septic condition did not regress and anastomotic leakage occurred. The patient was followed up with luminal and intraabdominal drainage after reoperation. The patient died due to sepsis on the postoperative 16th day. We will share this rare complication in the literature.

TJS. 2018;34(Suppl-1):S452.

PP-0481 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Analysis of Hemogram and CRP Parameters in Patients with Congenital Appendectomy

Hüseyin Cahit Yalçın ¹, Faik Tatlı ^1,^✉, Orhan Gözeneli ¹, Abdullah Özgönül ¹, Mehmet Kaplan ², Ali Uzunköy ¹

Objective

It is known that there are some difficulties in the diagnosis and treatment of acute appendicitis in pregnant women. Anamnesis, physical examination and laboratory findings are important in the diagnosis. In this study, it was aimed to investigate CRP values with hemogram parameters and predictive values of appendicitis diagnosis.

Material and Methods

38 patients who underwent emergency appendectomy with the prediagnosis of acute appendicitis between January 2010 and May 2016 were evaluated retrospectively. Age, gestational week, hemoglobin, leukocyte, neutrophil, lymphocyte, platelet, C-reactive protein (CRP), neutrophil/lymphocyte, platelet/lymphocyte, leukocyte/CRP, neutrophil/CRP, leukocyte + CRP, neutrophil + CRP values and histopathological results were investigated. According to the pathology results, three groups were determined. Group I: acute appendicitis, Group II: perforated appendicitis, Group III: normal appendix (pathology: lymphoid hyperplasia). In the analysis of the data, SPSS for Windows version 24.0 ”statistical program was used, p<0.05 was taken for statistical significance.

Results

The average age of the patients (O): 28,8; gestational week (O): 19,2; leukocyte (O): 13.3 103/uL; left shift (neutrophilia) (O): 78.8% 103/uL; CRP (O): 6.3 mg/dL; neutrophil/lymphocyte ratio: 8,0; platelet/lymphocyte ratio: 184,9; leukocyte/CRP ratio: 11,9; Neutrophil/CRP ratio: 9.2; leukocyte + CRP total: 20.1; Neutrophil + CRP total: 17,4; Group I: 26 patients with acute appendicitis (68%), Group II: 4 patients with perforated acute appendicitis (10%), Group III: 8 patients (21%) with lymphoid hyperplasia. There was no significant difference between Group I and Group III when compared in terms of CRP values (P=0,750); Significant differences were observed between Group II and Group III (P=0.022), between Group I and Group II (P=0.017). Leukocyte values were statistically significant between the Groups I, II, III (P=0,013), leukocyte/CRP ratio (P=0,001), leukocyte + CRP total (P=0,009), neutrophil + CRP total (P=0,018).

Conclusion

(AA), except obstetric emergencies, is the most common cause of acute abdomen in pregnant women. Perforated appendicitis rate, morbidity and mortality increase with the difficulties/delays in diagnosis and treatment; With the threat of premature birth/miscarriage, the life of the patient and the fetus is put at risk. Anatomical, physiological and laboratory changes during pregnancy make the differential diagnosis difficult. The displacement of the appendix with the growth of the uterus limits the value of USG in the diagnosis, and tomography is inconvenient in the pregnant woman. Diagnostic tools are history, physical examination, laboratory and USG. In this study, CRP in perforated appendicitis; leukocyte, neutrophil, leukocyte/CRP ratio, leukocyte + CRP and neutrophil + CRP levels were significantly higher in acute and perforated appendicitis. We believe that in the diagnosis of pregnant women (AA) and complicated/perforated (AA); in addition to leukocyte, neutrophil, CRP, “leukocyte/ CRP ratio, leukocyte + CRP and neutrophil + CRP total” will be useful. The data in this study were used at the 11th National Trauma and Emergency Congress held in Antalya on April 5–9, 2017 with the title of ‘Evaluation of Appendectomy in Pregnant Patients’ with report number 0298.

TJS. 2018;34(Suppl-1):S452–S453.

PP-0482 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Use of Bougie During Placing Anvil in Esophagus in Laparoscopic Total Gastrectomy Procedure

Hüseyin Çiyiltepe ^1,^✉, Nuriye Esen Bulut ¹, Anıl Ergin ¹, Aziz Bora Karip ¹, Kemal Memişoğlu ¹

Since it was first reported by Kitano et al., Laparoscopic distal gastrectomy (LDG) (laparoscopy-assisted or total laparoscopic) has been widely used in the treatment of early gastric cancer in the Far East countries.

Laparoscopic total gastrectomy (LTG) procedure is becoming more common with the help of LDG as well as technology and experience. However, there are technical difficulties in performing an esophagogjejunostomy anastomosis after LTG. Due to the limited work area and lack of experience, the placement of anvil and performing distal suture in the distal esophagus is still problematic.

Various techniques and tools have been reported for intracorporeal esophagojejunostomy. One of them, OrVil, can be a bit complicated and time consuming for inexperienced surgeons as well as increasing costs. Double stapler technique described by Kim et al. is a reliable technique that can be applied quickly. However, in this technique, technical difficulties are experienced during the withdrawal of the esophagus below from the opening to be formed with the help of the rope attached to the end of the anvil after being cut via endoscopic linear cutter-sealer stapler.

In this article, we aimed to describe a new technique that we applied in our own clinic.

In order to prevent the distal esophagus from escaping into the mediastinum, in the position of the lithotomy through entering appropriate ports, after the laparoscopic total gastrectomy + D2 dissection was completed, the sutures were placed on both sides of the esophagogastric junction to the cruses. A 3-cm mini laparotomy was performed from the epigastric area. The anvil of the 28 mm intraluminal stapler device was removed and a 10 cm prolene suture was ligated to the end. Again, the laparoscopy procedure was continued and anvil was pushed through distal esophagus from the gastrotomy area 1 cm below the OGB. The resection was then closed using endo-GIA stapler and discontinued. At this stage, the plan was, as described by Kim et al., the removal of the prolene suture and placing the anvil on the cut esophagus, but since the prolene suture was also cut during the stapler cut, the procedure could not be conducted. 36 Fr bougie that we use in oral vertical sleeve gastrectomy procedure was sent gradually and the anvil was pushed in the distal esophagus, opening was created through the end of esophageal incision spot with the help of hook koter. Anvil was placed securely. Roux-n-y esophagojejunostomy was applied smoothly. In the case of LTG + Roux-n-y esophagojejunostomy procedure, we believe that it may be possible to place the anvil in a safe way by inserting the bougie orally in addition to the double stapler method described in the insertion of anvil into the incised esophagus line. We believe that more surgical experience and clinical studies are needed to achieve more accurate results.

TJS. 2018;34(Suppl-1):S453.

PP-0483 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Esophageal Surgery Techniques

Ali Emre Naycı ^1,^✉, Mehmet Baki Doğan ¹, Aziz Arı ¹, Feyzullah Ersöz ¹, Serkan Sarı ¹, Abdülkerim Özakay ¹, Soykan Arıkan ¹

Objective

Esophagectomy is one of the problematic areas of surgery due to morbidity and mortality. There are differences between surgical types and length of hospital stay and number of complications. Esophagectomies performed in our department were analyzed retrospectively. We compared the transhithal esophagectomy + gastric pull-up (TH) technique with the others.

Material and Methods

34 patients who underwent general surgery at Istanbul Training and Research Hospital between the years of 2007–2018 were examined. Distal esophagectomy cases added to gastrectomy due to gastric cardia cancer and physicians who did not want their cases to be included were excluded from the study. Of the esophagectomy cases, 31 were operated due to esophageal cancer, 2 patients were operated due to hypopharyngeal cancer and 1 patient was operated due to achalasia.

Results

Of these, 14 were performed transhiatal esophagectomy + gastric pull-up technique (50% female, 50% male), and 20 of them underwent Ivor-Lewis or Mckeown-type esophagectomy + reconstruction (Average age 55). The duration of hospital stay in hospital for TH was 18 days, 21 days for MK-IL (p=0.6891). Fistula developed in one of the patients who had undergone TH for postoperative complications on the 6th postoperative day. And on the 10th day, it spontaneously closed and no other complications were observed. Complications were observed in 10 patients in the MK-IL group (pneumothorax (1), fistula (1), anastomosis stenosis (8)) (p=0.0101). One patient died in both groups.

There was a significantly lower complication in the TH group in terms of early complications. In terms of hospital stay duration, no significant difference was detected in the TH group (p=0.6891).

Conclusion

When acute complications and duration of hospitalization were compared, TH esophagectomy is seen as an advantageous technique. Lack of adequate lymph node dissection in terms of cancer surgery is a disadvantage for TH esophagectomy, but it is still used in terms of esophagectomy technique and it has been found to be more advantageous in this study in terms of early complications.

TJS. 2018;34(Suppl-1):S453–S454.

PP-0484 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. A Case of Giant Gastric Bezoar Extending to Duodenum

Yunus Yapalak ^1,^✉, Fatma Ümit Malya ¹, Hüseyin Kazım Bektaşoğlu ¹, Naim Memmi ¹

Introduction

We aimed to present a case of giant gastric trichobezoar detected and treated in an 18-year-old woman who presented with nausea, vomiting, epigastric pain and abdominal mass.

Case

In her history, the patient described trichophagia and trichotillomania for four years. On her physical examination, she had no tachycardia, hypertension or fever. There was a palpable mass extending from the epigastrium to the suprapubic region in her abdominal examination. Blood results were as follows: wbc: 17000, crp: negative. Abdominal tomography revealed a well-circumscribed, multilayered, heterogeneous, solid lesion extending from the gastric fundus to the pyloric duct and from there to the duodenum.

The patient underwent endoscopy with a preliminary diagnosis of giant tricobezoar but bezoar could not be removed. Minilaparotomy was performed. A severely dilated stomach extending to the pelvis was observed in the abdomen.

Bezoar was removed as an enbloc via gastrotomy. Stomach was repaired on double layers. In the postoperative period, the patient moved to full oral intake without any complications and was discharged. Her parents were also recommended that the patient should be monitored by the psychiatry department. At the first month of follow-up, esophagasroduodenoscopy was evaluated as normal.

Discussion

Tricobezoars are mostly localized in the stomach. However, as in our case, they may sometimes extend to the duodenum or small intestine. This condition, known as Rapunzel Syndrome, may cause complications such as intestinal obstruction, gastrointestinal perforation, and pancreatitis. It is typically seen in girls below the age of 18 years with trichotillomania and trichophagia and is accompanied by an acute abdomen.

Conclusion

Bezoar is one of the rare pathologies and should be considered in the differential diagnosis in young female patients presenting with abdominal mass and acute abdomen. In these patients, trichophagia and trichotillomania should absolutely be questioned.

TJS. 2018;34(Suppl-1):S454–S455.

PP-0485 [General Surgery Diseases]. Endometriosis Located in Rectus Abdominis Muscle, Case Report

Semra Demirli Atıcı ^1,^✉, Değercan Yeşilyurt ¹, Lütfi Mutlu ¹, Kadir Koray Baş ¹

Endometriosis is defined as the presence of endometrial tissue outside the uterine tissue. Although ectopic endometrial tissue is frequently located in the pelvis, it can also be found in other body regions. Abdominal wall endometriosis originate from endometrium gland and stroma which may develop in the incision tissue after laparoscopic gynecological interventions and cesarean section. The diagnosis of incisional endometriosis is often based on anamnesis and physical examination. Here, we report a case of endometriosis located postoperatively in the rectus abdominis muscle in a patient who had a cesarean delivery 2 years ago. A 21-year-old female was admitted to our outpatient unit with a history of cesarean section 2 years ago with the complaints of colic pain in the left lower quadrant of the abdomen, severe pain during menstruation periods and palpable swelling. On physical examination, a hard mass was palpated on the cesarean incision. Abdomen USG revealed a heterogeneous internal solid structure with a diameter of 18x11 mm in the left lower quadrant paracentral rectus muscle. MRI revealed T1A isointense-like lesion at the pelvic entrance level, in the abdominal wall located on the left side of the rectus muscle, 30x22x13mm in size, mild hyperintense according to T2 muscle. Total mass excision was performed. The patient was discharged from the hospital without any complication. The pathology of the total excised mass was consistent with endometriosis. Endometriosis is the presence of ectopic endometrial tissue outside the uterine cavity. Ectopic endometrial tissue is usually located in the pelvis; but can be seen in extrapelvic eye, kidney, surrenal, lung, bowel, umbilicus, diaphragm, gallbladder, heart, liver, bone, peripheral and central nervous systems and skin. Although endometriosis of the primary abdominal wall is rare, it usually consists of endometrial gland and stroma, which may develop in the incision scar tissue after gynecological interventions especially in the caesarean section and hysterectomy, episiotomy, tubal ligation, laparoscopic trocar entry or amniocentesis. There are theories about the placement of endometrial tissue outside the uterus. These are; cellular immunity, aerosolization, coelomic metaplasia, retrograde menstruation, venous and lymphatic metastasis and mechanical implantation. Endometriosis of the abdominal wall can also be seen without gynecologic intervention, it is believed that endometriosis developed after such cases is caused by the transfer of previously intraperitoneal endometriosis to the surgical incision. In gynecological interventions, we reduce endometrial tissue transplantation and mechanical transplantation by protecting the surrounding tissue. With the increase of laparoscopic surgical procedures, the incidence of endometriosis in the abdominal wall and trocar space has increased. We can reduce the incidence of abdominal wall and trocar endometriosis secondary to laparoscopic interventions by using endobag in the removal of the operation specimen, wound protector in the incision site, appropriate surgical techniques when closing the abdomen and by irrigation of the incision site. The presence of cyclic pain in a mass associated with cesarean scar is pathognomic for abdominal endometriosis and the removal of the mass with wide excision is the recommended treatment approach. The incidence of endometriosis in the abdominal wall and trocar space secondary to increased laparoscopic interventions can be reduced by using endobag in the removal of the operation specimen, wound protector in the incision site, appropriate surgical techniques when closing the abdomen and by irrigation of the incision site.

TJS. 2018;34(Suppl-1):S455.

PP-0487 [General Surgery Diseases]. A Case Report of Extraskeletal Retroperitoneal Chondrosarcoma

Serdar Culcu ^1,^✉, Ferit Aydın ¹, Cemil Yüksel ¹, Ömer Yalkin ¹, Ali Ekrem Ünal ¹

Chondrosarcomas usually originate from cartilage tissue. The extraskeletal origin is rare and there are cases defined in the head and neck region (including the brain and meninges), the retroperitoneum and the extremities. There are two subtypes of extraskeletal mesenchymal chondrosarcomas (ESMC) as those with central nervous system origin and with muscle-soft tissue origin. ESMCs with muscle-soft tissue origin are less common and they are frequently located in the lower extremities. Here, we present a case originating from the lateral wall of the abdomen and displaying retro-intraperitoneal extension. The diagnosis and treatment process of a 39-year-old male patient, who was diagnosed with chondrosarcoma by an external center where he consulted due to abdominal mass that had begun to grow suddenly 6 months before and then referred to our department, was presented.

TJS. 2018;34(Suppl-1):S455–S456.

PP-0488 [General Surgery Diseases]. Diffuse Large B Cell Lymphoma Confusing with Gluteal Sebaceous Cyst: A Case Report

Orhan Kalaycı ¹, Şevket Barış Morkavuk ^2,^✉, Mustafa Karagülle ³

Introduction

Diffuse large B-cell lymphomas (DLBCL) are the most common type of all non-Hodgkin lymphomas and constitute 60% of them. The incidence of DLBCL, which forms the largest subgroup of NHLs, is around 2.9/100000 per year. It is most commonly observed in the 5th and 6th decades. Approximately 30–40% of DLBCLs, which may exhibit either nodal or primary extranodal involvement, primarily arise from the extranodal regions. Paranasal sinus involvement is the most common, which is followed by the central nervous system, gastrointestinal system, testis, lung and eye involvement, respectively. Skin involvement is rarely seen with the rate of 6%. In this case, we aimed to present a patient who was performed excision for the pre-diagnosis of sebaceous cyst in the gluteal region and whose pathological evaluation was reported as DLBCL.

Case

A 77-year-old female patient was admitted to our outpatient clinic with the complaint of palpable swelling in the right gluteal region. In the examination, a lesion consistent with infected sebaceous cyst was observed. In the anamnesis, it was learned that the lesion had been present for about 2–3 months and pain and temperature increase began in the last 2 days. When her history was questioned, it was found that she had diffuse large B cell lymphoma in remission. In the analyses of the patient, Wbc was 11.000 (4–11 103/μL); Hgb was 10.8 (11–18.8 g/dl); and Plt was 412.000 (150–400 103/μL). Routine biochemistry evaluation of the patient was normal and there was no pathological finding in the PA X-ray. In the gluteal superficial ultrasonography, the thickness of the subcutaneous fat tissue and echo were increased in the area where the lesion was located. Because these findings were evaluated in favor of infective change, excision was planned for the patient. She was discharged with recommendations after performing excision under local anesthesia. In the pathological evaluation of the patient, the diffuse neoplastic lymphocytic infiltrate positivity showing locally nodular pattern in the dermis was reported to be consistent with diffuse large B cell lymphoma. With these findings, the whole abdomen Pet CT was performed for re-staging. No pathological SUV involvement was observed. The patient was referred to the department of hematology.

Conclusion

Lymphoma is a type of cancer formed by lymphocytes. It is a general name given to the malignant tumor of lymph tissue. Malignant lymphoid cells also proliferate in the lymph nodes, spleen, bone marrow, blood and other organs as normal lymphocytes. Lymphomas are divided into two major groups as Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL). NHL is divided into 2 groups as B cell lymphomas originating from abnormal B lymphocytes and T cell lymphomas originating from abnormal T lymphocytes. They are classified as low grade, moderate grade and high grade. DLBCL is involved in the high-grade group and has an aggressive course. After demonstrating that chemotherapy with 3–4 cycles of CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) and radiotherapy on the affected area have extended the lifetime, they have been accepted as the standard treatment method. In cases with recurrence after remission, the stem cell-based DHAP protocol consisting of dexamethasone, cytarabine and cisplatin should be added to the treatment.

TJS. 2018;34(Suppl-1):S456.

PP-0489 [General Surgery Diseases]. Psoas Abscess Developing Secondary to Brucellosis

Semra Demirli Atıcı ^1,^✉, Can Arıcan ¹, Emran Kuzey Avcı ¹, Murat Akalın ¹, Bülent Çalık ¹, Gökhan Akbulut ¹

Although the etiology is not known exactly in Psoas abscess, it is caused by a lymphogenic or hematogenous spread of microorganisms from an undetected focus in the body. The patients usually present with abdominal pain, side pain, weakness, fever, sweating, weight loss, limping, and back and leg pain. Staphylococcus aureus is the agent that is most commonly found in the abscess cultures. In this case report, we present the right psoas abscess developing secondary to Brucellosis, which is a rare cause.

A 70-year-old male patient was referred to our clinic by an external center where he had applied for the complaints of fever and pain radiating to the right hip, right leg and gluteal region. He had a fever of 37.8°C. The abdominal CT taken for abdominal and right side pain revealed a lesion consistent with right psoas abscess. Firstly, percutaneous drainage with USG was planned for the patient who was consulted with the Department of Interventional Radiology. However, because the abscess formation in the deep psoas had multiple septa, only diagnostic puncture was performed. Brucella growth was detected in the culture of the puncture material.

Acid-resistant bacilli (ARB) and polymerase chain reaction analyzed in the abscess material for tuberculosis were found to be negative. No growth was observed in the culture for tuberculosis. The antibiotherapy of the patient for brucellosis was planned and initiated by the department of infectious diseases. Because his pain did not heal under antibiotherapy, control abdominal CT was requested. It was observed in the CT that the abscess localized in the right psoas was progressed compared to the previous size. Because the present abscess of the patient had multiple septa and no regression, it was operated for drainage. Postoperative hemodynamics of the patient was stable and he was discharged after removing the drain.

Although the etiology is not known exactly in psoas abscess, its incidence is three times higher in males than females. Its localization is seen as the right side (57%), left side (40%), and bilateral side (3%). Patients usually present with the complaints of abdominal pain, side pain, weakness, fever, sweating, weight loss, limping, and waist and leg pain. Staphylococcus aureus is the most commonly detected agent in the abscess cultures. Escherichia coli, Pseudomonas aeruginosa, Mycobacterium tuberculosis and rarely Brucella species are also detected. Due to its proximity to the Psoas muscle, it may develop secondary to the infectious diseases of the gastrointestinal system, skeletal system and retroperitoneal organs. In secondary psoas abscesses, Crohn’s disease is the most common disorder with the rate of 60%. Other accompanying causes include appendicitis (16%), colon diseases (inflammation, ulcerative colitis, diverticulitis and tumors) (11%), disc infections and osteomyelitis (10%), perirenal infections, pyonephrosis, postoperative factors, foreign body complications, and tuberculosis.

Antibiotherapy and abscess evacuation should be used together in the treatment of Psoas abscess. Due to its being minimally invasive, USG or CT-guided percutaneous abscess drainage and accompanying antibiotherapy are the most preferred treatment modalities in psoas abscesses. In conclusion, although brucella bacteria are rarely seen in cases with psoas abscesses, they should be considered to affect and necessary examinations should be done for the diagnosis of brucellosis in these patients.

TJS. 2018;34(Suppl-1):S456–S457.

PP-0490 [General Surgery Diseases]. A Rare Case of Desmoid Tumor Invasive to the Pelvic Bone

Mehmet Ali Can ^1,^✉, Bahri Çakabay ¹, Abidin Tüzün ¹

Introduction

Desmoid Tumor (DT) is a rare, benign tumor with a high tendency to infiltrative growth and recurrence after local excision without metastasis. Its frequency is three times higher in women. Two thirds of the patients are between the ages of 20 and 40 years. It can be associated with FAP, Gardner syndrome, trauma, hormonal imbalance and previous surgeries. DTs are usually solitary and they are multiple in 10–15% of cases. DT is a locally invasive form of fibromatosis, accounting for only 0.03% of all fibromatoses. It can develop in the extremities, chest wall, abdominal wall and intraabdominal tissue. Imaging studies such as computed tomography (CT) and magnetic resonance (MR) are performed for preoperative diagnosis and surgery planning. Complete surgical resection is the first treatment option with a negative pathological border and careful follow-up is recommended because of its high recurrence rate.

Case

A 22-year-old female patient without any systemic disease was admitted to our hospital with the complaint of abdominal pain that was intermittently going on for the last one month. She had a history of caesarean section operation 7 months ago and her physical examination revealed a palpable giant mass with tenderness in the suprapubic area. Her laboratory values and tumor markers were within normal intervals. In CT, there was a well-circumscribed 98x79x90 mm solid mass including the rectus muscle at the anterior of the bladder, having close neighborhood with bilateral pubic bone, and displaying subcutaneous extension. The operation decision was taken and the mass was reached by passing the skin and subcutaneous area with the previous Pfannenstiel incision. The mass being approximately 10x8x9 cm in size, involving the rectus muscle, and invading to the pubic bone was completely resected with partial bone resection. The patient well-tolerated the operation and was discharged on the 6th postoperative day. Histopathological examination of the mass was reported as morphology consistent with deep fibromatosis (desmoid tumor). The lesion is infiltrated in focal areas to the surrounding fat, muscle and bone tissue.

Discussion

DT is a rare benign tumor that has a high tendency to infiltrative growth and recurrence after local excision, but does not metastasize. The female to male ratio is 3: 1. Two thirds of the patients are between the ages of 20 and 40 years. Its etiology includes FAP, Gardner syndrome, trauma, hormonal imbalance, and previous operations. DTs are usually solitary, but they are multiples in only 10–15% of cases. The DTs display a great growth before they become symptomatic. For preoperative diagnosis and surgery planning, imaging techniques such as CT and MRI are performed. Although its invasion to the bone structure is very rare, sporadic cases are present as in our case. In such cases, complete surgical resection with clean pathological margins is the primary treatment and careful follow-up is recommended because of the high recurrence rate.

Conclusion

As in our case, DT may be invasive to the bone and complete resection of the desmoid tumor with partial bone resection can be used as a treatment option.

TJS. 2018;34(Suppl-1):S457.

PP-0491 [General Surgery Diseases]. Necrotizing Fasciitis After Intramuscular Self-Injection; Case Report

Nuri Emrah Göret ¹, Ceren Canbey Göret ², Ömer Faruk Özkan ^3,^✉

Necrotizing fasciitis (NF) is a rare soft tissue infection that involves the skin, subcutaneous tissue, fascia, and muscle layer and threatens life with rapid invasion and spread. Its treatment is possible with early recognition, appropriate antibiotherapy, and rapid surgical intervention. However, despite all interventions, it is a disease the management of which is sometimes difficult. In our case, it was aimed to present a case of extensive multi-drug resistant necrotizing fasciitis, which developed due to intramuscular diclofenac sodium injection done by a non-healthcare worker, which grew multi-drug resistant acinetobacter baumannii in the wound site sample, and which was treated with negative pressure wound therapy system in addition to antibiotic therapy and wide surgical debridement.

TJS. 2018;34(Suppl-1):S457–S458.

PP-0492 [General Surgery Diseases]. Is Flap in Pilonidal Sinus Disease Needed for Each Patient?

Erkan Karacan ^1,^✉, Eyüp Murat Yılmaz ¹, Evrim Kallem ², Aykut Soyder ¹, Ahmet Ender Demirkıran ¹

Objective

Pilonidal sinus disease is a very frequently seen disease of intergluteal sulcus and it has many treatment modalities. In our study, we planned to compare the primary repair and Limberg flap method in terms of recurrence and complications.

Material and Methods

The patients who were diagnosed with pilonidal sinus and performed primary excision and Limberg flap in the Department of General Surgery in Adnan Menderes University Medical Faculty between September 2014 and September 2016 were included in the study and their recurrence rates and complications were compared.

Results

A total of 123 patients were included in the study. While 63 (51.2%) patients underwent primary excision, 60 (48.8%) patients underwent Limberg flap. Complications occurred in 13 (21.6%) patients undergoing primary excision and in 6 (10%) patients undergoing Limberg flap. While 8 patients developed recurrence, 6 (75%) of them were in the primary excision group and 2 (25%) were in the Limberg flap group. There was a statistically significant difference with regard to recurrence and complication (p=0.042).

Conclusion

In pilonidal sinus disease, flap method gives better results in terms of recurrence and complications compared to primary repair.

TJS. 2018;34(Suppl-1):S458.

PP-0493 [General Surgery Diseases]. Interdigital Pilonidal Sinus Treated with Crystallized Phenol

Osman Doğru ^1,^✉, Emet Ebru Ateş ¹, Süleyman Kargın ², Derviş Ateş ¹, Ersin Turan ³

Interdigital pilonidal sinus is a rare disease which is mostly observed in barbers as a result of prolonged exposure of interdigital space to hair, and patients reported in the literature have generally been treated by excision and primary repair, curettage and leaving to secondary recovery, or excision and skin grafts. Recurrences have been reported despite this aggressive treatment. In this report, it was aimed to present a case of interdigital pilonidal sinus that was treated with crystallized phenol method and obtained successful results in early period.

TJS. 2018;34(Suppl-1):S458.

PP-0494 [General Surgery Diseases]. A Case Performed Cytoreductive Surgery and HIPEC due to Primary Peritoneal Serous Carcinoma

Serdar Çulcu ¹, Ömer Yalkın ^1,^✉, Ferit Aydın ¹, Cemil Yüksel ¹, Ali Ekrem Ünal ¹

Primary peritoneal serous carcinomas are typically characterized by the presence of peritoneal tumors and normal-looking ovaries, which may be considered as peritoneal carcinomatosis or malignant mesothelioma. In this study, we presented a 72-yearold patient who was admitted due to abdominal swelling and performed cytoreductive surgery and HIPEK because the examinations revealed primary peritoneal serous carcinoma.

TJS. 2018;34(Suppl-1):S458–S459.

PP-0495 [General Surgery Diseases]. Abdominal Castleman’s Disease

Serdar Gümüş ^1,^✉, Mehmet Ali Can ¹, Mehmet Ali Açıkgöz ¹, Özkan Demiroğlu ¹, Bahri Çakabay ¹

Introduction

Castleman’s disease is a rare disease and it is a member of the group of lymphoproliferative diseases. It is usually detected during routine screening in asymptomatic cases. In this article, it was aimed to present a case of castelman disease presenting with an abdominal mass causing abdominal pain. Castleman’s Disease or angiofollicular lymphoid hyperplasia is a rarely encountered heterogeneous lymphoproliferative disease. According to localization, there are two forms as unicentric and multicentric. And, according to the histological characteristics, there are forms of plasma cell type, hyaline-vascular type, and mix type. Unisentric ones may be seen more frequently in the mediastinum and in the abdomen or in the retroperitoneum with enlarged lymph nodes. Multicentric ones may present with peripheral lymphadenopathy and hepatosplenomegaly accompanied by fever and weight loss.

Case

A 40-year-old male patient with a complaint of nonspecific abdominal pain had no significant feature in his history, physical examination or laboratory parameters. Abdominal ultrasonography revealed a mass of approximately 46 * 52 mm, which did not show a clear relationship with the pancreas and liver in the neighborhood of the pancreatic head. Intravenous contrast-enhanced abdominal tomography showed an extrapancreatic solid mass at the level of the portal hilus, displaying contrast-enhancement and no prominent invasion findings and having calcifications causing minimal striation. Hodking lymphoma could not be ruled out in the Tru-cut biopsy. The PET CT showed FDG uptake with SUVmax value of 3.7. In the laparotomy, a giant lymph node was detected at the level of the pancreas head and portal hilus and in the neighborhood of the vena cava, and it was totally excised. The patient was discharged on the postoperative 4th day without any complications. Pathology result was reported as Hyalin-vascular type Castelman disease. The patient is now in the second year of the follow-up and he lives with no recurrence and no symptoms.

Discussion

Castleman’s disease is characterized by benign lymph node hyperplasia. It can clinically present with abdominally, retroperitoneally or peripherally located enlarged lymph nodes, particularly with the localization of mediastinum. Besides lymph nodes, it can involve many regions such as lung, breast, pancreas, adrenal gland, spleen, muscle, salivary glands, larynx, and parapharyngeal region. In its etiopathogenesis, the immune system disorder is generally kept responsible.

Cytokines such as interleukin-6 and VEGF, EBV and Human Herpes Virus-8, and an atypical lymphoid hyperplasia caused by an abnormal immune response to antigenic sitimulation are among the agents that are considered to be responsible. In the multicentric type, nonspecific symptoms such as fever, weight loss, night sweating, diffuse lymphadenopathy and hepatosplenomegaly due to increased IL-6 level can be observed and POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, skin findings) is seen rarely. In imaging methods, it can be observed as a well-circumscribed soft tissue mass which is similar to lymphoma. Calcifications spreading radiatively from the mass center or having peripheral localization can be seen.

Conclusion

In our case, we radiographically applied to ultrasonography and then contrast-enhanced abdominal tomography. There are different modalities in the treatment. Localized disease can be treated and cured by surgery or radiotherapy. However, in patients with systemic disease, complete remission can only be achieved with prednisolone or chemotherapy.

TJS. 2018;34(Suppl-1):S459.

PP-0496 [General Surgery Diseases]. A Rare Case; Primary Splenic Angiosarcoma

Murat Güner ¹, Nurullah Damburacı ^1,^✉, Barış Sevinç ¹, Mehmet Gündoğan ², Coşkun Ege Oğuzer ¹, Ömer Karahan ¹

Introduction

Primary splenic angiosarcoma is an aggressive disease with poor prognosis. Tumor cells show CD31, CD34 and factor VIII expression. Its symptoms vary from abdominal pain to life-threatening bleeding, so patients can be diagnosed at advanced stages. The only treatment option that is currently accepted is early diagnosis and surgical treatment. In this study, it was aimed to evaluate a patient who was diagnosed with primary angiosarcoma and performed splenectomy.

Case

A 65-year-old male patient was admitted to the outpatient clinic with a complaint of pain in his left upper quadrant going on for 3 months. No pathological finding was observed in the laboratory values of the patient who had no history of trauma. His physical examination was usual. Abdominal ultrasound revealed no finding except a 17 mm hypoechoic lesion. The lesion was confirmed through computed tomography. In the CT, there was a splenic lesion that was isodense with spleen parenchyma in the portal phase and displayed heterogeneity in the arterial phase. The patient was performed splenectomy. In the pathological examination, it was observed that the spleen size was 14 x 9 x 5 cm and immunohistochemical examination revealed CD31, CD34, and factor VIII positivity. Ki-67 proliferation index was found to be 10–20%. The patient was evaluated as primary splenic angiosarcoma based on these findings. The patient was treated with 10 cycles of paclitaxel. The patient is still alive and under follow-up for 2 years.

Conclusion

Primary splenic angiosarcoma is a rare disease with an incidence of 0.1450.25/1000000. Although it is seen in middle aged group, there are studies indicating that it is seen between the ages of 14 and 89 years in the literature. As it is usually asymptomatic, it can be diagnosed in late stage. The most common symptoms include left upper quadrant pain, weight loss, fever, anemia, thrombocytopenia, and sometimes life-threatening splenic rupture. Ultrasonography, computed tomography, and magnetic resonance imaging are the auxiliary methods for diagnosis. The endothelial markers of CD31, CD34 and factor VIII play an important role in the diagnosis. Nowadays, there are studies investigating the effect of chemotherapy and radiotherapy, but the treatment method that is still accepted is splenectomy.

TJS. 2018;34(Suppl-1):S460.

PP-0498 [General Surgery Diseases]. Which Scoring System can Predict the Severity and Mortality of Fournier’s Gangrene?

Sadettin Er ¹, Deniz Tikici ^1,^✉, Sabri Özden ¹, Birkan Birben ¹, Metin Yalaza ¹, İsa Sözen ¹, Barış Saylam ¹, Özgür Akgül ¹, Erdinç Çetinkaya ¹, Mesut Tez ¹

Objective

The aim of this study was to investigate which scoring system could simply and easily be used in predicting the severity and mortality risk of the disease of a patient who was admitted to a health center due to Fournier’s gangrene.

Material and Methods

Demographic, clinical and laboratory data of 53 patients who were admitted to the Department of General Surgery in Ankara Numune Hospital between 2014 and 2017 with the diagnosis of Fournier’s gangrene were retrospectively analyzed and obtained in electronic environment. From these data, Fournier gangrene severity index, Uludağ Fournier gangrene severity index and NUMUNE Fournier scores were calculated.

Results

Of the 53 patients included in the study, 37 (69%) were male and 16 (31%) were female. The median age was 57 (Min: 25Max: 79) years. During the hospitalization, 7 (13.2%) patients developed mortality. 46 (86.8%) patients were discharged. When we evaluated the comorbidities, the majority (62%) of them had diabetes, cardiac causes, and lung problems. In the evaluation of the patients by using ROC curve, Fournier gangrene severity index, Uludağ Fournier gangrene severity index and NUMUNE Fournier scores for the determination of mortality were,887-, 886 and 878 (95% Confidence Interval), respectively.

Conclusion

Fournier’s gangrene is a life-threatening condition when effective surgical-medical treatment is not started. It is rarely seen in the perineal or male and female genital areas and it sometimes progresses rapidly towards the anterior and later walls of the abdomen. Aggressive debridement and appropriate medical treatment are the most important methods in its treatment. In most of series, the mortality rate is between 40.9% and 61.7%. To predict mortality rates, a number of Fournier’s gangrene violence indexes and scores are available in the literature. Of them, NUMUNE Fournier score includes some parameters such as age >60, urea >40 mg/dl, RDW >14.95%, albumin<20 mg/dl, and the presence of sepsis. We think that fewer parameters of this current score than other indices and its simple and easy applicability will facilitate the rapid detection of the severity of the patients at the primary healthcare centers and refer them to further centers.

TJS. 2018;34(Suppl-1):S460.

PP-0499 [General Surgery Diseases]. Retroperitoneal Mucinous Cystadenoma as a Rare Cause of Abdominal Mass

Hilmi Yazici ^1,^✉, Nurettin Kahramansoy ¹, Enver Vardar ², Mehmet Yıldırım ¹

Introduction

Primary mucinous type retroperitoneal cysts are very rarely seen masses. Benign cystadenoma is a mass with low malignant potential, which includes proliferative epithelium and may display the morphology of mucinous cystadenocarcinoma. In this study, it was aimed to present a case with primary retroperitoneal mucinous cystadenoma.

Case

A 29-year-old female patient was admitted to the emergency department with abdominal pain going on for about a week. She had no history of comorbid disease or surgery. Her menstrual cycles were regular. She had no familial history. The physical examination revealed only tenderness in the right lower abdominal quadrant. No abnormal finding was detected in the laboratory tests. Tumor markers were normal. Because the abdominal USG revealed a 73x33 mm cystic mass lesion in the cecum localization on the right side of the abdomen, CT was planned. In the CT, an isolated retroperitoneal cystic lesion with no relationship with the intestinal segments was reported in the lateral area of the cecum. Colonoscopic examination was performed and its result was reported as normal. The patient, whose gynecological examination was also normal, was performed laparotomy. Retroperitoneal cyst and edematous appendix were resected. On the postoperative 2nd day, the patient was discharged with healing. The pathology report was reported as mucinous cystadenoma and the patient was followed in the outpatient clinics of gynecology and general surgery.

Conclusion

Primary retroperitoneal mucinous masses are rarely encountered lesions. Although there are a few theories about the formation of lesions, the etiology is not clear. We think that these masses should be closely followed up and treated with multidisciplinary approaches because of the malignancy potential.

TJS. 2018;34(Suppl-1):S461.

PP-0500 [General Surgery Diseases]. Splenectomy Indications of a General Surgery Department and Post-Operative Mortality Profile

Mustafa Uğur ^1,^✉, Arif Emre ²

Objective

It was aimed to report the indications of patients who underwent splenectomy in the general surgery department in 6 years period and the profiles of the patients who developed postoperative mortality.

Material and Methods

The data of the study were obtained retrospectively by reviewing records of patients over 18 years old who underwent splenectomy in Department of General Surgery of Mustafa Kemal University Faculty of Medicine from January 2012 to January 2018. The patients were divided into two groups as those who were alive (Group 1) and those who developed mortality (Group 2). Demographic data including age and gender of patients, duration of hospitalization, seperation of surgical operations as emergency or elective, how they were performed, indications, histopathological evaluation results of splenectomy specimens, survey statuses of patients under follow-up until the study was completed, were investigated. Differences between the groups were analyzed. Quantitative data were displayed as mean±std. (standard deviation) and categorical variables as% (n).

Results

A total of 107 patients being 54.2% male and 45.8% female were included in the study. There were 94 patients in group 1 and 13 patients in group 2. The mean age of the patients in group 1 was 43.9±18.9 (min-max 18–88) and the mean age of the patients in group 2 was 48.4±23.9 (min-max 20–90). 61.7% of the patients were electively operated, and 38.3% of them were emergently operated. Mortality developed in 6% of electively operated patients and in 22% of emergently operated patients. The rate of mortality development was statistically higher in emergently operated patients compared to electively operated patients (p<0.05). When the indication profiles of the patients were examined, the most common splenectomy indication was trauma with 32.7%, followed by 26.2% as a component of debulking surgery in ovarian cancer, and 14% with Immune Thrombocytopenic Purpura. When the postoperative complications were examined, 82.2% of the patients had no complication and 17.8% of them had complications. The most common isolated complications were isolated abdominal hemorrhage in 6.5% of the patients and isolated atelectasis and pneumonia in 5.6% of them.

Conclusion

The most common indication of splenectomy in the general surgery department is trauma. In nontraumatic patients, it is most commonly performed as a component of the cancer surgery. Postoperative bleeding and pulmonary complications are seen in splenectomy patients and the rate of mortality development is higher in emergently operated patients compared to electively operated patients.

TJS. 2018;34(Suppl-1):S461–S462.

Non-operative treatment in the patients having penetrating abdominal GSI is quite rare and is a treatment option in selected cases. We think that the patients has to be stable hemodynamically and they should not have peritonitis findings in order to apply nonoperative treatment and it should be applied in cases selected carefully at centers where they can be followed closely with continuous monitoring and physical examination.

TJS. 2018;34(Suppl-1):S463.

PP-0505 [General Surgery Diseases]. Our Extremity Protective Surgery Experience After Hyperthermic Perfusion in Extremity Liposarcoma

TJS. 2018;34(Suppl-1):S465–S466.

PP-0509 [General Surgery Diseases]. Mass in the Spleen: Hydatid Cyst? Pseudocyst?

İhsan Burak Karakaya ^1,^✉, Alper Sözütek ¹, Mehmet Kemal Yener ¹, Hüseyin Kılavuz ¹, Fatih Akgündüz ¹

Introduction

The presence of a mass in the spleen is a condition we often encounter in daily practice. The majority of these masses are incidentally detected and are usually assessed for hydatid disease or metastasis. Spleen pseudocysts are much less common and the incidence is reported as 0.07%. This condition, which usually develops secondary to trauma, can be confused with hydatid cyst. In this study, surgical results of a patient who was diagnosed with hydatid cyst and underwent medical and surgical treatment were discussed.

Case

A 40-year-old female patient consulted to our clinic due to the left upper quadrant pain for 5 months. Immobile mass was palpated in the left upper quadrant in the physical examination of the patient who stated that he had taken Albendazole treatment for 3 months due to hydatid cyst in the external center. There was no other feature in his history. The results of ultrasonography, abdominal computed tomography (CT) and abdominal computed tomography (CT) were reported as an appearance consistent with Type 3–4 semisolid hydatid cyst including echogenic regions, applying compression to the stomach from the posterior with a size of 118x125x100 mm in superomedial neighborhood of spleen. IHA and ELIZA tests were negative. Laparotomy was planned because of compression symptoms. A solid mass of approximately 15 cm partially invasive to diaphragm on the left, stomach posterior in the front, and distal pancreas in the posterior, originating from posterior of spleen was detected. Splenectomy was performed. Histopathological examination was reported as spleen pseudocyst. No complications were encountered in the postoperative period and the patient was discharged. The patient was asymptomatic at the 1st year follow-up.

Conclusion

Spleen pseudocysts are often asymptomatic but incidentally detected in routine examinations and controls. It is often diagnosed and treated as hydatid cyst and primary spleen tumor, as it is seen more commonly and because of its radiological appearance. Although markers such as IHA and ELISA are sensitive for hydatid cysts, their being negative leads to the exclusion of the disease. However, the scolex-like appearances in the mass do not help differential diagnosis. Despite the evaluations in different sequences of the differential diagnosis with MRI, especially type 3–4 cysts can be confused with hydatid and the follow-up decision can be made and unnecessary antiparasitic therapy can be applied. Although the questioning of trauma history of the patient is the best differential diagnosis we have in hand, it can be detected idiopathically as in our case. The risks such as size of the cyst, the compression on the surrounding organs, bleeding into the cyst, and pseudoaneurysm are the main options of surgery. Total splenectomy with partial splenectomy is preferred due to remaining of remnant cyst and recurrent splenic pseudocyst formation. Since the approach to the spleen masses can change our diagnosis and treatment plan, spleen pseudocysts should be kept in mind in the differential diagnosis.

TJS. 2018;34(Suppl-1):S466–S467.

PP-0510 [General Surgery Diseases]. Intraperitoneal Large Mobile Mass Due to Spontaneous Appendix Epiploica Torsion; Case Presentation

Yeliz Candan ^1,^✉, Gökhan Gökten ¹, Melih Akıncı ¹, Zafer Ergül ¹, Serhat Tokgöz ¹

Introduction

We aimed to present a case of intraperitoneal mass due to spontaneous appendiceal epiploica torsion which is very rare in surgical practice.

Case

Appendiceal mucocele was primarily considered upon observing a lesion having a size of 68x55 mm with regular margins and calcification in the center in the appendix localization of the contrast-enhanced abdomen CT. Laparotomy was planned because the neoplastic findings could not be excluded in the radiological findings of the patient whose laboratory tests were normal. In the exploration, a giant nodule was found in the right lower quadrant which was free without invasion to the surrounding tissue and was excised and no additional pathology was observed. The removed free mass was 7x6.5 cm in size, having a shape of an egg, 180 grams in weight and hard with white-yellow color and slippery surface. As a result of histopathologic examination, it was reported as giant sclero calcified hard nodule having a lamellar appearance the middle of which was slightly calcified with regular margins. The patient was discharged without any problems on the second postoperative day without complication.

Conclusion

Although there are limited cases about intraperitoneal free masses in the literature, the exact pathogenesis is not clearly defined. Appendicitis is thought to be caused by epiploca, then omentum, adnexal autoamputation and pancreatic fatty tissue. The formation of the intraperitoneal free mass is thought to be caused by the reduction of blood flow as a result of torsion of the appendix epiploicus in the chronic process and consequently by necrosis, saponification in time, calcification and finally separation of the pedicle from the colon because of weakening of pedicle. In addition, if the masses increase in size, symptomatic progression can lead to clinical problems such as intestinal obstruction, urinary retention. Several authors have reported the increase of free masses by peritoneal fluid with protein absorption Leiomyoma, rhabdomyomas, teratomas, fibroma as benign masses and colorectal cancer, ovarian cancer and metastases should be considered as malignant masses in the differential diagnosis of such masses. In addition, it can be attributed to the effects or complications of other diseases such as urinary stones, gallstones and appendix stones and tubercular granuloma. Lymph nodes due to systemic diseases, lymphomas and calcifications of foreign bodies should be tried to be excluded. Although the primary pelvic/tubal hydatid cyst located in the intraabdominal region is very rare in endemic areas such as our country, it should be kept in mind in the preoperative diagnosis in endemic areas like our country. As a result, small, mobile nodules associated with liquefaction necrosis due to different causes can be seen in intraperitoneal exploration of patients who are operated intraabdominally due to different causes. Because of their growth, it can be associated with different diseases as in our case and because the neoplasms cannot be excluded, peritoneal exploration decision can be made. In this case, we aimed to remind these masses, which are very rare in surgical practice. Although these masses are rare, it should be kept in mind that they can reach large dimensions as in this case.

TJS. 2018;34(Suppl-1):S467.

PP-0511 [General Surgery Diseases]. Comparison of Open and Laparoscopic Splenectomy in Elective Cases: Çukurova University Experience

Uğur Topal ^1,^✉, İshak Aydın ¹, İsmail Cem Eray ¹, Orçun Yalav ¹, Kubilay Dalcı ¹, Ahmet Rencüzoğulları ¹

Objective

Elective splenectomies are performed with various indications, especially benign hematologic diseases. Hemolytic anemias and idiopathic thrombocytopenic purpura are among these. With technological improvements and increased surgical experience, surgeons have begun to perform most open surgical procedures laparoscopically. Today, laparoscopic splenectomy (LS) has become an alternative to open splenectomy (OS) in benign hematologic diseases, except for patients who have very large spleen. Many studies have shown that it is the gold standard for the treatment of benign hematologic diseases. We aimed to compare laparoscopic splenectomy and open splenectomy with our own findings and to evaluate the results in the light of literature.

Material and Methods

The study included 95 patients who underwent elective splenectomy for various diseases in the Department of General Surgery at Çukurova University Faculty of Medicine between 2013 and 2018. Twenty of the patients underwent laparoscopic surgery and 75th of them underwent conventional surgery. Patients were evaluated retrospectively using an electronic database. In addition to demographic information of the patients, preoperative blood counts, etiologic cause, duration of operation, amount of blood loss, splenic size and weight, necessity to switch from laparoscopic surgery to open surgery, duration of hospitalization and postoperative developing complications were investigated.

Results

A total of 95 patients undergoing 75 open, (79%) and 20 laparascopic (21%) splenectomy were included in our study. The mean age of the patients who underwent open splenectomy (OS) was 43,3 (18–78) and it was 39,2 (19–61) in the patients who underwent laparoscopic splenectomy (LS). Six of the cases who underwent LS were male (30%) and 14 were female (70%). Thirty two of the cases who underwent OS were male (42.6%) and 43 (57.4%) of them were female. The indications for splenectomy were 12 ITP, 4 hemolytic anemia, thalassemia, 4 cysts, tumor in LS and 16 ITP, 23 hemolytic anemia, thalassemia, 17 cysts, tumor, 19 hypersplenism in OS. Duration of operation and bleeding in LS patients were (105min, 125 ml), and they were (80 min, 175 ml) in OS patients, mean spleen size and weight in LS patients were (13cm/225 g) and they were (17 cm, 245 g) in OS patients, switch from laparoscopy to open surgery took place in 5 patients, postoperative hospitalization period in LS patients was 3,7 days and 4.8 days in AS patients. Subcutaneous infection developed in 4 patients, atelectasis developed in 6 patients in atelectasis 2 patients and chylous fistula developed in 2 patients in AS patients and atelectasis developed in 3 patients among OS patients.

Conclusion

PP-0515 [General Surgery Diseases]. Intraabdominal Benign Cystic Mesothelioma

Mürşit Dincer ^1,^✉, Yusuf Emre Altundal ¹, Alp Ömer Cantürk ¹

Introduction

Cystic mesothelioma is a rare disease. Although it is usually pleural originated, it can also develop from peritoneal surface. It is more common in women than men. Intraabdominal lesions present symptoms with bloating and pain complaints. Diagnosis is difficult with imaging methods. The treatment is surgery. In this report, we present a case being admitted with abdominal pain and bloating in whom cystic lesion in the abdomen was detected and a final pathology of benign cystic mesothelioma was obtained.

Case

A thirty-year-old female patient presented with complaints of abdominal pain and distention. She had a history of operation 3 times due to intra-abdominal cystic mass. The pelvic MRI revealed a cystic, lobulated mass with a 12x11x16 cm in size in the right quadrant of the pelvic region filling Douglas and extending to the adnexal lodge, including fine septa and having contrast involvement in its septas after giving intravenous contrast material. The operation was decided due to recurrent mesothelioma. In the exploration, a large number of cystic lesions having the largest diameter of which was approximately 15 cm were detected, with a large sigmoid column, probably of gynecologic origin, filling the pelvis almost completely and intermediate plains with sigmoid colon were unclear. The cysts were separated from the organs. The cyst contents were sampled for histopathological examination. The pericist layers were excised. All cystic structures were removed from the intraabdominal area and the operation was terminated. She was discharged on the postoperative course without any problems. Pathology result was obtained as benign cystic mesothelioma.

Conclusion

Benign cystic mesothelioma originating from peritoneal is rare. The etiology is not fully elucidated. It may present symptoms with abdominal bloating, palpable mass and pain. The diagnosis is made histopathologically. The treatment is surgery. Non-surgical therapies such as hormone therapy can be performed in recurrent cases. But their efficacies are limited. In this case, relaparotomy was decided due to the frequency and severity of the symptoms. In conclusion, benign cystic mesothelioma should be kept in mind in the differential diagnosis in cases with cystic mass in the abdomen.

TJS. 2018;34(Suppl-1):S470.

PP-0516 [General Surgery Diseases]. Aggressive Angiomyxoma: A Rare Perineal Mass

Mehmet Sait Özsoy ^1,^✉, Nuray Çolapkulu ¹, Aman Gapbarov ¹, Özgür Ekinci ¹, Nesrin Gündüz ², Ayşe Nur Toksöz ³, Orhan Alimoğlu ¹

Introduction

Aggressive angiomyxoma is rare and benign mesenchymal tumor, usually seen in women of reproductive age. Despite having benign nature, it is considered as aggressive due to its invasion capacity and recurrence tendency. Perineal abscess in imaging can be confused with vaginal cyst and bartolin cyst. In this study, we aimed to present a case presenting with perineal mass and having a rare case of histopathology.

Case

A 36-year-old female patient complaining of bloating and pain in her right hip for two years was admitted to the outpatient clinic. The patient who had a caesarean section a year ago stated that her complaints started in pregnancy. In physical examination, a massive lesion was palpated in the right gluteal area at a distance of 8cm to the anus at the direction of 9 o’clock, and it was soft, well-defined and with a mild swelling with fluctuation. Laboratory values were normal. In the ultrasonography, the collection of a dense content of 73 x 48 x 68 mm in size, including point like echogenities which is considered to be related with air was evaluated as consistent with abscess. In Magnetic Resonance Imaging a lesion which was isointense in T1A and hyperintense in T2A, starting with vaginal distal part neighborhood on the right side, extending to the posteroinferior and right neighborhood of intergluteal cleft was observed. The lesion dimensions were 35x25 mm in axial plane and coronal length was 62 mm. There was no restriction on diffusion-weighted images in the lesion. A-V malformation and angiomixoma were considered as differential diagnosis. The lesion was excised as a result of the examinations. Microscopic examination revealed tumor cell-poor, pale cytoplasm, myxoid stroma dominated formed of star-shaped fibroblasts and the most typical feature of small-medium thick-walled veins were seen. Immunohistochemical examination revealed desmin, CD (cluster of differentiation) 31, CD34, ER (estrogen receptor) and PR (progesterone receptor) positivity. SMA (smooth muscle actin) was focally positive, S-100 was negative and Ki67 staining was less than 1%. This information was used to diagnose aggressive angiomyxomas. Re-excision was performed in several foci since the lesion was adjacent to the surgical margin. The patient did not receive any additional treatment and had no evidence of relapse in the third postoperative month.

Conclusion

The aggressive angiomyxoma has a high potential for invasion and recurrence, and the primary treatment is surgery with negative margin.

TJS. 2018;34(Suppl-1):S470–S471.

PP-0517 [General Surgery Diseases]. Comparison of V-Y Flap Application and Limberg Flap Application in Pilonidal Sinus Patients

Ramazan Sarı ¹, Soner Akbaba ², Mustafa Ömer Yazıcıoğlu ^2,^✉, Rıza Haldun Gündoğdu ²

Objective

Although there are many methods defined in the surgical treatment of pilonidal sinus disease, recurrence rates are still high and the search for ideal treatment is still continuing. In this study, we prospectively followed 100 cases who underwent V-Y flap and Limberg flap techniques and reviewed the results in light of the literature. Our aim is to compare these methods in terms of patient satisfaction, complications, hospitalization durations, recovery period, getting back to work periods and recurrence rates.

Material and Methods

A total of 100 patients who were operated in Ankara Atatürk Training and Research Hospital with the diagnosis of pilonidal sinus between February 2012 and February 2016 were included in the study. The patients were divided randomly into two groups and V-Y flap was applied to 50 patients Limberg flap was applied to 50 patients. The cases were compared statistically in terms of complications developed, recovery times, labor losses, patient satisfaction and recurrence rates of 2 years.

Results

The demographic characteristics, complaints and clinical findings of both groups were similar. Although the rates of postoperative wound infection were close (26%, 28%; p> 0.005), wound dehiscence rates were higher in the Limberg group (26%, 36%; p<0.005). The wound healing process and labor force losses were longer in the Limberg flap group but the results were not statistically significant (p> 0.005). There were no significant differences between the groups in terms of patient satisfaction and recurrence in the 2-year follow-up period (p<0.005).

Discussion

Pilonidal sinus disease, which is usually seen in the sacrococcygeal region, mostly affects the young working population, continues with recurrences and remains as an important cause of morbidity. The aim of surgical treatment of pilonidal sinus disease is to ensure that the patient returns to work at minimum cost and in the shortest possible time. Therefore the complication rate of the procedure, the length of hospital stay and the recurrence should be low. In our study, the mean hospital stay was 2 days in both groups, the most common complications were wound infection and suture dehiscence and no flap necrosis was observed in any patient. In our study, it was found out that the return of the patients who had V-Y flap application was similar to the Limberg group and was shorter than the studies in the literature. It was remarkable that the recurrence rate in the V-Y group (4%) was less than the similar studies.

Conclusion

Long-term results of V-Y flap and Limberg flap techniques are similar. Although there is no statistically significant difference; V-Y flap method seems to be superior in terms of operation time, wound dehiscence and less labor loss. V-Y flap technique which is not very popular in pilonidal sinus surgery should be considered as an alternative. The results suggest that more cases and longer follow-up periods may yield more meaningful results.

TJS. 2018;34(Suppl-1):S471.

PP-0518 [General Surgery Diseases]. Follicular Dendritic Cell Sarcoma in the Spleen: Case Report

Mehmet Sait Özsoy ^1,^✉, Nuray Çolapkulu ¹, Aman Gapbarov ¹, Özgür Ekinci ¹, Salih Tosun ¹, Orhan Alimoğlu ¹

Introduction

Follicular dendritic cells act as antigen presenters in humoral immunity mediated by B lymphocytes. Although follicular dendritic cell sarcomas are rarely seen in cervical lymph nodes, but may rarely show extranodal localization. In this study, we aimed to present a case with follicular dendritic cell sarcoma diagnosis in the spleen.

Case

A 58-year-old male patient with no history of chronic disease presented with abdominal pain and diarrhea complaints for one month. Traube area was evaluated as closed in the physical examination and splenomegaly was detected. White blood cell count was

17.3 x 10 3/L, C-Reactive Protein was 8.28 mg/L, tumor markers were CA 15.3 30.1 U/mL, and CA was 125 45 U/mL. Other laboratory values were within normal limits. Splenic long axis was markedly increased by 168 mm in computed tomography. There was a heterogeneously enhanced bilobed solid lesion in the size of 12x10x14 cm extending from the spleen hilus to the lower pole, and the mass was compressing the left kidney in the inferomedial region. No pathological findings were found in colonoscopy and gastroscopy examinations. As a result of all the examinations, exploration was performed because of primary spleen tumor. It was observed that the mass was not invasive to the surrounding tissues and was well circumscribed with the spleen capsule. Splenectomy was performed with the inclusion of the mass. No additional pathology was found in other organs in the abdomen. Histopathologic examination revealed follicular dendritic cell sarcoma. Spleen capsule was intact and surgical margins were evaluated as negative. Significant cytological atypia and diffuse coagulative necrosis were detected in the mass. Immunohistochemical examination revealed CD (cluster of differentiation) 3, CD 20, CD 117, CD 138 as negative and CD 23 and CD 21 were positive. Ki-67 showed 60% staining in the hottest area. The patient who did not develop complication was discharged with healing in the postoperative period.

Conclusion

Surgery in spleen-derived sarcomas is one of the preferred treatment methods.

TJS. 2018;34(Suppl-1):S471–S472.

PP-0519 [General Surgery Diseases]. Effects of Drain Use on Intraabdominal Abscess, Collection and Drainage in Patients with Acute Appendicitis

Mitat Erdal ^1,^✉, Ertan Emek ¹, Zeki Yılmaz ¹, Osman Bandırmalı ¹

Objective

Surgery should be applied as soon as possible in acute appendicitis which is the most common pathology in patients presenting with acute abdomen. The use of drain after surgery causes a decrease in postoperative complications. The aim of this study was to determine the effect of silicone drainage and rubber drain on postoperative complications.

Material and Methods

Silicone and rubber drains were used in 41 patients with localized peritonitis appendicitis between November 2015 and July 2016 with the approval of the ethics committee of Erciyes University Health Application and Research Center. The patients were evaluated with ultrasonography (USG) on the 3rd postoperative day and 48 hours after the drain was withdrawn. Free fluid, loculation and abscess formation were checked in patients. After the drain was withdrawn, it was checked whether there was occlusion. Data were analyzed with SPSS 21 and evaluated by Chi-square test.

Results

The gender distribution of the patients was 66% male and 34% female. There was no statistically significant difference between the two groups in free fluid and abscess formation in USG controls. When the drains are evaluated for partial or complete occlusion; less occlusion was seen on the silicone drain. (p: 0.018) Clinically, the sequential USG imaging performed in this group had lower rates of loculation than the other group. (P=0.003 in the 1st USG, p=0.048 in 2nd USG) Although there was no statistically significant difference between the drains when the abscess rates were compared (p=0.107 in 1st USG and p=0.232 in 2nd USG) the abscess rate in the group of rubber drain was 33% higher than that of silicone drain.

Conclusion

Although drains are being left as a current approach in abdominal surgeries, silicone drainage is preferred due to low migration and occlusion rate and low localization, results in a decrease in postoperative complications.

TJS. 2018;34(Suppl-1):S472.

PP-0520 [General Surgery Diseases]. Appendiceal Endometriosis

Results

Of 13 patients, 12 were female (92.3%) and one was male (17.7%). The mean age of the patients was 53.07. The perioperative mean peritoneal carcinomatosis index score of the patients was calculated as 20.23. The CC (completeness of cytoreduction) score was 0 in two patients with recurrent ovarian carcinoma, and it was 2 in three patients. CC 0 resection was performed in two patients with peritoneal carcinoma and CC 1 resection was performed in 2 patients. The CC score was 1 in 3 patients with colon-derived tumors. The patient with the Krukenberg tumor had a CC score of two. All patients except the patient with the Krukenberg tumor responded well to the treatment. Two patients had a wound site problem as morbidity (15%) and one patient developed gastric and colon perforation (7.7%). Mean survival was 510 days in recurrent ovarian serous carcinoma, 415 days in peritoneal-derived carcinoma, 283 days in colon adenocarcinoma, and 153 days in gastric carcinoma. One of the patients who was operated due to ovarian recurrent serous adenocarcinoma died on the postoperative 50th day due to adjuvant treatment cytotoxicity and one patient died due to recurrence on the postoperative 630th day. The patient with the Krukenberg tumor died on the 153th postoperative day during palliative care.

Conclusion

In our early outcomes, we observed that full response to maximum cytoreduction performed with aggressive surgery can be achieved with acceptable morbidity rates and that the survival time of these patients can be improved by the use of appropriate drugs in appropriate time and conditions in the form of HIPEC for the treatment of ovarian, peritoneal, and colorectal PC cases. We think that large, randomized, controlled and long term follow-up studies should be performed in order to develop this technique. We believe that this may be done by raising our colleagues’ awareness of this approach and by the patients’ referral to experienced centers.

TJS. 2018;34(Suppl-1):S474.

PP-0524 [General Surgery Diseases]. Multiple Focal Necrosis in the Spleen: Brucellosis

Kevser Uzunoğlu ^1,^✉, Marlen Süleyman ¹, Yusuf Murat Bağ ¹, Aziz Mutlu Barlas ¹, Muzaffer Çaydere ², Serap Erel ¹

Introduction

Brucellosis is a common zoonotic infection and around 500,000 cases are reported worldwide annually. Although seen all over the world it is more common in Middle East, Mediterranean and Arabian Peninsula countries. It is more common in individuals dealing with livestock and using non-pasteurized dairy products. Brucellosis can involve any organ as a systemic infection and it may be asymptomatic or mortal. B. melitensis, B. abortus, B. suis, B. canis and B. ceti are known as pathogenic strains in humans. Brucellosis is a very rare etiologic cause for the diagnosis of the splenic necrosis and abscess can be diagnosed with imaging methods. In our case, we present a patient who had necrosis in the spleen due to brucellosis in the spleen.

Case

81 years old female patient was admitted to the emergency service with fatigue, abdominal pain and high fever. She had no known systemic disease and it was learned that she lived in a rural area and her family was engaged in animal husbandry. Her physical examination revealed tachypnea, tachycardia and diffuse tenderness across her abdomen, which was more apparent in the left upper quadrant. Complete blood count revealed thrombocytopenia, lymphopenia and mild monocytosis. Biochemical parameters were normal. The long axis of the spleen was measured 19 cm (splenomegaly) in the ultrasonographic examination. Parenchymal heterogeneity of the 8 cm nodular area was recorded in the upper pole of the spleen in CT. The long axis of the spleen is 19 cm (splenomegaly). There was a hypodense lesion according to parenchyma, holding wide space in superior half with a size of 11x8 cm on the widest spot and irregular border and evaluated in favor of infarct?. In all intraperitoneal recessions, free fluid measured 9 cm in the pelvis at the deepest part was noted. In the follow-up period, abdominal pain did not regress and fever did not decrease and elective splenectomy was performed with the diagnosis of spleen infarct. The number of leukocytes in the postoperative 1st day was increased to 45000x10 ^ 9/μL. The cause of leukocytosis was investigated by the infectious disease department and no significant infection focus was found. The number of leukocytes decreased to 16 x 10 ^ 9/μL on the 10th postoperative day. During this period, her fever continued to be measured up to 38°C 1 to 2 times a day. Pathology result was reported as acute inflammation and splenic tissue in which multiple necrosis areas were observed (Picture 3). Brucella (Rose Bengal) Agglutination Test, Brucella (Coombs) Agglutination Test, and Brucella Tube Agglutination test were positive. Doxycycline 2x100 mg and Rifampicin 1x600 mg tablet for brucellosis were added to the treatment. The patient’s general condition was improved and the patient was discharged after an infection clinic control was recommended.

Conclusion

Brucellosis is an endemic disease in Turkey. It is a multisystemic disease, spleen abscess, infarction and necrosis are rare complications. The clinical presentation of spleen infarction is non-specific, with left hypochondrial pain, fever, nausea and vomiting. Computed tomography is the best examination showing spleen infarct. Abscess foci in the spleen in acute period are seen as multiple hypoechoic nodules in USG. While conservative treatment with combination of Rifampicin, Doxycycline, Streptomycin and Ciprofloxacin is sufficient in the early stages of splenic abscess, splenectomy is necessary when large spleen abscess, diffuse necrosis develops as in our case.

TJS. 2018;34(Suppl-1):S475.

PP-0525 [General Surgery Diseases]. Venous Port Experience of our Department of General Surgery

Ekrem Ferlengez ¹, Gamze Çıtlak ¹, Fazilet Erözgen ¹, Sercan Yüksel ¹, Mahmut Said Değerli ^1,^✉

Objective

Venous catheters used for chemotherapy, total parenteral nutrition and fluid therapy have been used for a long time in patients receiving oncologic therapy. Complications such as pneumothorax, perforation, infection and thrombosis may be seen despite benefits. In this respect, our aim is to compare and share our experience with the literature.

Material and Methods

75 patients in whom permanent venous catheters were inserted at the Health Sciences University Haseki Training and Research Hospital Department of General Surgery were evaluated retrospectively with clinical and demographic data.

Results

Port for chemotherapy was placed in a total of 75 patients. The mean age of the patients was 58.2 years, and 62% of them were female and 38% of them were female. Pneumothorax occurred in 3 patients as a complication. One patient died due to major vascular injury, 1 patient developed malposition and1 patient had skin necrosis.

Conclusion

Although permanent venous catheter for chemotherapy can be used safely in experienced hands and a comfortable method for the patient, unexpected results can be rarely encountered.

TJS. 2018;34(Suppl-1):S475.

PP-0526 [General Surgery Diseases]. Retrocaval Ganglioneuroma: A Case Report

Fatih Dolu ^1,^✉, Mehmet Esat Duymuş ¹, Erkan Hazar ¹, Anıl Koçman ¹, Kürşat Karadayı ¹

Introduction

Ganglioneuromas are benign and rare tumors with slow course originating from sympathetic nerve ganglion cells. These tumors originating from paravertebral sympathetic ganglia are most commonly seen in mediastinum, retroperitoneum and adrenal glands and usually in the ages of 10–20. It presents with abdomen and/or back pain or compression symptoms in asymptomatic cases. However, the vast majority of cases are asymptomatic and therefore may not be detected until they reach large dimensions. Although they may secrete hormones clinically, those who are retroperitoneal are generally inactive.

We aimed to present a patient with retroperitoneal ganglioneuroma in the liver posteromedial hilar region.

Case

It was learned from the anamnesis of a 55-year-old male patient that he had a 2-month history of back and right upper quadrant pain and abdominal ultrasonography revealed a mass in the caudate lobe of the liver and thus was referred to our clinic. There was no feature in the patient’s medical history. Physical examination revealed minimal tenderness in the right upper quadrant. Laboratory tests and tumor markers were within normal limits. Abdominal computed tomography (CT) revealed no abnormal findings except calcified mass compressing the vena cava inferior at a size of 6x3x6 cm in the retrocaval area of the liver with liver hilar location. Total mass excision was performed in the patient. She was discharged on the 3rd postoperative day without any problem. The pathology result was reported as ganglioneuroma. The patient is still under follow-up in the first year.

Conclusion

Ganglioneuromas are very rare tumors. They may be confused with other neural origin tumors (paraganglioma, schwannoma), lymphadenopathies, or other malignant tumors. They are locally grown. They do not carry hematogenous or lymphatic metastases. Total excision is the ideal treatment.

TJS. 2018;34(Suppl-1):S475–S476.

PP-0527 [General Surgery Diseases]. Experience of Single Center Splenectomy Between 2007 and 2017

Özhan Albayrak ^1,^✉, Cihad Tatar ¹, Ali Emre Naycı ¹, Mehmet Baki Doğan ¹, Osman Yokuş ², Hilmi Doğu ², Oğuzkağan Batıkan ¹, Mehmet Yazıcı ¹, Feyzullah Ersöz ¹, Soykan Arıkan ¹

Objective

The spleen is an organ that has important functions especially in the hematological and immune system. Splenectomy is a type of operation performed in many diagnostic and therapeutic diseases. In this study, we aimed to present our cases of traumatic and non-iatrogenic splenectomy.

Material and Methods

The data of 135 patients who underwent splenectomy at İstanbul Training and Research Hospital between 2007 and 2017 were retrospectively analyzed. Demographic characteristics, indications of operation, length of hospital stay, postoperative pathologic diagnoses and complications were evaluated.

Results

The mean age of the patients was 44.9 years, 95 (70.3%) of the patients were female and 40 (29.7%) were male. 103 (76.2%) patients underwent open surgery and 29 (21.4%) patients underwent laparoscopic splenectomy. In 3 patients, the surgery starting laparoscopically was terminated with open surgery. While ITP was the most common cause of operation with 68 (50.3%) people, hypersplenism was the second most common indication for splenectomy and hemolytic anemia was the third. The mean postoperative hospital stay was measured as 6.09 days. This time was 6.57 days in open surgery and it was 4.86 days in laparoscopic operations. Complications were observed in the postoperative period in 24 (18.5%) patients. Among these, the most common complication was pulmonary complication (n: 7, 5.7%) and then wound infection (n: 4, 2.9%), whereas arterial thrombosis (n: 3, 2.2%) was found to have more frequent complication rate than expected. The complication rate in laparoscopic surgeries was 10.2% and the complication rate was 21.3% in open surgeries. The rate of complication was found to be 37.9% in patients over 60 years of age, whereas this rate was found to be 17.2% in patients under 60 years of age and a significant difference was observed (p: 0.0466).

Conclusion

The indications and operation methods of splenectomy are changing over the years. Laparoscopic approach, a more noninvasive procedure in splenectomy, has been increasing in recent years as in all areas of the surgery. When the complications are examined, the most striking point is the increased tendency towards arterial occlusion.

TJS. 2018;34(Suppl-1):S476.

PP-0528 [General Surgery Diseases]. Sleeve Gastrectomy and Incidental Gastrointestinal Stromal Tumors

Savaş Yakan ^1,^✉, Ahmet Mücteba Öztürk ¹, Burak Dede ¹, Mehmet Yıldırım ¹

Introduction

The popularity of bariatric surgery has increased in recent years with increasing obesity in our society. The development of minimally invasive technology and an increasing number of laparoscopic bariatric procedures have resulted in unsuspected unexpected pathologies prior to surgery. The incidence of incidental pathology during laparoscopic bariatric surgery is around 2%, and gastric gastrointestinal stromal tumors (GIST) have been found in 0.8% of cases. In this study, we aimed to present our cases of gastrointestinal stromal tumors which were detected incidentally after sleeve gastrectomy.

Case

301 patients underwent sleeve gastrectomy due to morbid obesity at Health Sciences University Izmir Bozyaka Health Application and Research Center between 2015 and 2018. Endoscopic examination was performed in all cases preoperatively and no pathology was detected. Gastrointestinal stromal tumor was detected in the pathological examination of postoperative gastrectomy specimens in 3 (1%) cases. Two of these patients were male and one of them was female and the mean age of the cases was 48 (38–56). The mean body mass index of the cases was 45.66 (44.1–47.8). The tumor size was 0.5, 0.6 and 0.7 cm in the pathological examination performed. They were included to the category of no risk in terms of progressive disease risk according to Miettinen Lasota classification pathologically due to mitosis below 50 BBA 5, the size being below 2 cm and gastric location in 3 cases. Follow-up was recommended to the patients evaluated in the Oncology Council and they have been followed for18.3 months (2–56) without any problem.

Conclusion

Pathological examination of the specimen after sleeve gastrectomy is important. Incidentally detected cases of gastrointestinal stromal tumors should be evaluated in a multidisciplinary approach in oncology councils and should be followed in terms of future pathologies.

TJS. 2018;34(Suppl-1):S476–S477.

PP-0529 [General Surgery Diseases]. Isolated Liver Cyst Hydatid Rupture after Blunt Trauma and Anaphylactic Shock

Murat Bayram ^1,^✉, Burak Dede ¹, Ahmet Deniz Uçar ¹, Savaş Yakan ¹, Mehmet Yıldırım ¹

Introduction

Cyst hydatid is a public health problem that is endemic in many countries of the world. There are many complications of liver hydatid cyst. In this study, we aimed to present our case who presented with isolated hydatid rupture after blunt trauma and anaphylactic shock.

Case

A 17-year-old male patient was referred to our emergency service because of a out of the vehicle traffic accident. The general condition of the patient was moderate, he had open consciousness and open cooperation and limited orientation. His values were as such: blood pressure: 80/50 pulse: 120/min and he was filiformic. The patient had diffuse tenderness and defense in the abdomen in the physical examination. The laboratory findings were WBC: 23000 HB: 12,5 AST: 281 ALT. Abdominal CT revealed fluid around the liver, hemorrhagic fluid in the liver and there was diffuse free fluid in the abdomen. Hypovolemic shock was considered and the patient was taken into emergency operation. In intraoperative exploration, there was serohemorrhagic fluid, daughter vesicles and pericyst membrane in the abdomen. The giant cyst hydatid lesion, which filled the whole liver segment 5–8, was probably perforated into the abdomen secondary to trauma. There was no pathology in other solid and luminal organs in the exploration. The operation was terminated by washing the abdomen with 3% NACL. The patient was discharged from the hospital on postoperative 5th day postoperatively.

Conclusion

Isolated liver cyst hydatid rupture and anaphylactic shock following blunt trauma is a rare complication of hydatid cyst. Cyst hydatid rupture after trauma should be taken into consideration in emergency surgical practice in regions where cyst hydatid is seen endemic as in our country.

TJS. 2018;34(Suppl-1):S477.

PP-0530 [General Surgery Diseases]. Forgotten Foreign Body in Incision Scar: Surgical Suture Material Container

Şahin Kahramanca ^1,^✉, Turgut Anuk ², Ali Cihat Yıldırım ¹

Objective

Cases in whom some complications occur after years due to some forgotten foreign bodies (sponge, surgical instrument, pet, etc.) have been reported in the literature. Complications due to forgotten foreign bodies have not been reported from centers that usually perform the operation due to medico-legal problems. Therefore, there is no clear information on the frequency of detection. In our case, we will present a case with a forgotten surgical suture material container, which is associated with appendectomy performed in Afghanistan and which is thought to be for drainage under the skin, was detected and taken under local anesthesia.

Case

It was learned from the history of a 21-year-old Afghan female patient who presented to the general surgery outpatient clinic with a complaint of painful swelling and metal-like, hard foreign body appearance on the upper part of the appendectomy surgery incision that she underwent appendectomy because of appendicitis in Afghanistan 6 months ago and she had a hardness in the incision line from that date. In the examination of the patient at the outpatient clinic, a metallic-colored appearance extending from the superior starting point of the incision line for the last 15 days, approximately 5–6 cm long and 2–4 mm thick, just below the scar, appearing 2–3 mm long hard object was detected in the area where presence of foreign body was described. When the object was intended to be moved, it was seen to be adherent to the tissue and the patient felt pain. It was planned to be removed by local anesthesia. The body was removed from the visible part of the body by applying the local anesthetic agent along the incision line. It was observed that the object was a vicryl suture material container folded with a width of 1 cm. However, the purpose of placement of the body could not be understood and it was thought to be due to drainage and no information could be obtained whether the object was forgotten or not.

Conclusion

Although there are no extensive literature data due to medicolegal problems after surgical operations, forgetting foreign body and some complications related to it develop. In order to prevent possible complications, more attention should be paid to the material counts and the removal of drains and sutures after surgery.

TJS. 2018;34(Suppl-1):S477–S478.

PP-0531 [General Surgery Diseases]. Abdominal Cocoon- Sclerozing Encapsulated Peritonitis (SEP)

Zümrüd Aliyeva ^1,^✉, Alpen Yahya Gümüşoğlu ¹, Hamit Ahmet Kabuli ¹, Kıvanç Derya Peker ¹, Nuri Alper Şahbaz ¹, Mehmet Emin Güneş ¹

Objective

Sclerosing encapsulated peritonitis (abdominal cocoon) is rarely seen. Although different etiologic factors are defined for this disease, some patients may be idiopathic. Preoperative diagnosis is difficult to establish with the current diagnosis methods and most of the cases can be diagnosed during surgery. We aimed to present our case with sclerosing encapsulated peritonitis which is one of the rare causes of mechanical intestinal obstruction.

Case

A 50-year-old male patient was admitted to the emergency service with a two-day abdominal pain. It was learned that he had a history of intermittent constipation, vomiting and weight loss. Physical examination revealed distended minimal tenderness with palpation in the abdomen. The patient was taken into operation because of suspicion of internal herniation in abdominal computed tomography. It was observed that the peritoneal layer was thickened and formed gato wrapping around the small intestine. The peritoneal layer was excised and the intestinal adhesions were removed. No necrosis and perforation were observed. Although the patient had defecation on the second postoperative day, intermittent abdominal pain and impairment of oral tolerability were observed. The patient was given oral and parenteral nutrition support and corticosteroid treatment was started. The patient was discharged on the 35th postoperative day. Pathology revealed nonspecific chronic inflammation, sclerotic changes in collagen, and fibrosis-walled tissue containing dystrophic calcification areas. No feature was observed in the immunological and infectious examinations requested in order to investigate the etiological factors.

Discussion

Tayfun Bisgin ^1,^✉, Aras Emre Canda ¹, Selman Sökmen ¹

Objective

Fecal incontinence is a serious physical and psychological condition affecting the patient’s quality of life. Sacral neuromodulation has emerged as a treatment option for fecal incontinence. In this study, we aimed to share our experience of sacral neuromodulation in fecal incontinence.

Material and Methods

Prospective accumulated data of six patients who underwent sacral neuromodulation due to fecal incontinence since August 2017 were retrospectively analyzed. Fecal incontinence score, fecal incontinence and quality of life scoring system, anorectal manometry and incontinence diary data were routinely evaluated in the pre-and post-treatment evaluation period.

Results

Six patients underwent sacral neuromodulation with the diagnosis of fecal incontinence. Four patients were female and 2 of them were male. The mean age of the patients was 53.5 (range: 32 to 68) years. The transient catheter was removed due to infection during the test period and the remaining 5 patients were implanted with a permanent sacral neuromodulation implant. All patients were using underpad for neuromodulation because of incontinence. Only one patient needed to use an underpad after neuromodulation. Three patients had no complaints of incontinence after the procedure, there was a decrease of incontinence complaint in one patient at a rate of 80% in one patient and at a rate of 60% in other patient. Fecal incontinence score and quality of life scores improved in all patients.

Conclusion

Sacral neuromodulation may be an effective and safe treatment option in selected patients with fecal incontinence.

TJS. 2018;34(Suppl-1):S481.

PP-0537 [General Surgery Diseases]. A Rare Spleen Lesion: Sclerosing Angiomatoid Nodular Transformation

Mehmet Uluşahin ^1,^✉, Coşkun Aydın ², Muhammed Selim Bodur ¹, Hakan Küçükaslan ¹, Adnan Çalık ¹

Introduction

Sclerosing angiomatoid nodular transformation (SANT) is one of the rare vascular lesions of the spleen. In this study, we present a patient who was referred to us for operation due to mass in the spleen by hematology and whose pathology was reported as SANT.

Case

A 51-year-old female patient was referred to our hospital’s gastoenterology and hematology outpatient clinics with splenomegaly and splenic mass in the upper pole of spleen after abdominal ultrasound (USG). The patient did not have any complaint except intermittent mild abdominal pain. It was learned that the patient without a history of drug use and additional disease, underwent appendectomy operation 10 years ago. No pathological findings were detected in physical examination. Abdominal computed tomography (CT) was performed in the patient who did not have any pathology in the laboratory values and the mass with a size of 87x84 mm which was thought to be due to lymphoma was reported in splenic upper pole. Peripheral smear and bone marrow biopsy performed by hematology did not reveal any pathological findings. The patient to whom surgery was recommended was referred to our department. The surgery was performed after necessary preoperative preparation. A mass of 8 cm in the left subcostal incision in the upper pole of the spleen was observed and splenectomy was performed. The patient who had no problem except for atelectasis in the postoperative period was discharged on the 4th postoperative day. As a result of the pathology, a well circumscribed solid lesion with a size of 8x8x3 cm including yellow gray sclerotic areas was observed in the spleen with a size of 16x14x8 cm in the macroscopic examination. Microscopic examination of the lesion showed multinodular appearance and the vascular structures and fusiform cells at the centers of the nodules. CD 34, CD 31 and CD 8 were found to be positive. No problems were encountered in the follow-up of the patient.

Conclusion

SANT is one of the rare vascular lesions of the spleen. It is a benign lesion and it is caused by red pulp. It is more common in middle age and women. The etiology has not been clearly elucidated. It is usually asymptomatic and large ones may cause abdominal pain. Sometimes it may cause thrombocytopenia and anemia picture. The diagnosis is mostly incidental. It is known that this lesion, whose incidence has increase with the development of imaging techniques, was gained to the literature in 2004. Abdominal USG and CT are successful in the pre-diagnosis and the abdomen may show hypodense and multinodular appearance on CT. The definitive diagnosis can usually be made by postoperative pathological examination. Needle biopsies are not recommended because they can lead to intraabdominal seeding in potentially malign pathological conditions. Benign lesions such as hemangioma, hamartoma, hemangioendothelioma and malignant lesions such as angiosarcoma are present in the differential diagnosis of SANT. Splenectomy is recommended in the treatment of benign lesions, because of malignancy exclusion and the risk of rupture in large ones. The prognosis is good and recurrence has not been reported in the literature.

TJS. 2018;34(Suppl-1):S481–S482.

PP-0539 [General Surgery Diseases]. Unicentric Retroperitoneal Mass: Castleman’s Disease

Feyyaz Güngör ^1,^✉, Erdinç Kamer ¹, Ahmet Er ¹, Ahmet Atasever ¹, Mustafa Peşkersoy ¹

Introduction

Castleman’s disease (CH) is a rare disease characterized by benign lymph node hyperplasia. Unicentric Castleman’s disease (UCH) has a survival rate of 95.3% and is usually asymptomatic. In this report, we present a 36-year-old male patient who presented with dyspepsia and was diagnosed as UCH incidentally.

Case

A 36-year-old male patient was admitted to the external center with the complaint of indigestion after meals for 4–5 months and a mass was detected in the left pararenal area in the abdominal ultrasonography (USG) and the patient was referred to us for advanced examination and treatment. There was no comorbid disease except for hypertension and coronary artery disease in his history. His family history was without any feature. Physical examination revealed no pathological findings except minimal sensitivity in the left colic region. There was no pathological findings in his laboratory values. Intravenous opaque thoracoabdominal computed tomography (CT) revealed a mass lesion of 54x33 mm in retrocaval located at the left renal hilus level compressing the vena cava (VC) with internal structure of homogenous solid density, evaluated primarily in favor of retrocaval lymphanopathy due to location. Biopsy could not be obtained for tissue diagnosis due to localization of the mass and the operation decision was made. In the exploration, the mass was seen to invade the left renal vein in the left renal hilus behind VC. The patient underwent a partial resection due to cytology of the lymphoid tissue during the frozen examination performed preoperatively. There was no other pathology in abdomen in the exploration. The patient was discharged on postoperative 2nd day without any complication. The histopathological diagnosis of the patient was reported as hyaline vascular type Castleman’s disease. There was no change in the size of the mass in CT performed in the postoperative 1st year and no other focus was detected.

Conclusion

Castleman’s disease is one of the rare causes of lymphadenopathy. It was described as a chronic nonspecific inflammatory formation in terms of histological pattern when it was first defined by Castleman in 1956. The etiology of the disease has been focused on viral stimulation and human immunodeficiency virus and human herpes virus-8 were accused due to histopathological appearances involving lymph node features associated with systemic symptoms such as fever and lymphadenopathy in patients over time and chronic viral infections. UCH is more benign than multicentric CH and divided into two histological types. Hyaline vascular type compression symptoms in 90% of the cases can be seen, but they are usually asymptomatic and are incidentally detected. Plasma cell type is seen in 10% of cases and this type is detected more mesentery and retroperitoneal. Although there is no randomized trial, complete removal of the mass is sufficient in the treatment of UCH and it is the gold standard method. It has also been reported that the removal of the mass partly is beneficial in cases where surgical excision is not possible. Recurrence is very rare and is usually associated with incomplete resection or neglected lymph nodes in the first operation. Systemic symptoms and laboratory abnormalities, if any, are eliminated by total resection. In conclusion, although UCH is a rare condition, it should always be kept in mind in the differential diagnosis of retroperitoneal masses.

TJS. 2018;34(Suppl-1):S482–S483.

PP-0540 [General Surgery Diseases]. Relationship between Body Mass Index and Irritable Bowel Syndrome Subtype According to Rome 4 Criteria

Çağrı Akalın ^1,^✉

Objective

Irritable bowel syndrome (IBS) is a common disease in the community and deteriorates the quality of life. The patients with irritable bowel syndrome was examined retrospectively and their data were analyzed to investigate the relationship between body mass index and IBS subtypes of the patients.

Material and Methods

452 patients were admitted to Ordu University Training and Research Hospital Department of General Surgery and were diagnosed with irritable bowel syndrome according to Rome 4 criteria. The subtypes of irritable bowel (with constipation, with diarrhea, complex and unclassified) of the patients and the patients with body mass indexes of<20 kg/m2, 20–25 kg/m2, 25–30 kg/m2, 30–35 kg/m2 and>35 kg/m2 were analyzed retrospectively.

Results

Body mass index values of 452 patients with irritable bowel syndrome were detected as<20 kg/m2 in 16 patients (3.5%), 20–25 kg/m2 in 92 patients (20.3%), 25–30 kg/m2 in 134 patients (29.6%), 30–35 kg/m2 in 161 patients (35.6%) and>35 kg/m2 in 49 (10.8%) patients. Of these 452 patients, 78 (17.2%) patients were diarrhea-weighted, 214 (47.3%) patients were constipation-weighted, 124 patients were mixed weight (27.4%) and 35 (7%) patients were classified as unclassified according to Rome 4 criteria. In the study, no statistically significant difference was found between irritable bowel syndrome subtypes of patients classified according to body mass index (p>0.05).

Introduction

The lesions that are forgotten in the surgical operations and which develop due to the non-absorbable materials, with the image of mass are called gossypiboma. In this study, it was aimed to present a case of gossypiboma presenting with abdominal pain and considered as hemorrhagic mesenteric cyst as a result of imaging.

Case

A 54-year-old female patient was admitted to our outpatient clinic with complaints of abdominal pain for 2–3 months. The patient’s pain was not very severe and she had no complaints other than pain. It was learned from her history that she was under follow-up due to thyroid nodule, and she underwent open cholecystectomy due to gallbladder stone 6 months ago and she had no history of drug use. The patient’s vitals were stable. No abnormality could be detected in the physical examination. Laboratory values were within normal limits. Abdominal ultrasonography (USG) was performed and a cyst was reported to extend to the pelvis in USG. Abdominal computed tomography (CT) was performed in the patient and a well circumscribed cystic lesion 156x92x75 mm in size, on the right of the midline, extending to the pelvis, with a thin wall and hyperdense areas thought to belong to the hemorrhagic mesenteric cyst in the foreground was reported. Operation was recommended to the patient. A laparotomy with a midline incision revealed a cystic flat contoured mass extending from below the liver to the pelvis. When the purulent content was seen in the puncture performed in the cyst, precaution with 20% NaCl impregnated compressions were taken for the possible cyst hydatid and the cyst wall was opened and the purulent material was aspirated. A mass formation consisting of several sponges considered to be forgotten in the old operation was seen and after the sponges were taken out, the abdomen was washed and the operation was terminated by inserting a drain. There was no problem in the postoperative period and oral intake of the patient was opened on the 2nd day and she was discharged on the 4th day.

Conclusion

Gossypiboma is a condition usually encountered after sponge or buffer-like materials are forgotten inside. It can cause many problems of medical and legal problems. As patients with no symptoms may be encountered, there may be patients presenting with symptoms such as nonspesific abdominal pain, fever, nausea and vomiting in the early or late period. While some of the patients had encapsulation and granulation as in the patient presented in the study, abscess formation may be encountered in other patients. Imaging methods are partially helpful in the diagnosis. Radiological diagnosis can be much more difficult, as is the case in a group presented with encapsulation and granulation; it may be confused with other intraabdominal pathologies. Fistulization of intraabdominal organs, perforation and ileus can be seen in these patients. As a result, gossypiboma is a rare condition, although there are radiologic signs that are helpful in diagnosis, there is no pathognomonic image and may be confused with other abdominal pathologies. It is important to question the history of the operation and to keep in mind the possibility of gossypiboma in patients with a history of operation.

TJS. 2018;34(Suppl-1):S485.

PP-0545 [General Surgery Diseases]. Evaluation of 63 Patients who were Operated with Karydakis Method between 2014 and 2017

Halis Bağ ^1,^✉, Haldun Kar ¹, Feyyaz Güngör ¹, Yasin Peker ¹

Pilonidal sinus is usually seen in young men. It is frequently observed in the sacrococcygeal region. Many various factors such as male gender, anatomical structure and hair among its causes are mentioned. Surgical treatment is common. Phenol treatment is another option. Surgical treatment is to leave the wound open or close after cyst excision. The closure options include primary closure, midline sliding closure (such as Karydakis and Bascom) and full-thickness skin flap closure (such as Limberg, Z plasty). Sixty three patients were operated with Karydakis method with the diagnosis of pilonidal sinus between 2014 and 2017. Six patients had recurrence (1 female, 5 male). 57 patients were male and 6 were female. The age range was 15–60 years. The duration of surgery was between 23–68 minutes. The mean hospital stay was 2 days. 6 patients underwent hemova drainage. Infection developed in 2 patients. They recovered with antibiotic therapy. Three of 6 recurrent patients (1 female, 2 male) had recurrence again in the first month. These patients were re-operated with open technique. Postoperative follow-up period of all patients was 6 months. No recurrence was observed in other patients during this period. Karydakis method is an ideal method in pilonidal sinus surgery in terms of ease of learning and application. It has a lower recurrence rate than primary closure. The duration of surgery and hospital stay is shorter than the full thickness skin flap. In addition, patient satisfaction is high in terms of postoperative scar.

TJS. 2018;34(Suppl-1):S486.

PP-0546 [General Surgery Diseases]. Comparison of Preoperative Anxiety Levels of Emergency and Elective Surgery Patients

Sinem Seyrek ^1,^✉, Elif Alagöz Delibaş ¹, Gülnur Ateş ¹, Orhan Alimoğlu ¹, Aynur Görmez ², Serhat Çıtak ²

Objective

The conditions such as diagnosis, risk of the surgery, prejudices of the patients and preparation for the surgery will affect the preoperative level of anxiety. The aim of this study is to compare the preoperative anxiety levels of general surgery patients who will undergo emergency and elective surgery.

Material and Methods

The study was carried out with 100 general surgery patients (50 emergency, 50 elective). The State Anxiety Scale (SAS) and the Surgery Specific Anxiety Scale (SSAS) were applied to both groups to determine the preoperative state of anxiety.

Results

SAS and SSAS scores of the patients who would undergo elective surgery were significantly lower than the patients who would undergo emergency operation (P<0.05). None of the patients included in the study were in the “No Anxiety” state. “Severe Anxiety” and “Moderate Anxiety” were found to be significantly higher in the patient group who would undergo emergency surgery (p<0.05). Only “moderate anxiety” was detected in patients who would undergo elective surgery. The difference between anxiety levels was statistically significant (p<0.05).

Conclusion

As a result of this study, the anxiety level of the patients to be operated urgently is higher than that of the patients who are planned to be operated electively. It is predicted that the patients’ pre-operative anxiety status depends on the preparation process for the operation, and can be significantly reduced with an effective pre-operative training and preparation process.

TJS. 2018;34(Suppl-1):S486–S487.

Prostate cancer is the second most common malignancy in males in the Western world, and is the second leading cause of cancer-related deaths among men worldwide. Metastatic examination is necessary for a small number of patients with high risk prostate cancer for excluding metastases except bone metastases because few of the patients with advanced disease undergo atypical metastasis. Retroperitoneal involvement is a rare manifestation of prostate cancer, and an increased level of nodal metastases is due to lymphatic spread.

TJS. 2018;34(Suppl-1):S488.

PP-0550 [General Surgery Diseases]. ASK2ME.ORG: A Review on a Web Based Online Genetic Risk Calculator for Different Cancer Types

Kinyas Kartal ^1,^✉, Danielle Braun ⁴, Jiabei Yang ⁴, Molly Griffin ³, Cathy Wang ⁴, Giovanni Parmigiani ⁴, Kevin S Hughes ²

The aim of this study is to present a web-based online calculator for different types of cancer and also a compilation of “www.ask2me.org”, which provides physicians with clinical support in the light of current literature. Twenty six or more cancer-associated genes have become to be routinely tested with the introduction of the Next Generation Sequencing method into clinical use. However, it is a fact that many of the physicians have a lack of knowledge and experience about these genes and test results. ASK2ME calculates the possible risks for many types of cancers such as breast cancer, colon cancer and pancreatic cancer following genetic testing and presents available literature information to the physicians in managing the follow-up plans of patients with mutant genes. To ensure this, it is sufficient to specify the patient’s demographic characteristics (age and gender), the mutated gene and the type of cancer present in the patient’s history, if any, and the type of conservative surgery in the on line calculator. ASK2ME calculates the cancer risks for patients by statistical calculations and comparing them with the non-mutant individuals and visualizes them by means of graphs. It uses reliable sources in the literature about the gene that is present and constantly updated when making these statistics. It specifies the literature information used in the calculations presented and the reliability index of this information as a reference. In addition, ASK2ME provides clinical support to physicians by presenting the relevant sections of international guidelines published by NCCN, ESMO, Graffeo et al. and Tung et al.

TJS. 2018;34(Suppl-1):S488–S489.

PP-0551 [General Surgery Diseases]. The Effects of Hypothermic (21 ° C) and Isothermic (37 ° C) Peritoneal Lavage on Lung Damage in Intestinal Ischemia and Reperfusion Model

Gökhan Avşar ¹, Bekir Sarıcık ^2,^✉, Ömer Rıdvan Tarhan ²

Objective

Injury after intestinal ischemia reperfusion is not mostly confined to the organ that develops ischemia. It can cause damage to many distant organs, especially the lung with the activated inflammatory system and mediator effect. Currently, studies are underway to prevent the etiopathogenesis and prevention of this lung injury. The effects of cytokines and polymorphonuclear leukocytes in the development of lung injury are known in intestinal ischemia reperfusion. However, there are not enough studies investigating the effects of the temperature of the intraabdominal peritoneal lavage on this damage. Therefore, we investigated the effects of hypothermic (21° C) and isothermal (37 ° C) peritoneal lavage on lung injury by creating an intestinal ischemia reperfusion model.

Material and Methods

Seventy two adult male Wistar-Albino type rats were used in our study. Twelve rats were used in the Sham group and 20 rats were used in the other 3 experimental groups. Sham group underwent only laparotomy after anesthesia. Intestinal ischemia and reperfusion were performed for 60 minutes in the control group. Peritoneal lavage was applied to the hypothermic (21° C) and isothermal (37 ° C) lavage groups for 5 minutes at the beginning of reperfusion in addition to the control group. Lung injury was evaluated histopathologically in lung samples taken after reperfusion. TNF-α, IL-6 and IL-10 values in the blood were measured.

Conclusion

Peritoneal lavage applied during intestinal ischemia reperfusion was found to decrease lung injury and decrease IL-6 and TNF-α levels (control, cold and hot peritoneal lavage, p= 0.011, p<0.001, respectively) in blood. Histopathologically, hot lavage is more effective than cold lavage (p= 0.046). As a result, performing peritoneal lavage by heating (isothermic, 37 ° C) in patients with risk of developing intestinal ischemia reperfusion injury (eg, shock) has been shown to have protective effects on lung injury.

TJS. 2018;34(Suppl-1):S489.

PP-0552 [General Surgery Diseases]. Extragenital Endometriosis: A Tertiary Hospital Experience with Current Literature

Cengiz Tavusbay ^1,^✉, Serkan Karaisli ¹, Emine Gür ¹, Haldun Kar ¹, Erdinç Kamer ¹, Kemal Atahan ¹, Neşe Ekici ², Mehmet Hacıyanlı ¹

Endometriosis is the location of functional endometrial gland and stromal tissue outside the uterus. These foci, which respond to the hormonal stimulation of the ovaries, are most commonly localized in the incision scar and pelvic region, especially after caesarean section, but also in various organs and tissues other than the pelvis (eye, abdominal wall, kidney, gastrointestinal system, central nervous system, bone, etc.). Sometimes secondary changes such as carcinoma development may be seen. The aim of this study was to discuss the clinical and pathological dataand therapies applied in patients with extragenital endometriosis in our center which is one of the largest tertiary hospitals in our region between January 2006 and January 2018 in the light of the current literature.

TJS. 2018;34(Suppl-1):S489–S490.

PP-0553 [General Surgery Diseases]. Alternative Therapy of Recurrent Pilonidal Sinus Disease: Phenol Sclerotherapy

Gülden Ballı ^1,^✉, Melek Bekler Gökova ¹, Atahan Acar ¹, Murat Kemal Atahan ¹, Ercüment Tarcan ¹

Objective

Pilonidal sinus disease is often seen in the sacrococcygeal region and discussions about the etiology and optimal management of the disease are still ongoing. Although it was accepted that the first choice treatment was surgery, the elite method could not be decided. In addition to surgical methods such as excision, excision and primary closure, excision and marsupialization, excision and flap methods, conservative methods such as depilation, cavity cauterization and phenol treatment are also used. In the light of literature, we aimed to evaluate the effectiveness of intracavitary phenol treatment as a less painful, no hospitalization necessitating, providing fast return to work with low complication and recurrence rate, low cost and good aesthetic results.

Material and Methods

For this purpose, 43 patients, who were treated due to recurrence, among 255 patients who was admitted to the outpatient clinic with the complaint of pilonidal sinus and underwent phenol treatment between June 2014 and November 2017 were evaluated retrospectively. Ten patients were female and 33 patients were male. The mean age was 26.2 years. 20.9% of patients had antibiotic use due to a history of previous abscess. The procedure was performed by two surgeons. Following local site cleaning with povidone iodure in the prone position under outpatient conditions; local anesthesia was performed around the sinus orifices with 1 cc lidocaine solution. The cavity was dilated with a mini incision connecting the orifices. Cavity content was mechanically removed from hair, debris and granulation tissues. The pure alcohol solution of phenol as much as cavity volume was injected with a blunt-tipped syringe from enlarged orifice after washing with oxygenated water and 0.9% isotonic NaCl. It was waited for for 5 minutes and was aspirated. The orifice was cauterized with silver nitrate and covered with dressing. The procedure was repeated if the epithelization was not completed on the 10th day and 6th week follow-up. The mean number of sessions was 2.4 and the mean follow-up was 15.7 months. Complete epithelization in the patients who were called for monthly controls was accepted as cure. During the follow-up period, recurrence was detected in one patient in 6 months and phenol was performed.

Conclusion

It is concluded that phenol treatment can be an alternative method to surgical treatment because of its high treatment success, low cost, easy application, low morbidity and since it provides early return to work.

TJS. 2018;34(Suppl-1):S490.

PP-0555 [General Surgery Diseases]. Isolated Splenic Metastasis due to Ovarian Carcinoma

Mehmet Uluşahin ^1,^✉, Muhammed Selim Bodur ¹, Mehmet Arif Usta ¹, Ali Güner ¹, Serdar Türkyılmaz ¹

Introduction

Metastatic masses in the spleen are rare lesions. They are usually seen in advanced stage disease. In this study, a case of splenic metastasis occurring after 8 years in the patient who underwent curative surgical procedure due to ovarian cancer and being followed without any problem will be presented.

Case

A 78-year-old female patient who was operated for ovarian cancer 8 years ago was admitted to medical oncology outpatient clinic with complaints of fatigue. It was learned that she had been suffering from fatigue for 2–3 months and did not affect her daily life very much. It was also learned that the patient had no additional problems other than diabetes, was treated with oncology department after transabdominal hysterectomy and bilateral salfingoogerectomy (TAH + BSO) operation because of ovarian cancer and she was under disease-free follow-up. Rotine blood analyses and tumor markers because of ovarian cancer were studied. The patient had no problem in the routine laboratory values and the Ca-125 level was above the normal with

77.9 U/mL. Abdominal computed tomography (CT) was performed for possible metastasis of the patient, and a mass of 36x28 mm in size in the middle part of the spleen that was understood to appear newly when compared with the CT 3 years ago and considered to be possibly metastatic was reported when compared with CT. The patient was evaluated by oncology department and an operation was recommended. The patient was operated after preoperative anesthesia preparation and pneumococcal vaccination for splenectomy. The abdomen was entered by supraumbilical median incision and the lesion was thought to be metastatic in the spleen was seen. Spleen ligaments were excised and the spleen was released and splenic artery and vein were ligated in the hilus region and splenectomy was performed. The patient was discharged on the fifth postoperative day without any problems other than atelectasis. The pathology result was reported as 4x3x3,5 cm carcinoma metastasis. The patient was evaluated with postoperative pathology by medical oncology and no adjuvant therapy was considered due to advanced age. Outpatient clinic controls continue without any problems

Conclusion

Although spleen metastases in ovarian tumors can be seen in advanced stage disease, isolated spleen metastasis is a very rare condition. There is no specific symptom. It can be detected during routine controls or in patients presenting with complaints such as fatigue and nonspecific abdominal pain. Generally, Ca-125 level is expected to increase. CT is successful in demonstrating the lesion in the spleen, but a definitive diagnosis requires pathological examination. Needle biopsies are not recommended for pathological examination and pathological diagnosis option is more preferred after splenectomy. Splenectomy applied to isolated spleen metastases without any other organ invasion is reported to prolong survival. In appropriate patients, adjuvant chemotherapy after surgery may further improve survival in the patient. As a result, splenectomy is the most appropriate option in isolated splenic metastases detected in patients who were operated for ovarian cancer. It has a positive effect on survival. It should be noted that adjuvant chemotherapy added to splenectomy may further increase survival.

TJS. 2018;34(Suppl-1):S491.

PP-0556 [General Surgery Diseases]. The Possible Predictive Differences of Acute Appendicitis Caused by Enterobius vermicularis in Terms of Blood Count Parameters Compared to Other Causes

Bartu Badak ¹, Mustafa Salış ^1,^✉

Introduction

Appendectomy is one of the most common emergency surgical procedures. It is the most common surgical operation in the world and in our country as a part of emergency abdominal surgery. Addiss et al. in their study, have found that the risk of appendicitis throughout the life was around 8.6%. In another study, almost 7% of all people were reported having undergone appendectomy during their lifetime. Acute appendicitis, which is defined as inflammation of the appendix tissue, is more common in the 2nd and 3rd decades. The histopathological examinations of the patients who underwent appendectomy were reported to be frequently caused by acute inflammation, fibrous tissue, neoplasms, neuroendocrine tumors, tuberculosis, diverticulosis, granulomatous inflammation, adenomas, actinomyces, endometriosis and Enterobius vermicularis. Closure of the appendiceal lumen due to the cause of the event and the inflammation surrounding the tissue is the reason of reflection to the clinic. The most common symptoms are abdominal pain (78%) and nausea-vomiting (26%). (6) The aim of this study was to determine whether pre-operative whole blood count has a possible predictive effect between patients undergoing appendectomy and the cause is reported as Enterobius vermicularis and other group patients.

Material and Methods

The study was designed and applied in Eskisehir Osmangazi University Department of General Surgery. Approximately 250 appendectomy operations are performed annually in our center due to acute appendicitis. The operations can be performed open and laparoscopic. In this study, 17 patients who underwent appendectomy between the years of 2012–2017 and enterobius vermicularis was detected as a cause in the final pathology report and 21 patients whose pathologic examination was reported as mainly acute inflammation were compared. The complete blood count values of the patients at the time of admission were used as the comparison parameter. Statistical analyzes were performed using IBM SPSS, version 21. Enterobius-caused specimens and specimens with the causes other than Enterobius vermicularis were evaluated by T-test according to their normal distribution and by Mann-Whitney U test because displaying differences.

Conclusion

According to the distribution test since the variables of “Hb, Htc, erythrocyte and MPV” display normal distribution and the T test was used to compare these variables with E. vermicularis and inflammation patients. According to the T test results, no significant difference was found between the groups for Hb, Htc, erythrocyte and MPV variables. The Mann-Whitney U test among nonparametric tests was used because other variables did not show normal distribution. In the examination, a significant difference was found in absolute neutrophil and Plt which are among these variables. As a result; absolute monocyte and plt (thrombocyte) values except for the usual parameters frequently used in patients with abdominal pain and suspected acute appendicitis should be considered as predictive for enterobius vermicularis infection and it should be examined whether the event can be suppressed with anthelmintic medical treatment or not in the questioning taking into account a good anamnesis and socioeconomic status. With this study in which the number of support and literature is limited, continuation and support studies should be designed.

TJS. 2018;34(Suppl-1):S491–S492.

PP-0557 [General Surgery Diseases]. Benefits of Vacuum Assisted Closure Therapy in Fournier Gangrene

Oğuzhan Sunamak ¹, Umut Kına ¹, Mehmet Onur Gül ¹, Mehmet Torun ^1,^✉

Introduction

Necrotizing fasciitis; is a bacterial infection of the fascia that can be mortal in a very short time. It is also referred to as Fournier’s gangrene if it concerns genital and perineal regions. Although it is stated in the original definition of Fournier’s gangrene that it develops without an underlying cause, it has now been found that diseases such as diabetes mellitus (DM), alcohol use and HIV are the causes of the disease [2]. In this article, we will discuss 3 different cases we treated by antibiotherapy, debridement, vacuum assisted wound closure (VAC) systems and HBO treatment.

Case 1

A 52-year-old female patient was admitted to our hospital with swelling in her genital region which had been present for 4 days. The patient was evaluated with multidisciplinary approach and wide debridement was performed on the same day and her wound was closed with VAC treatment. She was under follow-up in intensive care unit (ICU) for 2 days due to hypertension (HT), Graves and peripheral arterial diseases and sepsis. The patient required 7 times debridement and VAC including iliofemoral bypass graft.

Case 2

A fifty-eight-year-old male patient was admitted to our clinic because his complaints did not regress after perianal abscess drainage performed 4 days ago. Insulin treatment was initiated in the patient with swelling, redness and edema extending from perineum on the left side to scrotum and groin and who had known DM and the first debridement was performed on the same day. Diverting colostomy was opened in the patient, whose necrosis area extended to the perineal region, in the same session. The patient was followed up for 22 days with VAC treatment and debridement and VAC change was performed 8 times in this process. The patient was not treated with HBO.

Case 3

A 50-year-old woman with known DM, hypercholesterolemia, HT, asthma and chronic renal failure (CRF) was consulted to our clinic for a 1-month history of a fistula with discharge on her left groin and was referred with a pre-diagnosis of necrotizing fasciitis. VAC was performed by extensive debridement and HBO treatment was added since it was in the abdominal region.

Discussion

In case of delayed diagnosis or treatment, mortality and morbidity are high. Mortality and morbidity are high with surgical debridement alone. For this reason, additional therapies such as HBO and VAC treatment are used. Based on culture reproduction, broad spectrum antibiotics should be started as soon as the patient is diagnosed. Age, diabetes, immunosuppression, other systemic diseases, the disease’s being focal or diffuse, and stress conditions can affect the immune system, causing sepsis to become uncontrollable and mortal. HBO therapy and VAC application and diverting ostomy make treatment more effective. Using VAC accelerates angiogenesis by preventing contamination.

Conclusion

After debridement, we found that the VAC, which allows sterile closure of the wound, is successful without using HBO alone. Especially after debridement in ganglia of perineum, VAC alone can provide adequate treatment without HBO. VAC and HBO treatment has been shown to reduce mortality and morbidity when used in addition to debridement and antibiotherapy.

TJS. 2018;34(Suppl-1):S492.

PP-0558 [General Surgery Diseases]. Single Center Experience in Splenectomies with Non-Trauma Causes

Gökhan Demiral ^1,^✉, Muhammed Kadri Çolakoğlu ¹, Süleyman Kalcan ¹, Ali Özdemir ¹, Ali Demir ¹, Ahmet Pergel ¹

Objective

The second most frequently injured organ in abdominal trauma is the spleen and trauma is the most common cause of splenectomy. On the other hand, splenectomy is an important treatment option in the presence of hematological disease which is resistant and aggressive to medical treatment. In addition, splenectomy can be performed procedurally in primary diseases of spleen and other malignancy operations. In this study, we aimed to evaluate the indications of splenectomy for non-traumatic reasons in our clinic.

Material and Methods

Data of 37 patients who underwent splenectomy for non-trauma reasons between January 2012 and December 2017 were retrospectively analyzed. The indications of age, gender and splenectomy were evaluated.

Results

Of the patients, 19 (51.3%) were male and 18 (48.7%) were male. The mean age was 55.1 (18–79). The causes of splenectomy were gastric adenocarcinoma in 13 patients (48.6%), colon carcinoma in 3 patients (8.1%), splenic cyst, splenic abscess, pancreatic neuroendocrine tumor and hemangioma in two patients (5.4%) respectively and follicular hyperplasia, idiopathic thrombocytopenic purpura (ITP), mesothelial cyst, suspected atypical lymphoid, renal carcinoma, urothelial carcinoma, pancreatic mucinous cystadenocarcinoma, esophageal cancer, pancreas mucinous cyst adenoma, pancreatic intrapancreatic mucinous neoplasm (IPMN), renal sarcomatoid carcinoma, non-Hodgkin lymphoma, thrombotic thrombocytopenic purpura (TTP) and spontaneous rupture in 1 patient (2.7%).

Conclusion

Although it varies with age in different countries, hematological diseases and infections are among the indications of non-traumatic splenectomy, and other intraabdominal operations are among the most common procedures. It was observed that the rate of splenectomy was very low due to hematological diseases and other primary pathologies of the spleen. On the other hand, it was observed that the number of procedural splenectomies was high due to intraabdominal malignancies. We think that the rate of procedural splenectomy will decrease with both the change of principles of approach to tumor surgery in recent years and increasing frequency of the use of energy devices used in vessel sealing and tissue dissection.

TJS. 2018;34(Suppl-1):S493.

PP-0559 [General Surgery Diseases]. A Case of Sarcoidosis Diagnosed after Splenectomy

Mehmet Uluşahin ^1,^✉, Arif Burak Çekiç ¹, Reyyan Yıldırım ¹, Ali Güner ¹, Serdar Türkyılmaz ¹

Introduction

Sarcoidosis is a granulomatous disease affecting many systems. It most commonly involves the lungs. In this report, a case of sarcoidosis diagnosed after splenectomy will be presented.

Case

A 35-year-old male patient was admitted to the outpatient clinic of chest diseases with complaints of phlegmy cough for one and a half months. Right chest rhonchus was detected in the thoracal examination of the patient. Thoracic chest computed tomography (CT) performed in the external center showed a bilateral patchy ground-glass appearance. 31% lymphocyte was detected in the lavage performed with bronchoscopy, and biopsies taken were reported as benign. Microbiological tests for tuberculosis were reported as negative. Methylprednisolone treatment was started in the patient with the diagnosis of hypersensitivity pneumonia and improvement in her symptoms was detected.

The patient developed abdominal pain one month later and abdominal CT performed in the emergency service the patient was admitted, revealed multiple hypodense lesions larger than 1 cm in spleen and liver and lymph nodes in the portal hilus. Diagnostic splenectomy was recommended in the patient who was evaluated by the hematology department. The operation was planned laparoscopically. The operation was started with one 12mm, one 10 mm and two 5mm ports inserted into the midclavicular line on left subcostal line, umbilicus neighborhood from anterior and posterior axillary lines in the right lateral decubitus position. Spleen was completely separated with laparoscopic vascular stapler placed in the splenic hilus after the spleen was separated from ligaments and splenectomy was performed. It was removed out of the abdomen in large pieces with the aid of specimen bag. The patient without any problem in the postoperative period was discharged on the 3rd day. Pathology result revealed granulomatous inflammation without caseification consistent with sarcoidosis. The patient was followed up by chest diseases in the postoperative period, and he was treated with methylprednisolone for 1 year with the diagnosis of sarcoidosis with liver, lung and spleen involvement. Then, the patient was discontinued with methylprednisolone his outpatient clinic follow-ups continue.

Conclusion

Sarcoidosis is known as a granulomatous disease of unknown cause. It appears more in young ages and women. It can involve many systems and is characterized by the formation of granulomas without caseification in the systems it involves. Although the most common involvement is seen in lungs and lymph nodes it can be seen in the other organs as well. Although most of the patients are asymptomatic, the most common symptom is cough and shortness of breath in patients who are symptomatic. Spontaneous remission may occur in some patients. Although imaging techniques are valuable when combined with symptoms and physical examination findings, diagnosis is usually made by biopsy. It can be encountered with multiple nodular lesions, hepatomegaly, splenomegaly and lymphadenopathy in the liver and spleen in abdominal CT. The diagnosis of sarcoidosis should always be kept in mind in case the described rare lesions occur or respiratory symptoms accompany these lesions.

TJS. 2018;34(Suppl-1):S493–S494.

Tailgut cysts are mostly asymptomatic cysts that occur as a result of embryological tailgut regression defects observed frequently in women in the 4th decade with an incidence of 1/40.000–63.000 incidence. Therefore, if it is not found incidentally in rectal or gynecological examination, it can be diagnosed when it reaches to large size or complication develops. Surgical resection should be planned because of complications such as infection and malignant transformation.

TJS. 2018;34(Suppl-1):S495.

PP-0563 [General Surgery Diseases]. Perineal Agressive Angiomyxoma

Süleyman Atalay ^1,^✉, Güler Gamze Eren Özcan ², Tuba Gülçelik ¹, Emine Sümeyra Bölük ¹, Adem Aslan ¹, Ahmet Ziya Balta ¹, İlker Sücüllü ¹, Yavuz Kurt ¹

Angiomyxoma is a rare benign tumor especially in women of childbearing age, especially in the perineum, pelvis and gluteal region. Herein we report a 39-year-old female patient who was operated with the diagnosis of perineal hemangioma and whose pathological evaluation was reported as angiomyxoma.

TJS. 2018;34(Suppl-1):S495–S496.

MFH is a tumor originating from fibroblasts and histiocytes and is rare. It is reported that it is mostly seen in men of advanced age. Approximately half of the cases are lower extremity originated. Upper extremity, retroperitoneum, trunk and abdominal cavity are the other locations it is commonly seen. The etiology is not clearly known, but it is reported that it may be associated with trauma, surgical incisions and radiation. It may display very different symptoms according to the location. Although imaging methods are helpful in diagnosis, definitive diagnosis can be made pathologically. It is known to have 5 types as pleomorphic, myxoid, giant cell, inflammatory and angiomatoid. The one with the worst prognosis, with the fastest growth potential and the most common one is the pleomorphic type. MFH is a malignancy having a course of recurrence and metastases. Recurrence and metastasis are more common in larger ones. Surgery is the most preferred option in the treatment according to the stage of the disease. Although radiotherapy and chemotherapy are the other treatment methods, the response of the tumor is usually not good. Recurrence and metastasis screening should be performed with frequent imaging methods according to tumor location.

TJS. 2018;34(Suppl-1):S498.

PP-0569 [General Surgery Diseases]. A Rare Case: Bilateral Elastofibroma Dorsi

Ozan Barış Namdaroğlu ^1,^✉, Orkun Subaşı ¹, Savaş Yakan ¹, Ahmet Mücteba Öztürk ¹, Mehmet Yıldırım ¹

Introduction

Elastofibroma dorsi was first defined as a reactional condition with collagen degeneration and excessive elastin production caused by friction of the scapula to the chest wall. Elastofibroma dorsi is a rare, benign soft tissue tumor growing slowly. It is usually located in the inferomedial of the scapula and serratus anterior muscle. It is more common in advanced ages and women. It is unilateral in 90% of the patients. Although its etiopathogenesis is not known, it is thought that it may be a reactive lesion that develops as a result of rubbing of the lower end of the scapula to the chest wall after repeated microtraumas in the subscapular region. Elastofibroma dorsi may be clinically asymptomatic as it may present with a subscapular mass that typically causes long-term sensation of scapular snapping, discomfort, swelling and sometimes pain. Magnetic resonance imaging is the most reliable and non-invasive technique that can show the characteristic fibrous and fat component of the mass. We aimed to present a patient with bilateral elastofibroma dorsi since it is a rare chest wall tumor and can be easily overlooked in physical examination.

Case

A 67-year-old female patient was admitted to our general surgery outpatient clinic with complaints of pain and swelling under both scapula. Physical examination revealed an infrascapular, painless, mobile, semi-rigid, mass when shoulder joint was in flexion and the arm was in abduction. The patient underwent ultrasonography and a tumoral lesion under the latissimus dorsi muscle with the size 9x7x5cm on the left and 5x3x3cm on the right in favor of soft tissue was detected.

In the magnetic resonance imaging of the patient, a 9x8x6 cm (on the left) and a 5x4x3 cm (on the right) fusiform soft tissue lesions between the thoracoposterolateral wall and scapula body in the inferior area of the scapula, having features similar to muscle tissue in T1 and T2 AG and having no capsule formation and sharp margins were recorded.

The patient underwent a left infrascapular lesion total excision in June 2017 and right infrascapular lesion excision was performed in January 2018. The drain of the patient was withdrawn in the postoperative 2nd day and the patient was discharged with healing. The pathological examination of the masses revealed elastofibroma. During the follow-up period, the patient’s pain regressed and no additional complication developed.

Conclusion

Elastofibroma dorsi is a rare chest wall tumor and can be easily overlooked in physical examination so it should be considered in the differential diagnosis, especially if trauma is defined in patients with long back pain. It should first be investigated radiologically and it should be kept in mind that it may be bilateral. Unnecessary invasive procedure should be avoided according to the patient’s condition. In the light of the literature, although the recommended treatment of the elastofibroma dorsi, which is a benign soft tissue tumor, in symptomatic and large lesions is total surgical excision, we are of the opinion that one should not be aggressive in local recurrences and small lesions and follow-up may be sufficient.

TJS. 2018;34(Suppl-1):S499.

PP-0570 [General Surgery Diseases]. A Hard Mass on the Shoulder: Tumor Calcinosis

Altan Aydın ^1,^✉, Şaban Uysal ¹

Tumor calcinosis is mostly seen in children and young adults; and characterized by swellings located often close to large joints such as the hips, shoulders and elbows. Most of them have multiple localization and some of the cases show familial transition. It is rarely seen in advanced ages. There are mainly primary and secondary forms. There are normophosphatemic and hyperphosphatemic subtypes in its primary form, but both types have normal blood calcium levels. Various diseases such as hyperparathyroidism secondary to chronic renal failure, vitamin D hypervitaminosis and milk alkaline syndrome play a role in the secondary form of the disease. Its microscopic appearance varies according to the active (cellular activity in the foreground) and inactive (calcification in the foreground) period. Phosphorus metabolism disturbance, recurrent minor traumas and the presence of an underlying soft tissue disease can be considered as predisposing factors. Total excision of the mass and sometimes phosphorous binding preparations are used in the treatment. Our case in our case presentation was a 61-year-old female patient with no history of comorbid disease. The patient was admitted to our clinic with the complaint of swelling on the right shoulder for the last 1 year which caused pain from time to time. She had a history of trauma of her shoulder site in the past 2 years. Physical examination revealed a hard mass of approximately 3 cm. The graphy performed since the mass was calcified a calcified mass shade was seen in the shoulder region. The superficial ultrasonography of the patient was interpreted as “mass under the skin, approximately 32x10 mm in size, hypoechoic areas were observed in the central and hyperechoic areas were observed in the periphery”. The mass was totally removed in the treatment. The pathology result was obtained as “tumoral calcinosis”. The calcium and phosphorus levels of the patient were seen as normal. The patient was consulted to the relevant departments for other possible secondary causes, but no comorbid disease was detected. There was no evidence of a positive family history in the questioning. The trauma history of the shoulder region two years ago was considered as a predisposing factor and the patient was informed about the disease.

TJS. 2018;34(Suppl-1):S499.

Laparoscopic technique is a safe and minimally invasive method that can be preferred in the placement of CAPD catheter and correction of malfunction.

TJS. 2018;34(Suppl-1):S501–S502.

PP-0576 [General Surgery Diseases]. Scar Endometriosis: Is It A Preventable Pathology?

Banu Karapolat ^1,^✉, Halil Afşin Taşdelen ¹, Suat Erkul ², Sercan Büyükakıncak ³, Ömer İleli ¹, Yusuf Ziya Yamak ¹

Objective

Endometriosis is defined as the presence of functional endometrial tissue in other parts of the body except the uterus. Endometriosis can be caused following gynecological or obstetric operations as a result of the endometrial tissue’s getting out of uterine cavity.

This presentation discusses how to prevent scar endometriosis which is a rare complication that can be seen after gynecological surgeries.

Material and Methods

Nineteen cases with endometriosis who were admitted to our clinic between January 2013 and January 2018 were evaluated retrospectively and their ages, complaints and onset time, location and size of the masses were evaluated.

Results

The mean age of the patients was 30.8 (20–49). All cases had a history of cesarean section. All of the patients had pain and swelling symptoms at the incision site. Complaints of the cases occurred after an average of 1.8 years (6 months-3 years) after the last cesarean operation. Endometriosis was detected on the right side of the scar in 9 cases (47.4%), in the left side (36.8%) in 7 cases, in the midline (10.5%) in 2 cases and in the inguinal region (5.3%) in 1 case. In all cases, the lesions were totally excised by surgery. The diameter of the endometriosis masses was measured as 30 mm (10 mm-55 mm).

Conclusion

The incidence of scar endometriosis varies between 0.03% and 1.7% after cesarean section. Endometriosis should be the first diagnosis that should be considered when a mass is palpated at the side of scar tissue in the abdominal wall during physical examination in cases with a palpable mass in the lower abdomen and pain complaints consistent with menstrual cycle. However, pathologies such as incisional hernia, suture granuloma, abscess or abdominal wall tumor should be excluded by additional procedures. In the etiology of scar endometriosis, the most accepted theory is that the endometrial cells are considered to be implanted iatrogenically in the skin secondary to surgical procedures for the uterus. In this study, endometriosis focus was found in only one of the cases after cesarean operation in the inguinal region apart from the scar edge and the endometriosis focus was detected in the neighborhood of cesarean scar in the remaining cases. The right side and other sides as localization were detected almost equal. We believe that the surgical field of the surgeon does not affect the formation area of scar endometriosis. In general, many obstetric surgeons clean the uterine cavity with wet or dry buffers after caesarean section. This increases the risk of endometrial tissue inoculation to the environment. Here, we think that irrigation of skin, subcutaneous, muscle and fascias with abundant physiological saline solution after the closure of the uterine cavity and not using the suture materials and surgical tools, which were used when suturing the uterus, for closing skin and subcutaneous are important to prevent the formation of endometriosis.

TJS. 2018;34(Suppl-1):S502.

A 73-year-old male patient was operated upon detection of a mass in the anterior abdominal wall, and his histopathology was reported as dermatofibrosarcoma protuberans (DFSP) and did not receive any additional treatment. He was admitted with a palpable swelling in his operation area approximately 1 year after his first operation. The examination revealed limited mass in the anterior abdominal wall and pathological lymphadenopathies (LAP) in the inguinal region. Resection was performed to the mass with wide surgical margins. Excisional biopsy was performed in the inguinal LAPs. Mass histopathology was reported as DFSP and that of LAPs was reactive. In the immunohistochemical study on the mass, CD34 (+), CD10 focal (+), SMA (−), MSA (−), F13A (−) in tumor cells and proliferative index with Ki67 was 20%. Although the surgical margins of the mass were intact, cavity resection was performed again because 1 mm of surgical margins were obtained in two areas and no tumor was seen. No additional treatment was planned. The case is followed up smoothly in the postoperative second year.

Conclusion

Although dermatofibrosarcoma protuberans is rarely detected, local recurrence is common if resection is not performed with intact surgical margins. The patients who are thought to be DFSP with the findings of the inspection should be resected with intact surgical margins and their follow-up should be done keeping in mind the possibility of local recurrence.

TJS. 2018;34(Suppl-1):S505.

PP-0583 [General Surgery Diseases]. A Case of Spermatic Cord Liposarcoma Imitating Right Inguinal Hernia

Süleyman Çağlar Ertekin ^1,^✉, Yalçın Burak Kara ³, Mümin Coşkun ², Tevfik Kıvılcım Uprak ², Vafi Atalay ², Şevket Cumhur Yeğen ², Ömer Günal ²

Introduction

Spermatic cord liposarcoma is a rare disease characterized by inguinal or scrotal swelling. These tumors are often thought to be inguinal hernia or hydrocele at the time of admission. As far as we know there are about 200 cases previously reported in the literature.

Case

A 68-year-old male patient was admitted to the outpatient clinic with a complaint of painless swelling increasingly growing in 12 months in the right inguinal region. In physical examination it was observed that the lesion was getting smaller in supine position, and becoming larger when intraabdominal pressure increased, and a hard fixed lesion was palpated in the lateral. Superficial ultrasonography was reported as right inguinal hernia and 37 mm lymphadenopathy or mass lesion. Additional symptoms such as constipation, nausea, vomiting, and weight loss was not detected. He was referred to the interventional radiology department for biopsy. It was reported by interventional radiology that it was not suitable for biopsy as it was close to intestinal and vascular structures due to inguinal hernia. It was decided to perform surgery due to inguinal hernia repair and mass excision. No pathology was detected in preoperative complete blood count, biochemistry and lung X-rays. There was no metastatic finding in abdominopelvic computed tomography. Right direct hernia sac and spermatic cord-induced hard fixed lesion were detected in the exploration performed in right inguinal area. The mass was excised by preserving the cord structures, ilioinguinal lymph node dissection and right inguinal (liechtenstein) repair were performed. Histological evaluation revealed 43mm well-differentiated myxoid liposarcoma and no metastasis was seen. The patient was discharged on the 3rd postoperative day. No recurrence or metastasis was detected in the 12-month follow-up period.

Conclusion

Primary epiploic appendagitis is a rare inflammatory disease that causes sudden onset of local abdominal pain caused by torsion of epiploic appendix or by thrombus of appendiceal veins. Acute cholecystitis, appendicitis, diverticulitis, and acute gynecological diseases are also included in the differential diagnosis of epiploic appendagitis and may imitate acute abdominal pictures requiring surgical intervention. Treatment with conservative antibiotics is possible. The imaging can easily be diagnosed with gold standard CT. It should be taken into consideratiın in differential diagnosis in order to prevent unnecessary surgical interventions.

TJS. 2018;34(Suppl-1):S509.

PP-0590 [General Surgery Diseases]. Sacrococcygeal Pilonidal Sinus: How Significant is Histopathological Evaluation?

TJS. 2018;34(Suppl-1):S511–S512.

PP-0594 [General Surgery Diseases]. Supralevator Abscess by Necrosis of the Anterior Abdominal Wall

Abit Yaman ^1,^✉, Enver Reyhan ¹, Alper Sözütek ¹, Fatih Akgündüz ¹, Mehmet Kemal Yener ¹, Hüseyin Kılavuz ¹, Ali Kaan Şanal ¹, Oktay İrkörücü ¹

Perianal abscess is a common benign anorectal disease and can cause serious complications if left untreated. The most frequent and serious complications in perianal abscess are fournier gangrene in the acute period and perianal fistula in the chronic period. The cases with necrotizing fasciitis in the anterior abdominal wall are much more rare and thus we aimed to present here. The patient was referred to us from the external center due to abdominal pain and acute abdomen 3 days ago. Tomographic imaging of the patient revealed free air in the parietal and paravesical areas in the pelvis and a collection and free air in the right anterior wall of the abdomen. A laparotomy decision was made because of acute abdomen findings consistent with acute abdomen in the clinic of the patient. Perioperatively, a collection extending along pararectal adipose tissues from the supralevator region along anterior wall of right abdomen in preperitoneal area and partly necrosis were observed. The patient was discharged with healing by VAC treatment after debridement and drainage.

TJS. 2018;34(Suppl-1):S512.

PP-0595 [General Surgery Diseases]. Responses of Patients with Irresectable Peritoneal Surface Malignancy to Laparoscopic Hyperthermic Intraperitoneal Chemotherapy and Induction Chemotherapy

Emel Canbay ^1,^✉, Bahar Canbay Torun ², Cetin Altunal ¹, Yusuf Celik ¹, Yutaka Yonemura ³

Objective

Induction chemotherapy is a systemic method used to provide resection in irresectable cancers and locally advanced cancers and to enable surgery by reducing tumor burden. In this study, the results of patients with peritoneal surface malignancy which were irresectable with laparoscopic hyperthermic intraoperative intraperitoneal chemotherapy as induction chemotherapy have been reported.

Material and Methods

The results of the patients who underwent laparoscopic hyperthermic intraperitoneal induction chemotherapy until 2013–2018 were evaluated.

Results

Fourteen patients underwent laparoscopic hyperthermic intraperitoneal chemotherapy. The mean age of the patients was 53.8±8.75 (32–74). Eleven patients were female and 3 of them were male. The mean procedure time was 2 hours 30 minutes±1 hour and 16 minutes. Of the tumors, 8 were associated with gastric cancer, 4 were due to colon cancer, 2 were due to biliary tract, 1 was due to peritoneal mesothelioma and 1 had peritoneal metastasis due to ovarian cancer. Peritoneal cancer index decreased in 3 of gastric cancer patients (37.5%), ovarian cancer patient (100%) and mesothelioma (100%) and surgery and hyperthermic intraperitoneal chemotherapy could be performed. No early or late complications were observed. Acid could be controlled in all patients. Acid could not be controlled only in the peritoneal metastasis of the liver metastasis of gastric cancer. The disease-free survival of the patients was 3–11 months (±3.14) and the overall survival was 8.9±3.28 months.

Conclusion

Laparoscopic hyperthermic intraperitoneal chemotherapy may be a method for reducing tumor burden and controlling acid in patients with irresectable peritoneal surface malignancy.

TJS. 2018;34(Suppl-1):S512–S513.

PP-0596 [General Surgery Diseases]. Polycystic Over Syndrome as a Predisposing Factor in Pilonidal Sinus Disease

Celil Uğurlu ¹, Özhan Özcan ^1,^✉, Serkan Karayiğit ¹

Objective

Male gender, obesity, occupations or sports requiring sitting, excessive body hair, poor body hygiene and excessive sweating are described as the primary risk factors for pilonidal sinus disease (PSD). Polycystic ovarian syndrome (PCOS) affects approximately 2%–7% of women in general population. Hirsutism is defined as excessive terminal hair growth in an androgen-sensitive skin distribution in women and is the most common cause of which is PCOS.

The aim of the study is to determine whether PCOS can be shown as one of the uptake factors of PSD.

Material and Methods

This is a retrospective study. 102 female patients who underwent surgery due to symptomatic PSD were included in the study. The control group comprised of 215 female patients from general surgery and gynecology clinic without pilonidal sinus disease. Age, body mass index (BMI), number of baths taken per week, pcos, family history were examined as risk factors and compared between the two groups. Depending on the BMI range, 20–25.9, 26–29.9, and over 30, patients were classified as normal range, overweight, and obese, respectively.

Results

In terms of BMI, family history, age, number of baths, there was no significant difference between the two groups. The number of patients who has pcos was 19(%18.6) in the study group, while it was 8(%3,5). in the control group. Statistically significant difference has been found between, study and control groups (p<0,05).

Conclusion

Many studies have shown a positive correlation between obesity and PS. In our study we did not detect a statistical significance between BMI and PSD. Many studies have reported that practicing good hygienereduces the risk of PSD. This effect is believed to be associated with the removal of collected hair from the intergluteal sulcus. In our study, the number of baths per week was similar for both groups. Family tendency is also an important factor. Doll et al. 7 reported that family tendency accelerates the development of PSD, causing higher risk of recurrence, while suggesting that the positive patients should be closely followed up. Family history was evident in %32.3 of our study group that consistent with the literature. There is no literature on PCOS and PSD association. In our study we have found statistically significant difference between two groups because this might be the increase correlation of hirsutsm and PCOS.

PCOS could increase the risk of PSD because the most common cause of hirsutism is pcos.

TJS. 2018;34(Suppl-1):S513.

PP-0598 [Hepatobiliary Surgery]. Asymptomatic Bilioenteric Fistula and Gallstone Ileus: Presentation of Two Consecutive Cases

Baha Arslan ^1,^✉, Tuğba Han Yılmaz ¹, Varlık Erol ¹, Hüseyin Gülay ¹

Introduction

Mechanical bowel obstructions due to gallstone (ST) is a rare cause of mechanical ileus which may be encountered in the course of acute and chronic cholecystitis affecting generally elderly women.

Case 1

A 69-year-old female patient who did not have a comorbid disease except hypertension and atrial fibrillation was admitted to the emergency service with the complaint of colic-style abdominal pain, nausea and vomiting for three days. She was taken to the operation due to ST ileus since air was detected in the bile ducts, she had a state of ileus in proximal bowel loops and a stone causing obstruction in jejunoileal loops was detected in computed tomography. Abdominal radiography revealed diffuse air fluid levels. ST segmentary which was in 140 cm distal from the Treitz ligament causing obstruction, was removed by bowel resection. The procedure for the gallbladder was left to the second session and the procedure was terminated.

Case 2

A 67-year-old patient presented with acute abdominal pain spreading to the back received symptomatic treatment in the emergency service two times in a year. The patient applied to the physical therapy and rehabilitation department for back pain. Abdominal ultrasound on suspicion revealed multiple millimetric stones in the gallbladder and was referred to the general surgery department. The patient did not have comorbid disease except being Mediterranean anemia carrier and hypothyroidism. Cholecystoduodenal fistula was detected during laparoscopic cholecystectomy when the adhesion between the gallbladder neck and the postpiloric region was attempted to open. It was switched to open surgery. The duodenum was repaired. Type 2 Mirizzi syndrome was detected during cholecystectomy. Cholangiography was taken. No additional problems were observed in the biliary tract and the surgery was terminated by repairing bile duct.

Conclusion

Gallstone ileus is a rare cause of mechanical bowel obstruction, but it affects elderly patients with comorbid conditions. Therefore, mortality rates of the treated patients are between 5–6.7%. Ileus manifests itself as recurrent ileus episodes as stone advancing in the intestinal organ associated with cholecystenteric fistula (CEF) and ileus clinic improves when the obstruction is complete. The mean duration of hospitalization was 5 days. While 20% of these patients had acute cholecystitis, there was jaundice in less than 15% of the patients. Stone remains rarely at the CEF level and causes gastric outlet syndrome (Bouveret Syndrome). Very small stones can be removed from the digestive system without creating the ileus picture. Not observing ST in the ultrasound of the abdomen in cases with known ST, pneumobilia, bowel obstruction, and the presence of ST in the lumen of the intestine make us suspect-Rigler triad-. In the treatment of ileus, if the patient is not high-risk and there is no intense inflammatory process in the abdomen, CEF can be repaired with cholecystectomy after the abolition of the ileus by enterolitotomy or segmental resection. However, in high-risk patients, treatment with ileus may be treated in a second session. It is necessary to repair the CEF detected during the elective surgery at the same session and to eliminate the gallbladder disease. The imaging study to be performed during the surgery also helps reveal the possible ST disease.

TJS. 2018;34(Suppl-1):S514.

PP-0599 [Hepatobiliary Surgery]. Liver Protective Effect of Calcium Dobesylate in Experimental Obstructive Jaundice

Yılmaz Ünal ^1,^✉, Salih Tuncal ¹, Koray Koşmaz ¹, Berkay Küçük ¹, Kemal Kısmet ¹, Nadir Turgut Çavuşoğlu ¹, Selin Yıldız ², Mehmet Şenes ², Pınar Celepli ³, Sema Hücümenoğlu ³

Objective

Liver damage after obstructive jaundice occurs with a multifactorial and complex mechanism. Oxidative stress and inflammation are important factors affecting the degree of this damage. In this study, we aimed to investigate the protective effect of Calcium Dobesylate (Ca-Dob) with antioxidant and anti-inflammatory effect on liver injury caused by experimental obstructive jaundice model.

Material and Methods

Thirty Wistar Albino female rats were randomly divided into three groups. Laparotomy was performed on rats in Group 1 (Sham/n: 10), only the bile duct was dissected. Laparotomy and bile duct ligation were performed to rats in Group 2 (Control/n: 10) and Group 3 (Ca-Dob/n: 10). No other treatment was given to Group 1 and Group 2 rats. Group 3 rats were given 100 mg/kg/day Ca-Dob through orogastric tube for 10 (ten) days following the procedure. All rats were sacrificed after ten days. Blood and liver tissue samples were collected for biochemical and histopathological analyses.

Results

Serum liver function test values were significantly lower in the Ca-Dob group (p<0.05). In the Ca-Dob group, the levels of malondialdehyde (MDA) and fluoruscent oxidation products (FOP) were significantly lower (p<0.05) in liver tissue samples than the control group whereas total sulfydryl (SH) values were significantly higher (p>0.05). In addition, when the groups were compared in terms of histopathological score, the histopathological damage value in Ca-Dob group was significantly lower than the control group (p<0.05).

Conclusion

In our study, we found that Ca-Dob significantly reduced liver function test values and oxidative stress parameters in liver tissue besides reducing inflammation and fibrosis in liver tissue with obstructive jaundice. We think that Ca-Dob may be a hepatoprotective agent because of its anti-inflammatory and antioxidant effect. We believe that our results will be supported with the studies conducted with wide case-control series.

TJS. 2018;34(Suppl-1):S514.

PP-0600 [Hepatobiliary Surgery]. Hepatocellular Carcinoma Case Imitating Hepatic Adenoma

Ceren Canbey Göret ¹, Nuri Emrah Göret ², Ömer Faruk Özkan ^3,^✉

Hepatocellular adenomas (HA) are rare, benign natured masses which are reported to reach tumor sizes up to 30 cm. Hepatocellular carcinomas (HCC) are the most common primary malignancies of the liver and are reported to develop usually on the basis of cirrhosis of the liver and to be more common in males. It has been reported that they present with masses that are often smaller than 5 cm and less frequently with larger than 10 cm masses. We aimed to present a case of hepatocellular carcinoma presenting with a hypodense mass of 13 cm in size, filling almost entire right lobe of the liver in the case of a 72-year-old female patient with fatigue and pain spreading to the back on the right upper quadrant; due to its histopathologic image similar to both telangiectatic variant hepatic adenoma and false diagnosis as “cavernous hemangioma” in the first biopsy specimen.

TJS. 2018;34(Suppl-1):S514–S515.

PP-0601 [Hepatobiliary Surgery]. Splenic Metastasis Due to Endometrium Carcinoma Operated with Subcapsular Hematoma: Case Presentation

Bülent Kaya ^1,^✉, Anıl Ergin ², Ender Onur ², Kemal Memişoğlu ²

Introduction

Splenic metastases are rare pathologies. Splenic metastasis develops most commonly associated with lung and ovarian cancers. The metastasis due to endometrial carcinoma is very rare. We aimed to discuss the patient in whom splenic metastasis developed due to endometrial carcinoma and was operated with subcapsular hematoma.

Case

A 63-year-old female patient was admitted to the emergency department with the complaints of abdominal pain, nausea and vomiting. It was learned that total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed due to endometrium cancer approximately 10 months before her anamnesis. Physical examination showed sensitivity on the left upper abdomen. An approximately 7 cm diameter lesion was detected in the anterior spleen in the abdominal computed tomography examination performed. There was a lesion showing irregular contrast in the spleen in contrast enhanced magnetic resonance imaging. It was stated that the lesion could be spleen hematoma and there could be metastasis. The patient was explored with the present findings. There was non-ruptured hematoma on the anterior spleen at the exploration. The massive lesion was palpated in this hematoma. Standard splenectomy was performed. Postoperative period was without any problem. Pathology result was reported as endometrial carcinoma metastasis in the spleen.

Conclusion

Splenic metastasis of solid tumors is rare. The most common one is hematogenous metastasis. Metastases can occur by lymphatic, transperitoneal and by way of close neighborhood. Abdominal pain and compression symptoms may be seen in these patients. However, an important part of the patients is asymptomatic and they reveal incidentally by imaging methods. The spleen rupture in these patients is a major complication. Splenic metastasis of endometrial carcinoma is uncommon. The cases reported in the literature may appear very long after the initial surgical procedure. In our case, metastasis was detected about 10 months after primary surgery. However, splenic subcapsular hematoma was primarily considered according to the patient’s findings at her admission. Splenic metastasis was considered as differential diagnosis. Splenectomy is the treatment method that should be preferred in patients with splenic metastasis due to endometrial carcinoma both for treatment and prevention of complications such as splenic rupture.

TJS. 2018;34(Suppl-1):S515–S516.

PP-0602 [Hepatobiliary Surgery]. Factors Affecting the Development of Postoperative Bile Fistula in Patients with Liver Cyst Hydatid

Mehmet Gümer ^1,^✉, Abdullah Özgönül ¹, Faik Tatlı ¹, Orhan Gözeneli ¹, Hüseyin Cahit Yalçın ¹, Osman Bardakçı ¹, Reşit Çiftçi ², Fırat Erkmen ¹, Emre Karaca ¹, Ali Uzunköy ¹

Objective

It was aimed to investigate the factors affecting the development of biliary fistulas in patients with liver hydatid cyst disease and to predict in which patient biliary fistula can form while preparing cyst hydatid patients for the operation and making a treatment and follow-up plan accordingly.

Material and Methods

Fifty-five patients who was operated due to cyst hydatid of the liver in our hospital between January 2016 and July 2017 were included in the prospective study. Patients were examined in terms of age, sex, size of cyst, location of cyst, number of cysts, cystic phase (gharbi classification used), comorbid disease (only DM), synchronous cyst (presence of cyst outside the liver), and preoperative albumin values. Patients were divided into two groups as patients with and without biliary fistula. All patients underwent partial cystectomy + drainage as surgical technique. Contents of all cysts were irrigated with povidone-iodine and 3% NaCl. In all cases; drain guard was placed in and out of the cyst cavity. It was routinely checked whether there was a biliary fistula in the cyst lodge. Biliary fistula test was not performed. Intraoperative bile leakages were repaired primarily. All patients were treated with albendazole (10 mg/kg/day) for 3 months postoperatively. If there is no reduction in the amount of bile released from the spontaneous drain, or if the flow rate is high, MRCP followed by ERCP (endoscopic retrograde cholangiopancreatography), in the patients for whom these were necessary, were performed. The collected data were calculated using SPSS (22.0 for Windows, SPSS Inc., Chicago, Illinois, USA). Suitability of the variables to the normal distribution was examined by the Kolmogorov-Smirnov test. Pearson Chi Square and Fisher’s Exact Tests were used. A P-value of less than 0.05 was considered statistically significant.

Results

Of the patients included in the study, 45 (82%) of them were female and 10 (18%) were male. Their mean age was 39.3±16.6 years. 14 (25.5%) patients had biliary fistula. Fistula was removed after performing ERCP in 4 patients and it was cut spontaneously in 10 patients. The average time to ERCP was 14.25 days. Biliary fistulas were detected in per-op 5 patients and these were closed primarily. No biliary fistula was seen in these patients in the postoperative period. Mean cyst diameter was measured as 8,39±2,87 cm. A statistically significant relationship between the gharbi stage of the cyst and bile leakage (p <0.05) was detected. At the same time, the mean number of cysts (2,07±2.16) in patients with biliary leakage was found significantly higher than that in patients without biliary leakage (1,7±0,59) (p=0.007).

Discussion

Biliary fistula is the most common complication after liver cyst hydatid surgery. It is reported in the literature between 2.6–28.6%. This rate is 25,5% in our series. When we look at the literature in the formation of biliary fistula; cyst size, location, cystic degenerative appearance have been reported to be effective. In our study; according to the Gharbi classification, advanced cysts and increased number of cysts were found statistically significant in the development of the biliary fistula.

TJS. 2018;34(Suppl-1):S516.

PP-0603 [Hepatobiliary Surgery]. A Rare Cause of Pneumophila: Papilla Opening Anomaly and Dysfunctional Oddi Sphincter Coexistence

Çağrı Akalın ^1,^✉

Introduction

The presence of air (pneumobilia) in bile ducts can occur in cases such as bilioenteric fistula, bilioenteric anastomosis, emphysematous cholecystitis, dysfunctional oddi sphincter and sphincterotomy. Under normal conditions, the choledoch is opened to the second part of the duodenum and rarely it can be opened to the first part of the duodenum. We aimed to present pneumobilia coexistence with papilla anomaly in our case.

Case

A 51-year-old male patient was admitted to the emergency service with a complaint of abdominal pain. Abdominal pain was about 1 day and it was localized and continuous in the upper right quadrant. Fever among vital findings was 37,7°C. Physical examination revealed tenderness and defense in the right upper quadrant. The laboratory parameters were as such; white blood cell count: 14900/mm3, C-reactive protein (CRP) 10,9 mg/l, total bilirubin 3,82 mg/dl, direct bilirubin 2,89 mg/dl, ALT 234 U/AST: 169 U/L, LDH: 224 U/L. Hepatocellular ultrasound performed was interpreted as; bile wall had distant view, wall thickness was normal, wall was regular, lumen had compatible appearance with intensive bile content, pericholecystic fluid was not observed, diameter was 9 mm at the choledochic site and increased, air densities in intrahepatic bile ducts and choledoc were observed, appearance was suspicious in terms of choledocholithiasis and spontaneous stone passage. In the abdominal computed tomography; bile duct had a distended appearence (cholecystitis?) and was dilated in intrahepatic bile ducts. The patient was hospitalized with physical examination and laboratory parameters and cholecystitis diagnosis and medical treatment was started. The patient was consulted for gastroenterology in the external center and ERCP (endoscopic retrograde cholangiography) was decided to perform. It was determined that there was an apical narrowness in ERCP and the papilla of vater was opened to the first part of the duodenum (bulbus). The largest portion of the choledochus was found to be 12 mm and the intrahepatic bile ducts were apparently wider on the left. Sphincterotomy was not performed in the patient because the vater of ampula sphincter tonus was little and biliary sludge in the choledoch was swept by stone balloon. Laparoscopic cholecystectomy was performed after the procedure without any complication during ERCP. The complication did not develop in the per-operative period and the patient was discharged on the first postoperative day.

Conclusion

It is very rare that both the odd sphincter tonus is reduced (dysfunctional odd sphincter) and the anomaly of papilla opening together with many reasons for air in the bile ducts. Presence of cholecystitis picture together with these two findings in our case made us consider the emphysematous cholecystitis and the picture of bilioenteric fistula before performing ERCP. The detection of anomalies of the papilla opening with ERCP and removing the biliary sludge in choledoch made cholecystectomy under elective conditions safer. We are of the opinion that anomaly of papilla opening and dysfunctional oddi sphincter in the presence of pneumobilia should always be kept in mind and imaging bile ducts with interdisciplinary approach before the surgery would facilitate diagnosis and thus prevent possible morbidity and mortality and make safer surgical intervention.

TJS. 2018;34(Suppl-1):S516–S517.

PP-0604 [Hepatobiliary Surgery]. Mixed Adenoneuroendocrine Carcinoma with Distal Choledoch Location

Yiğit Düzköylü ^1,^✉, Orhan Aras ¹, Erdal Birol Bostancı ¹

Introduction

Mixed adenoneuroendocrine carcinoma (MANEC) is a rare pathology and is diagnosed by immunohistochemical examination. In the literature, case presentations and rarely series have been published. Due to the rarity of the treatment, the treatment recommendations still vary according to the various authors and the place of location. One of the two most important diagnostic criteria is that each component constitutes at least 30% of the tumor and both components are malignant. The biliary location is very rare, and the number od studies reporting distal choledochus placement is only a few. We aimed to present the pathological diagnostic features, surgical treatment and follow-up parameters of this rare tumor with a patient who had a diagnosis of MANEC with distal choledoch localization.

Case

A 70-year-old male patient was admitted to the clinic with dyspepsia, nausea and weight loss. Following radiological studies and laboratory findings, a mass with malignant features of the distal choledoch was observed. Pancreaticoduodenectomy was performed following preoperative preparations. Histopathological examination showed that the mass was consistent with the mixed adenoneuroendocrine tumor. The adenocarcinoma component was well differentiated and neuroendocrine component consitituted more than 30% of the tumor and had grade 1 features. The tumor was accepted as pT2 and perineural, intraneural and lymphovascular invasion was observed. Surgical margins were negative. The patient was discharged without any complications on postoperative 14th day. Thee patient received postoperative short-term adjuvant chemotherapy and continued to be followed without any recurrence at the 26th postoperative week.

Conclusion

MANEC is a very rare diagnosis and was defined by the World Health Organization in 2010 as neoplasms containing epithelial and neuroendocrine components. Cordier was the first researcher to define as a two-component gastrointestinal tumor in 1924. To date, MANECs have been shown in various localizations in the literature and the cases of distal choledoch is still a few. Unlike the literature in our case, metastasis was not observed in the liver. Although it has been 100 years since its first diagnosis, it has been still undefined and there are controversial findings due to its low incidence.

TJS. 2018;34(Suppl-1):S517.

PP-0605 [Hepatobiliary Surgery]. Migration of the Pancreaticojejunostomy Stent to the Biliary System; a Rare Complication of Pancreaticoduodenectomy and its Non-Operative Treatment

Yiğit Düzköylü ^1,^✉, Deniz Öçal ¹, Erdal Birol Bostancı ¹

Introduction

Pancreaticoduodenectomy (PD) is a complex procedure involving three separate anastomoses. Placement of stent to the pancreatic canal is thought to be useful in maintaining anastomotic safety and continuity. Although it is an effective choice, the procedure has various complications and migration of pancreatic stent to the biliary system can be rarely observed. In this case, we aimed to present the migration of placement of stent preoperatively to hepaticojejunostomy (HJ) anastomosis.

Case

The patient was a 37-year-old woman who underwent Whipple procedure due to pancreatic head cancer two years ago. Pathologic examination was consistent with adenocancer and the surgical margins were clear. Short-term chemotherapy was applied postoperatively. She was admitted to the outpatient clinic with the complaint of jaundice. Bilirubin levels were high in the laboratory findings (total 12.6, direct 11.3). Computerized tomography with intravenous contrast showed that the pancreaticojejunostomy (PJ) stent migrated to the HJ anastomosis site. After consultation with the interventional radiology department, a right posterior bile duct was entered and hepaticojejunostomy stricture was expanded with balloon dilatation and the stent was pushed into the small intestine with calculus. After one week no bile duct dilatation was observed and bilirubin levels began to decline.

Conclusion

Pancreaticojejunostomy stent placed during the whipple procedure is the standard method for many surgeons to prevent anastomotic leaks. However, many studies published in the literature show various complications of the stent including migrations. Stent migration is most common in the small intestine. Rarely, PJ stents can be delivered to the biliary system via choledochoduodenostomy. In our case, the stent reached the HJ area, leading to local inflammation and consequent stenosis, causing obstructive symptoms such as icterus. Although migration of surgically inserted internal stents is rarely reported in this way, it should be kept in mind in patients who develop icterus postoperatively, and non-operative treatment methods should be tried first.

TJS. 2018;34(Suppl-1):S518.

PP-0606 [Hepatobiliary Surgery]. Fuzzy Mathematical Model in the Risk Assessment of Postoperative Complications and Selection of Individual Surgical Tactics in Patients With Obstructive Jaundice

Cabbar Hajiev ¹, Elman Tagiev ¹, Novruz Hajiev ¹, Reyhan Shikhlinskaya ¹

Introduction

There are various opinions with regard to choosing an appropriate surgical tactics when treating obstructive jaundice, and postoperative complications and high mortality caused by this pathology require close attention by the specialists.

Aim

Creation of a fuzzy logic model to predict the risk of postoperative complications and to select an individual optimal surgical approach and the evaluation of its clinical efficiency in obstructive jaundice caused by choledocholithiasis.

Material and Methods

Clinical efficacy of the original mathematical model that we created based on the Lutvi–Zad’s fuzzy logic theory was studied in 150 patients with obstructive jaundice. By selecting seven criteria of a greater prognostic significance affecting the postoperative complications, their linguistic indicators were evaluated, and based on the scheme of the phase logic output, the following sequences were defined for all fuzzy input and output variables: X1, patient’s age {«middle» (up to 60 years), «old» (more than 60)}; X2, duration of jaundice {«short» (1–7 days), «little» (8–14 days), «much» (15–21 days), «more» (more than 21 days)}; X3, temperature {«normal» (37.0°С –38.0°С), «high» (38.1°С –39.0°С), «higher» (more than 39.0°С)}; X4, comorbidities {«compensation» (0), «subcompensation» (0,5), «decompensation» (1,0)}; X5, the level of liver dysfunction {«I⁰» (total bilirubine up to 50 mcmol/l), «II⁰» (50–100 mcmol/l), «III⁰» (100–200 mcmol/l), «IV⁰» (more than 200 mcmol/l)}; X6, CD4⁺ in the blood {«low» (more than 25%), «middle» (17.0%-25.0%), «high» (up to 16%)}; X7, interleukin-2 in the serum {«low» (more than 35.0 pcq/ml), «middle» (25.0–35.0 pcq/ml), «high» (up to 25.0 pcq/ml)}; Y, level of risk {«low» (0.0–0.49), «suspicion» (0.5), «high» (0.51–0.8), «higher» (0.8–1.0)}.

The values of input variables were introduced into the model and transformed in the “Phaser” block. The seven input and one output variables using the FUZZY LOGİC sub-system of the MATLAB TOOLBOX software are connected with the fuzzy logic model.

Results and Conclusion

(1) The risk is absent or low: (A) (Y=0.0–0.49), an unambiguously one-stage approach is used; (2) suspected risk: (B) (Y=0.5), if the risk assessment in the dynamics after the preoperative therapy decreases, then use tactics A; if the score does not decrease or increase, use tactics C; (3) high risk (Y=0.51–0.8) and very high risk (Y=0.81–1.0): (C) A multi-stage surgical approach is used.

According to the defned level of risk, in 92 patients, a one-stage procedure was used, while 58 underwent a two-stage procedure. In these patients, the rate of postoperative complications was reduced to 4.7% and mortality rate to 1.3% due to the optimization of surgical tactics.

Thus, the proposed model specifically allows to evaluate the degree of risk of postsurgical complications, select individual surgical tactics, and significantly improve treatment results for each patient.

TJS. 2018;34(Suppl-1):S518–S519.

PP-0607 [Hepatobiliary Surgery]. ERCP-Associated Periampullary Retroperitoneal Choledochal Perforation: Two Case Reports

Furkan Savaş ¹, İbrahim Kılınç ¹, Şevket Barış Morkavuk ^1,^✉, Abdussamed Yalçın ¹, Ali Coşkun ¹, Mehmet Kılıç ¹

Introduction

Endoscopic retrograde cholangiography (ERCP) is a method for the treatment of obstruction and the imaging of the bile duct and pancreatic duct. It is the most frequently used diagnosis and treatment method in both benign and malignant obstructive icterus. It is a procedure that has serious complications as well as being an advanced diagnosis and treatment method. When the literature is examined, morbidity rates of up to 10% and mortality rates of up to 1% are observed. Complications such as pancreatitis, hemorrhage, and cholangitis are common after ERCP procedure. Perforation is a rare but most feared complication and most commonly associated with mortality. In this study, we aimed to present two patients with periampullary retroperioneal perforation after ERCP with literature.

Case 1

A 53-year-old female patient was admitted to the emergency service with a right upper quadrant abdominal pain complaint. WBc and Hgb were monitored in the normal range in laboratory evaluation at the time of admission. ALP 359 U/L and GGT 455 U/L and normal and direct bilirubin were found between normal limits. The patient was hospitalized in the gastroenterology department upon observing stone in bile duct lumen and stenosis in distal choledoch in abdominal USG. Stenosis in distal choledoch was observed in the patient who underwent ERCP.

Minimal hemorrhage was observed in the patient who underwent EST after sweeping with balloon. After the adrenaline injection hemorrhage control of the patient was provided, increase of Wbc and CRP was observed and defense and rebound in all quadrants, being especially evident in the right quadrant, were positive in the abdominal examination.

The whole abdominal CT revealed free air prominently in the paraduoednal and subhepatic area, and free fluid between the pelvis and the bowel loops. Considering perforation, the patient was performed laparotomy. The hepatoduodenal ligament was explored. The choledoch was suspended. After duodenum coherization, periampullar posterior choledochal perforation was observed. T-tube was placed by performing choledochotomy. The operation was terminated. In the follow-up, the patient had no additional pathology and was discharged on the 21st postoperative day after removing t-tube catheter.

Case 2

A 79-year-old female patient underwent ERCP in the gastroenterology department upon observing choledochal 15mm dilated lesion consistent with stone in the lumen in USG and MRCP reports of. Stone extraction by sweeping with balloon in ERCP and EST were performed. Patient with abdominal pain finding in the physical examination underwent acute abdominal CT and it revealed free air in paraduodenal region and then was consulted to our clinic. Retroperitoneal periampullary choledocheal perforation was observed at the exploration of the patient who had undergone operation with the prediagnosis of perforation. We performed a choledocotomy after primary repair and placed a T-tube. The patient whose T-tube was removed on the postoperative 21st day was discharged with healing.

Conclusion

Perforations caused by ERCP are known as Howard classification. Type 1 is papillary distant duodenal perforation, type 2 is periampullary perforation and type 3 is guide wire perforation. Early diagnosis and treatment is life saving. Otherwise mortality rates associated with biliary peritonitis and sepsis is quite high. For type 1 perforations, surgical intervention should be performed as in the upper GIS perforation. Biliary diversion and biliary drainage should be performed in type 2 and type 3. T-tube drainage, drainage gastrostomy and duodenostomy applications and nutritional jejunostomy opening are among the methods to be applied according to the localization of the perforation.

TJS. 2018;34(Suppl-1):S519.

PP-0608 [Hepatobiliary Surgery]. Association Between Forms of Inflammation and Antimicrobial Peptides in Acute Calculous Cholecystitis

Cabbar Hajiyev ¹, Novruz Hajiyev ¹, Shahla Gasimova ¹

Introduction

In any inflammatory process, regardless of the cause, cytokines and antimicrobial peptides (AMP) play the major role. Although the cytokine profile in the acute calculous cholecystitis has been studied, AMP has not been studied sufficiently.

Aim

To study the relationship between the forms of inflammatory and AMP in acute calculous cholecystitis.

Material and Methods

The study was carried out on 69 patients who underwent surgery due to catarrhal (26 patients), phlegmonous (24 patients), and gangrenous (19 patients) cholecystitis. The α-defensin (HNPα) and endotoxin levels in blood serum were identified by the IFA method (“Hycult Biotech” kit), the bactericidal-permeability-increasing (BPI) protein by BPI-IFA-BEST (“Vector-Best”), and hepsidine by the direct IFA method. Neutrophil elastase (NE) and lactoferrin (LF) have also been studied in patients. The indicators of 10 healthy individuals were taken as a norm.

Results

Generally, in the preoperative period, compared with norm, the concentration of HNPα in blood significantly increased 2.4 times; BPI, 6.9 times; endotoxin, 8.6 times; NE, 3.2 times; LF, 2.2 times; and hepidine, 3.5 times. Further studies have shown the interaction between AMP and morphological forms of inflammation in the blood. The HNPα blood levels were 162.1±6.6 ng/ml in the catarrhal form; 216.5±10.7 ng/ml in the phlegmonous form; and 344.1±11.6 ng/ml in the gangrenous form of acute calculous cholecystitis. Similar analogs have also been found for other AMPs. In patients with a gangrenous form of acute calculous cholecystitis, the level of BPI protein, endotoxin, NE, LF, and hepsidine in blood compared with catarrhal and phlegmonous forms was higher 3.5 times (P₁<0.001) and 16.5% (P₂<0.05); 2.1 times (P₁<0.001) and 38.2% (P₂<0.001); 90.3% (P₁<0.001) and 42.7%; 68.9% (P₁<0.001) and 37.9% (P₂<0.001); and 54.4% (P₁<0.001) and 37.7 (P₂<0.001), respectively.

Conclusion

In patients with acute calculous cholecystitis, the level of AMP concentration in the blood directly depends on the morphological form of inflammation.
AMP indicators can be used as informative biomarkers in early diagnosis of destructive forms of acute calculous cholecystitis.

TJS. 2018;34(Suppl-1):S520.

PP-0609 [Hepatobiliary Surgery]. The Importance of Biomarkers in the Early Diagnosis of Destructive Cholecystitis

Rena Babayeva ^1,^✉

Introduction

The early diagnosis of acute calculous cholecystitis (ACC), which is included in the wide practical area of modern diagnostic agents, is actual. Therefore, delayed diagnosis of acute cholecystitis causes destruction in the gallbladder, some dangerous complications and even death. In this regard, biological markers like inflammatory processes have high sensitivity and include acute phase proteins (APP)

Objective

To investigate the clinical importance of C-reactive protein (CRP) and ferritin in early diagnosis in the destructive forms of APP ACC.

Material and Methods

In the study, 37 patients operated for the diagnosis of ACC were examined. The patients were divided into 3 groups by considering the clinical and morphological form of ACC: Group I - cataract form (12 patients); Group II - phlegmonous form (14 patients), and Group 3 with gangrenous patients (11 patients).

Results

Generally in all patients, preoperative plasma values of CRP was 8,5±0,7 mg/l (2,4 times higher than in healthy individuals; p<0,001) and ferritin level was 327,8±16,8 nq/ml (2,4 times higher than normal, p<0,001). Further studies have revealed the direct relationship between the morphologic form of inflammation in the gallbladder and both APPs in the plasma. The highest levels of CRP and ferritin were 16.3±1.4 mg/l (norm 3.5±0.4 mg/l) and 520.0±34.2 ng/ml (norm − 136.1±8.1 ng/ml) in the ACC gangrenous form. The levels of CRP and ferritin in the plasmide inflammation in the gallbladder were 12.4±1.1 mg/l and 438.1±20.2 ng/ml, respectively. The lowest level of both biomarkers was detected in the catarrhal form of ACC: CRP − 6,1±0,8 mg/l and ferritin − 262,9±11,6 nq/ml.

Conclusion

According to the obtained data, CRP and ferritin represent the morphological form of the inflammation in the gallbladder and they can be used as informative biomarkers in the early diagnosis of destructive forms.

TJS. 2018;34(Suppl-1):S520.

PP-0610 [Hepatobiliary Surgery]. Coexistence of Synchronous Ampullary Adenocarcinoma and Liver Hepatocellular Carcinoma

Ömer Yalkın ^1,^✉, Salim İlksen Başçeken ¹, Serdar Çulcu ¹, Ferit Aydın ¹, Cemil Yüksel ¹, Ali Ekrem Ünal ¹

Ampulla of vater adenocarcinoma is rarely found in periampullary regional tumors. It causes obstruction of the bile duct due to localization and thus early diagnosis is made. Although there are minimal invasive approaches such as local excision for treatment, the gold standard is pancreaticoduodenectomy. Hepatocellular carcinoma is the most common primary malignant tumor of the liver and its incidence is between 20–200/100,000. A 62-year-old male patient presented with a jaundice, which occasionally disappeared. The biopsy performed from the lesion having malignant appearance in ampulla was reported as ampulla adenocarcinoma in the gastroscopy performed. Tumor markers were normal and the patient was operable in preoperative imaging studies and distant metastasis was not observed. In laparoscopic exploration, a 2 cm diameter mass was observed in segment 3 of the liver. Frozen was sent. It was stated to be consistent with hepatocellular carcinoma. Then a laparoscopic Whipple procedure was conducted and a segmental liver resection was performed. He was discharged without any problems on the 5th day after surgery. Pathology result was reported as ampullar adenocarcinoma T2N0 and moderately differentiated hepatocellular carcinoma. We aimed to present the coexistence of ampullary adenocarcinoma and hepatocellular carcinoma which have not been previously reported in the literature.

TJS. 2018;34(Suppl-1):S520–S521.

PP-0611 [Hepatobiliary Surgery]. Postpartum Spontaneous Choledochal Perforation

İlhan Zencirci ¹, Burcu Mühürdaroğlu Timurlenk ^1,^✉, Atila Sayar ¹

Spontaneous choledochal perforation is a rare condition in adults and may lead to biliary peritonitis. Cholelithiasis, choledochal cysts, and tumor obstruction of ampulla are among the etiological factors that are accused. Development of spontaneous choledochal perforation is rare in adults without etiological factors and is limited to only a few cases in the literature. Biliary system stone diseases are the second most common cause of non-obstetric cases requiring surgical interventions in pregnants.60–70% of the patients are asymptomatic. Biliary colic is seen at a rate of 1%. Choledochal stone is a rare condition in pregnancy and is seen in 10% of pregnant patients who underwent cholecystectomy.7–10% of jaundice in pregnancy is due to choledochal stone. It has been shown that there was biliary sludge in ¼ of the pregnant patients and gallstone in 5% of them in pastpartum period. The frequency of gallstone formation increased within 5 years. Our case who was a post-partum female patient, after preterm labor at the age of 17, was operated with acute abdominal picture and perforation was seen in the posterior part of the distal choledoch. Cholecystectomy, primary repair of choledoch and T-tube drainage from the perforation region were performed. ERCP was applied with T-tube 2 weeks later. Then T-tube was withdrawn after 6 weeks. The patient was discharged with healing.

Case

A 17-year-old female patient was referred to the general surgery department for complaints of abdominal pain, nausea and vomiting that started suddenly on postpartum day 1 after preterm labor. Physical examination of the patient with no systemic comorbidities showed extensive defenses and rebound. There was no significant laboratory finding other than leucocytosis (19.500 gr/ dl) and hyperamylasemia (365 U/L). Abdominal ultrasonography (USG) and computerized tomography (CT) revealed that the bile duct was hydropic and pericholecystic, peripancreatic fluid was present. It was evaluated as acute cholecystitis or bile duct perforation with imaging methods and laboratory tests. The patient, whose clinical findings did not regress in her follow up with conservative treatment, was taken to the operation urgently. In laparotomy, fluid with intense bile was present in the abdomen especially in the subhepatic area. It was observed that the sac was hydropic, and the stone was not palpable. A 1 cm perforation area was detected in the posterolateral part of the distal coledoch at the exploration site. After the cholecystectomy was performed, the choledoch is irrigated with isotonic solution and the transition to papilla was controlled. No choledochal stone, papilla stenosis, choledochal cyst or pancreatic mass were detected. Primary sutures were placed in the perforation area, T-tube drains were applied into the choledoch, and the lodge was drained. Postoperative biliary leakage was not seen. She was referred to a center where Ercp was performed on the postoperative 14th day. The patient’s T-tube was removed 4 weeks after Ercp. The patient was discharged with healing.

TJS. 2018;34(Suppl-1):S527.

PP-0622 [Hepatobiliary Surgery]. Hepatocellular Carcinoma Imitating Liver Abscess

Burak Çelik ^1,^✉, Feza Ekiz ¹, Ali Fuat Kaan Gök ¹, Abdil Cem İbiş ¹, Arzu Poyanlı ²

Hepatocellular carcinoma (HCC) is the most common primary tumor of the liver and can manifest itself in many different ways. It may also develop without a known risk factor. We present a case of hepatocellular carcinoma that imitates hepatic abscess that we successfully treated. A 20-year-old female patient was admitted to the emergency unit with complaints of fever and abdominal pain. There was an increase in leukocytosis and acute phase indicators in the examinations performed. The whole abdominal ultrasonography and computed tomography showed a heterogeneous mass lesion of approximately 15 cm in diameter, which was thought to be originated from the left lobe of the liver, and abscessing mass lesion with air bubbles. Transaminases were elevated. As a preliminary diagnosis, liver abscess was considered, but magnetic resonance imaging was performed in terms of mass characterization and it was found that the mass contained necrotic areas and was solid. The patient was prepared for surgical exploration with intravenous antibiotic therapy and fluid support. In the exploration, a mass originating from the left lobe of the liver was determined and left lateral sectionectomy was performed. The patient who had an uncomplicated postoperative period was discharged on the 7th postoperative day. On histopathological examination, the mass was evaluated as a well differentiated hepatocellular carcinoma with 90% coagulative necrosis. Patients with hepatocellular carcinoma may come to the hospital with various clinical scenarios. In the differential diagnosis of liver masses, advanced imaging methods play an important role in acute abdominal pain and fever. Hepatocellular carcinoma should be considered in differential diagnosis in young patients in whom there is no known risk factor.

TJS. 2018;34(Suppl-1):S527–S528.

PP-0623 [Hepatobiliary Surgery]. Paraoxonase and Oxidative Stress Parameters in Patients with Acute Pancreatitis: Prospective Clinical Trial

Esra Yüksel ¹, Sema Yüksekdağ ¹, Özgül Düzgün ¹, Neslihan Karaağaç ², Hafize Uzun ³, Ali Rıza Kızıler ⁴, Ömer Faruk Özkan ^1,^✉, Ethem Ünal ¹

Objective

In this study, we investigated the possible role of paraoxonase (PON-1) in acute pancreatitis physiopathogenesis and clinical follow-up as a lipophilic antioxidant enzyme transported by HDL (high density lipoprotein) cholesterol. In addition, we evaluated the correlation with known biochemical parameters and clinical severity scores by presenting the possible relationship between other antioxidant agents, oxidative stress and lipid profile.

Material and Methods

Blood was drawn from the patients diagnosed with acute pancreatitis and followed in our clinic at the time of admission (0 day), 3rd day and 10th day and hemogram, broad biochemistry, lipid profile, PON-1 and oxidative stress parameters (malonyl dialdehyde, MDA, superoxide dismutase, SOD, total antioxidant capacity, TAC) were analyzed. Clinical scores were noted and correlated with biochemical results, including demographic data and radiographic imaging methods of all patients. Statistical analyzes were performed with Kolmogorov-Smirnov, Friedman and Wilcoxon tests, Spearman test was used for correlation, and p<0.05 was considered significant.

Results

The mean age of 25 patients was 51.4. Ranson scores were calculated as 0–2 points (60%), 3–4 points (24%) and 5–6 points (16%) respectively. According to computed tomography severity index (CTSI); 72% mildly severe, 24% moderate, and 4% of them had severe pancreatitis picture. Clinical severity of the disease was noted as mild, moderate and severe pancreatitis (64%, 28% and 8%, respectively). When the biochemical data were analyzed, it was seen that the values of LDH (mean 452.5 U/L) and AST (mean 417.08 U/L) were reflected in Ranson scores. Total cholesterol, triglyceride, and LDL (low density lipoprotein) values remained at the normal reference interval, while HDL level was significantly higher than the 10th reference interval (p<0.001) while the 3rd and 10th day tended to decrease significantly. PON-1 levels were calculated at mean values of 69.23, 76.72 and 113.15 U/mL at 0, 3rd and 10th days, respectively; there was a positive correlation with HDL (p<0.001). MDA level decreased significantly (mean 3.9 vs. 2.28 μM/L, p<0.001) while serum SOD level increased in parallel with PON-1 (mean 20.49 vs.39.46 U/ mL). TAC increased significantly with treatment (mean 0.52 vs. 1.22 mM/L).

Conclusion

Radiologic and clinical severity scores are compatible in patients with clinically mild pancreatitis associated with gallstone. The low PON-1 and HDL levels detected in the initial phase of acute pancreatitis and the antioxidant SOD and TAC concentrations increase with clinical positive correlation with treatment; MDA, which is an oxidative stress marker, which is initially elevated, falls in parallel. This demonstrates the importance of the balance between oxidative stress and antioxidant defense mechanisms in the clinical course of the disease and the potential to use PON-1 as a clinical marker.

TJS. 2018;34(Suppl-1):S528.

PP-0624 [Hepatobiliary Surgery]. Is Laparoscopic Approach to Complicated Liver Cyst Hydatid Patients Possible?

Mehmet Ali Gök ^1,^✉, Mehmet Tolga Kafadar ²

Objective

Cyst hydatid disease remains a common health problem for our region and country. In this clinical retrospective study, complicated liver cyst hydatid cases treated laparoscopically were examined.

Material and Methods

We retrospectively reviewed the medical records of 8 complicated patients (5 women, 3 men; mean age 45±4.42; range 30 to 78) who were treated for liver cyst hydatic in our clinic between June 2016 and October 2017. Patients were evaluated in terms of age, sex, location of cyst, surgical method applied, duration of hospital stay, preoperative and postoperative complications and treatment methods applied for complications.

Results

The longest mean diameter of the cases detected by ultrasonography was evaluated as 82.6±7.53 mm. When we looked at the anatomical location of the cysts in the liver, it was observed that they were located in segment 8 in 3 patients, segment 4 in 3 patients and segment 2 in the other 2 patients. Two patients (25%) were evaluated as ASA 1, 3 patients (37.5%) as ASA 2, and 3patients (37.5%) as ASA 3. Mean operation duration was 68±8.91 minutes. The longest surgery lasted 115 minutes and the shortest surgery lasted 45 minutes. Perioperative bleeding occurred in one of the patients. Bleeding control was provided with vascular ligation. Three patients were found to have bile duct involvement during the operation. It was repaired primarily and laparoscopically. Bile fluid was observed (150 cc per day) in one patient. Postoperative ERCP was performed. During the follow up of the patient, bile drainage was reduced and the biliary fistula closed itself. The mean duration of hospitalization was 4 (min: 2; max: 9) days. The patient developed a biliary fistula and was discharged on the 9th postoperative day. The mean follow-up period of the patients was 6±4.15 months. No finding to consider recurrence was found in any of the patients who were followed-up at the outpatient clinic and evaluated every 3 months with USG. There was no correlation between the age of the patients and the diameter of the cyst (p=0.460). There was no significant correlation between the diameter of the cyst and the operation duration (p=0.818). There was no significant correlation between age and operation duration (p=0.626). The relationship between diameter and duration was statistically significant (p=0.005). It was determined that as the diameter of the cyst increased the duration of operation extended.

Conclusion

We did not find any recurrence in our follow-ups. Laparoscopic Liver Cyst Hydatid surgery is a surgical technique that combines the advantages of open surgery and percutaneous interventions. We think that removing the endocyst and exocyst that we routinely extract is sufficient. Today, laparoscopic surgical interventions in experienced centers take place in the treatment algorithm as an effective and safe method in the treatment of liver hydatid cyst disease. We think that standard laparoscopic instruments are sufficient for the surgery of complicated hydatid cysts.

TJS. 2018;34(Suppl-1):S528–S529.

PP-0625 [Hepatobiliary Surgery]. Case Report of Spleen Infarction Developing after P. Falciparum

Yasin Alper Yıldız ^1,^✉, Necattin Fırat ¹, Yeşim Akdeniz ¹, Merve Yiğit ¹

Introduction

Splenic infarct is a rare spleen pathology that is often seen as a complication of other diseases and malaria is a rare complication that occurs most commonly during malaria infection, which is caused by P. falciparum or P. vivax. Plasmodium falciparum infection is rare in our country, but has been reported in cases of travel stories to endemic regions. As a complication of malaria, splenic infarct has been reported in very few cases.

Case

A 35-year-old male patient presented with a fever complaint to the emergency service and was evaluated by the department of infectious diseases. White cell 4.2 K/uL platelet 56.7 K/uL crp 99.5 mg/L P. Falciparum was seen in peripheral smear. The patient had a malaria diagnosis due to P. falciparum. Artemeter Lumefantrine treatment was initiated and completed in 4 days. P. falciparum was not observed in the new smear and the patient was discharged with healing from infectious diseases. One week later, the patient was admitted with complaints of abdominal pain in the emergency department. Defense and rebound were positive in the physical examination and there was acute abdominal findings. White cell 11.2 K/Ul CRP, 75.2 mg/L procalcitonin normal, platelet 191000 K/uL. Computed Tomography (CT) revealed that the spleen was larger than 15 cm and there was hypodense areas (splenic infarction) with no significant contrast enhancement, it was stated that it gained an abseiform appearance. Operation decision was made. Splenectomy was done. The postoperative complication did not occur. The patient had oral intake and he tolerated. Hemogram and vital findings were stabilized and the patient was discharged with healing.

P. falciparum malaria is seen especially in tropical regions. P. vivax is usually seen in our country. P. falciparum and P. malaria malaria were also found in the stories of patients who travelled abroad. P. falciparum has a severe course and it is the most fatal malaria and has a clinic of chill, shivering, fever and sweating as in other malaria species. Since surgical methods are generally not preferred in the treatment of patients, histologic examination usually could not be performed. In a case reported by Hovette et al., a microscopic examination of the spleen showed that the infarct was surrounded by fibroblastic granuloma tissue. Our case was interpreted as a spleen containing infarct areas. In the studies examining the occurrence of splenic infarct, it is known that most of the patients are young (3–30 years). Our case was 35 years old. In the literature, splenic infarcts appeared 7 to 30 days after the start of treatment and most cases developed due to P. falciparum malaria. In 60–70% of cases, there is pain in the left upper quadrant of the abdomen. In our case complaints started after a week of treatment and the patient presented with complaints of abdominal pain. Splenic infarct usually responds to medical treatment and has good prognosis. Surgery is not considered unless there is bleeding, rupture, abscess and pseudocyst. In our case, the infarct area became in the form of an abscess.

Hepatic adenoma is a capsular benign tumor as result of benign proliferation of hepatocytes. It is most commonly seen in women using oral contraceptives. About 85% of cases with hepatic adenomas consist of young women and are unlikely to be seen in children, men and the elderly. About 10% of patients are asymptomatic and are detected incidentally; about 50–60% of the patients present with abdominal pain or mass complaints. 30–40% of the cases are admitted to the hospital with shock and acute abdomen as a result of hemorrhage. The atypical condition in our case was that the patient was an old male. Patient with sudden hemoglobin decline and tachypnea, dizziness, sweating and severe abdominal pain was admitted to the external center. He was referred to us with the diagnosis of liver hemangioma rupture as a result of examinations performed here. It was observed as a result of the first interventions that the patient had hemorrhagic shock and emergency laparotomy was performed. After hemostasis was achieved, the lesion with hemangioma pre-diagnosis was sent to pathology and the operation was terminated. Pathology resulted in hepatic adenoma. Hepatic adenomas carry a markedly spontaneous rupture risk with intraperitoneal hemorrhage and are admitted with up to 25% of abdominal pain. In this case; spontaneous rupture due to hemangioma was first considered with laboratory and imaging findings but histopathologic diagnosis after surgical resection was seen as a rare hepatic adenoma in men and in the elderly.

TJS. 2018;34(Suppl-1):S531.

PP-0630 [Hepatobiliary Surgery]. Hepatic Arterial Pseudoanalysis Occurred During the Placement of the External Drainage Catheter to the Patient with Biliary Leakage Developing Intraabdominal Abscess after ERCP

Semih Yaman ^1,^✉, Mustafa Şit ¹, Bahri Özer ¹, Oğuz Çatal ¹, Muhammet Fatih Keyif ¹, Selçuk Köksal ¹, Elif Yalçın ¹, Özgür Kuttkulağı ¹, Mehmet Hayri Erkol ¹

Hepatic artery pseudoaneurysm is a rare vascular complication. It occurs in about 2% of patients. Intrahepatic pseudoaneurysms usually occur after liver biopsy or transhepatic biliary drainage. It may be ruptured and may be the cause of bleeding. If an arteriovenous fistula or pseudoaneurysm is detected, it is usually embolized. Visceral artery pseudoaneurysms are rare, but their mortality is high. They initiate immediately and the first clinical symptom of these aneurysms is acute rupture and is associated with haemodynamic instability causing perioperative morbidity and mortality. Hepatic artery aneurysm has the fourth place among intra-abdominal aneurysms after infrarenal aorta, iliac arteries and splenic artery. Hepatic artery aneurysms have 80% extrahepatic and 20% intrahepatic localization. Intrahepatic pseudoaneurysms usually occur after liver biopsy or transhepatic biliary drainage. The most important detail of our case was that if the USG had not been performed by an experienced and careful radiologist after the external abscess drainage, the hepatic artery pseudoaneurysm could be interpreted in favor of the abscess and attempted to drain it and encounter a serious and very mortal picture. We would like to emphasize that careful attention should be paid to pseudoaneurysms that may develop secondary to abscess drainage catheter placement, in control imagings following abscess drainage, which is especially close to the arteries. It is very easy to rupture the pseudoaneurysm when the catheter is inserted with the preliminary diagnosis that it may be a new abscess center.

TJS. 2018;34(Suppl-1):S532.

PP-0631 [Hepatobiliary Surgery]. Can Excessive Clip Use in Laparoscopic Cholecystectomy Be a Stimulating Factor in Anticipating Bile Duct Injury?

Fatih Büyüker ^1,^✉, Tuğrul Özdemir ¹, Özgür Ekinci ¹, Furkan Kılıç ¹, Medeni Şermet ¹, İhsan Metin Leblebici ¹, Gürhan Baş ¹, Orhan Alimoğlu ¹

Objective

Bile duct injury due to laparoscopic gall bladder operations is a serious complication that can cause morbidity and mortality. The reported frequency is reported at 0.2–1.1%. In this study, we retrospectively analyzed 7 cases followed and treated due to bile duct injury in terms of types of injuries and the number of clips used.

Material and Methods

Seven cases, 4 of which in our clinic, with bile duct injury between January 2016 and December 2017, were included in evaluation. The injury types of the patients were determined according to the Strasberg classification. The numbers of the clips used in the operations in which injuries occurred were determined.

Results

It was found that an average of 5.4 (3–8) clips were used in the cases. According to Strasberg classification; Strasberg D in 2 cases, Strasberg E2 in 1 case, Strasberg E3 in 3 cases, and Strasberg E4 injury in 1 case were detected. One of the patients with type D injuries underwent primary repair, and a late admitted case was treated with ERCP stenting and percutaneous biloma drainage. Bilioenteric anastomosis was performed in cases of E type injury. No complications were observed in the early postoperative period.

Conclusion

Excessive clip use during laparoscopic cholecystectomy was considered to be a stimulating factor for possible bile duct injury.

TJS. 2018;34(Suppl-1):S532–S533.

PP-0632 [Hepatobiliary Surgery]. Our Approach in Gall Bladder Cancers: Series Presentation of 51 Cases

Feyyaz Güngör ^1,^✉, Mehmet Sercan Candan ¹, Turan Acar ¹, Oğuzhan Özşay ¹, Gülden Ballı ¹, Cengiz Tavusbay ¹, Neşe Ekinci ², Osman Nuri Dilek ¹

Gall bladder cancer is the fifth most common malignant tumor of the gastrointestinal system with very low survival despite improvements in modern diagnostic and therapeutic methods and continues to be a serious problem due to the low chance of curative treatment. In Turkey, annual incidence of it is 1.6/100,000. It is usually detected in late stages when clinical symptoms occur except its detection incidentally in cholecystectomy specimens.

In this study, file data of patients with gall bladder cancer diagnosed or referred to our hospital between 2012 and 2017 were examined. According to this; the data of 51 patients, 24 of whom were male and 27 were female, were evaluated. The mean age was 66 (42–87). There were 6 (11.76%) patients between the ages of 40–50, 6 (11.76%) between the ages of 51–60, and 39 (76.42%) patients over the age of 60 years. Diagnosis was established incidentally in cholecystectomy specimens in 19 (37.25%) patients, with invasive and non-invasive imaging methods in 9 (17,64%) patients, with biopsy upon suspicion in imaging in 13 (25,49%) patients, with frozen examination performed during laparotomy because of the suspicion of gall bladder cancer in pre-operative period imaging in 10 (19,60%) patients. The distributions of 39 (76.47%) patients operated were; 24 (61.58%) cholecystectomy, 3 (5,88%) radical cholecystectomy, 2 (5,12%) hepatectomy and 10 (25,64%) patients had palliative interventions. In the postoperative period, 3 (7,69%) patients had high cholestatic enzymes, 2 (5,12%) patients had cholangitis, 2 (5,12%) patients had biliary leakage, 2 (5,12%) patients had intraabdominal abscesses and 1 (2.56%) patients developed postoperative bleeding.

Distribution of patients according to histopathology; adenocarcinoma in 43 patients (84.31%), signet-ring cell carcinoma in 1 patient (1.96%), mixed adenoneuroendocrine carcinoma in 3 patients (5.88%), squamous cell carcinoma in 2 patients (3.92%), clear cell carcinoma in 1 patient (1.96%) and adenosquamous carcinoma was diagnosed in 1 patient (1.96%). The mean life span was 9,10 (1–49) months in all patients who were followed up operatively and nonoperatively. The mean survival time was 11.46 months (1–49) months in patients treated with operative treatment and 1.41 (1–8) months in nonoperatively treated patients. Today, despite progress in early diagnosis and increased survival in gall bladder cancers, they are still one of the deadly cancers in cases of late stage. No satisfactory results were obtained with radiotherapy and chemotherapy. Today, the most effective treatment for gall bladder cancers is early diagnosis and surgery. Palliative procedures are not effective on survival in late-stage cases when resection is unlikely, but they are still applications that increase the quality of life of the patient.

TJS. 2018;34(Suppl-1):S533.

PP-0633 [Hepatobiliary Surgery]. Determination of Information Needs of Pre-discharge Patients on Laparoscopic Cholecystectomy

Hasret Kübra Zengin Çakır ^1,^✉, Ümran Dal Yılmaz ²

Objective

This study was conducted with the aim of determining the information needs of the patients who underwent laparoscopic cholecystectomy before discharge.

Material and Methods

The research was conducted with 78 patients undergoing laparoscopic cholecystectomy in Dr. Burhan Nalbantoğlu State Hospital surgical service. Data were collected between 15 December 2014 to 31 May 2015 with the data collection form created by the researcher by searching the relevant literature. The data were collected by the investigator by face to face meetings with the patients. Permission was obtained from the institutions to be carried out and from the ethics committee. Frequency analysis and Chi square tests were used in SPSS (Statistical Package for the Social Sciences) 20.0 package program in the analysis of the data.

Results

It was determined that 64,10% of the patients participated in the research were female, 44,87% were in the 30–49 age group and 41,03% were high school graduates. After the procedure, 93.59% of the patients were hospitalized for 1–3 days, 5,13% of them for 4–6 days and 61.4% of them had never undergone surgery before. According to the results obtained from the study, it was determined that 28.2% of the patients were not informed about the operation in the preoperative period and 83.3% of the patients were not informed related to the emergency cases that should be referred to the doctor after discharge. With respect to home care of patients; 85.9% of them were informed about wound care, 92.3% of them about using drugs, 78.2% of them about nutrition, and 30.7% of them were informed about activities. It was determined that 93.5% of the patients were not informed about problems that they might encounter at home. None of the patients were given t written leaflet, booklet etc. about the discharge information when they were discharged from the hospital and 82% of the patients wanted to be given a training booklet.

Conclusion

It was concluded that nurses did not take an active role in the discharge Training process of the patients. Patients want that the training book should include topics such as exercise, nutrition, wound care, drug use, things that need to be done in emergency situations to be encountered at home, pain management and postoperative information. It may be advisable to conduct planned discharge training in accordance with the individual characteristics of the patients and their learning needs and to prepare a patient Training booklet.

Footnotes

^*

There is no need to immediately perform ERCP when bilirubin values of patients who are admitted due to acute biliary pancreatitis clinic are high and tend to elevate. The clinical condition of the patient can have a tendency to improve spontaneously in the 48-hour follow-up,. Similarly, routine use of MRCP is not correct. 62% of the patients had MRCP and colechecolithiasis was detected, but 68.1% of them did not need ERCP. As a conclusion, if patients being admitted with biliary pancreatitis are exposed to an increase in bilirubin level, follow-up should be done for 48 hours. If suspicion persists, performing MRCP and ERCP should be cost-effective.

TJS. 2018;34(Suppl-1):S535–S536.

PP-0637 [Hepatobiliary Surgery]. Our Laparoscopic Cholecystectomy Experience in the Patient with Situs Inversus Totalis

TJS. 2018;34(Suppl-1):S539.

PP-0644 [Hepatobiliary Surgery]. A Rare Pancreatic Pathology; Hemangioendothelioma

İlhan Taşdöven ^1,^✉, Ramazan Kozan ¹, Gamze Yurdakan ², Mustafa Cömert ¹

Introduction

A case of hemangioendothelioma (HE), a rare pancreatic pathology, is presented in a patient with intraabdominal mass. It was aimed to draw attention to this rare pathology and location in the differential diagnosis of abdominal masses.

Case

A 24-year-old female patient was evaluated at the external center for 2 years due to ongoing abdominal pain and dyspeptic complaints. An intaperitoneal mass, 12x10x9.5 cm in diameter adjacent to the head of the pancreas located in the inferior part of the liver, displacing the 2nd and 3rd parts of the duodenum to posterior and displacing the intestinal segments in its neighborhood to posterolateral, was found in the dynamic magnetic resonance (MR) examination.

No pathological finding was found in physical examination of our patient. Upper and lower gastrointestinal endoscopy and thorax computerized tomography (CT) examinations of the patient with normal laboratory parameters were also normal. Abdominal CT revealed a lobulated contoured, intraperitoneal, solid, heterogeneous, mass having a size of 105x93x82 mm, with apparent contrast enhancement and multiple necrotic areas was observed in the anterolateral vicinity of the pancreatic head. Although, the findings were firstly interpreted in favor of neuroendocrine tumors originating from pancreas, gastrointestinal stromal tumor or paraganglioma originating from duodenum was also considered. A solid mass localized to the posterolateral of duodenum, about 12–14 cm in diameter was observed at laparoscopic exploration. It was seen that the lesion was a mass with exophytic growth pattern which did not invade neighboring structures originating from the pancreas neck in the evaluation made by switching to the open procedure for detailed exploration. The mass was excised with respect to the strict surgical margin. HE diagnosis was established in postoperative pathological evaluation.

Conclusion

HEs are intermediate class vascular tumors. The recurrence or metastatic potentials are very low. They may occur in many organs such as skin, liver, spleen and salivary glands. Localization in pancreas is very rare for HE. Patients usually present with nonspecific symptoms such as abdominal pain, jaundice, hepatomegaly, palpable mass or obstruction. Radiological differential diagnosis has some limitations, especially in lesions with close neighborhood relationship. The imaging findings of HE are similar to hemangioma except for the local invasive feature. There is no consensus regarding the procedure although the treatment is surgical. Resections that take into account intact surgical margins may be sufficient because of minimal local invasive properties, low recurrence and potential for metastases. The typical histological findings of HE are vascular structures containing erythrocyte in the lumen having diameters close to each other, and laid with bulged endothelium. It reacts immunohistochemically, with endothelial markers such as CD31, CD34 and Factor VIII antigen. In addition to capillary forming cell proliferation in our case, detection of positivity with CD34 and Factor 13a indicates an endothelial origin. As well as being a rare pathology, patients’ tumors may not be diagnosed until massive masses are formed due to behavior pattern of the tumors. It should be kept in mind that this pathology may also be located in rare locations such as the pancreas in clinical practice and the surgical procedure should be determined according to the invasion state of the disease.

TJS. 2018;34(Suppl-1):S540.

PP-0645 [Hepatobiliary Surgery]. Endoscopic Treatment of Infected Hydatid Cyst with Rupture Into Biliary Tracts

Alpen Yahya Gümüşoğlu ¹, Hamit Ahmet Kabuli ¹, Sezer Akbulut ^1,^✉, Mehmet Karabulut ¹, Osman Köneş ¹, Ali Kocataş ¹, Kıvanç Derya Peker ¹, Halil Alış ², Mehmet Emin Güneş ¹

Objective

Liver cyst hypertrophy is a serious public health problem in endemic areas. Many complications related to liver cyst hydatid can be seen. The most common one is the rupture of the cyst into the bile ducts. The findings of liver abscess and cholangitis occur after rupture into the bile ducts. We aimed to present the efficacy of endoscopic treatment in the cases who were admitted to our clinic with liver abscess and cholangitis findings.

Material and Methods

We retrospectively reviewed the data of 11 patients who had liver cyst hydatid diagnosis between 2010 and 2017 who were hospitalized with liver abscess and cholangitis diagnosis and who underwent endoscopic treatment for rupture into the bile ducts in our clinic.

Results

Seven of the patients were male and 4 were female and the mean age was 43.5 years. The location of the liver cysts was observed as 5 of them in the right lobe and 6 of them in the left lobe. The mean diameter of the cysts was found to be 6.63cm (2.5–10cm). ERP procedure was performed in the patients at an average of 3.18 times (2–8). Drainage of the abscess was performed internally in patients who underwent drainage and stenting in the first procedure, then in the second procedure, the stent was removed and the treatment was completed. Nasobilier drainage and drainage was performed washing the cyst cavity during ERP procedure in one patient. Surgical drainage was performed due to sepsis in one patient. The mean hospital stay was detected as 11.18 (2–34). While the mean follow-up period was 17 months, recurrence developed in one patient and the patient was treated with percutaneous drainage.

Conclusion

ERCP plays an active role in the treatment of ruptured hydatid cysts in the bile ducts. Endoscopic drainage is an applicable treatment method in complicated and infected cysts ruptured in biliary tracts.

TJS. 2018;34(Suppl-1):S540–S541.

PP-0646 [Hepatobiliary Surgery]. The New Diagnosis Ruptured Giant Cyst Hydatid with the Findings of Acute Abdomen

Arif Burak Çekiç ¹, Mehmet Uluşahin ^1,^✉, Muhammed Selim Bodur ¹, Mehmet Arif Usta ¹, Ali Güner ¹

Introduction

Cyst hydatid (CH) is a zoonotic disease that causes severe economic loss caused by echinococcus granulosus. In this study we present a newly diagnosed ruptured giant hydatid cyst case with abdominal computed tomography (CT) in a patient who was admitted to the emergency service with abdominal pain and considered acute abdomen.

Case

A 28-year-old female patient presented with severe abdominal pain, which started immediately 5–6 hours before and she stated that it was effective on all quadrants. There was no known disease, operation history or drug use. There was tenderness in all quadrants and defense and rebound were positive in abdominal examination. The leukocyte count in the laboratory values was measured as 11400/μL; other laboratory values were normal. Abdominal CT was performed in the patient who had diffuse fluid in all quadrants in abdominal ultrasonography (USG). In CT performed it was stated that there was type 3A CH completely covering the left lobe of the liver, germinative membrane was seen in the cyst and there was diffuse fluid in the cyst. Emergency laparotomy was planned for the patient with current examination findings and CT outcome. The abdomen was opened with supraumbilical midline incision. About 2 liters of biliary fluid was seen at exploration and was aspirated. A 20x15x12 cm CH filling almost the entire left liver lobe that still had active leakage from the rupture site was seen. After the content of the cyst in the abdomen was aspirated, compress and gauze impregnated with 20% NaCl were placed around the liver. Then part of the cyst wall was excised and opened wide and partial cystectomy was performed. The entire germinative membrane was removed from the cyst. Cystobilier connectivity presence was tested with white gauze placed in the cyst cavity. The cystobilier connections detected at three different points were closed with 4/0 prolens. Omentum was detected in the cyst cavity and omentopexy was applied. The operation was terminated by placing 1 drain both in the cyst cavity and in the abdomen. In the postoperative period, bile was observed from the drain in the cavity. The daily flow was between 500–600 cc. The patient underwent endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy and a stent was placed in the choledoch. After ERCP, the bile leakage was completely cut off. Drains were withdrawn in the following days and the patient was discharged with albendazole treatment on the 10th postoperative day. Stent was taken with ERCP one month later. No problems were detected at the outpatient clinic follow-ups.

Conclusion

Cysts hydatidic patients without specific symptoms may be diagnosed when they are admitted with complications, as in our case. Rupture is a serious complication, especially in large hydatid cysts. In these types of cases, anaphylaxis can occur and cause a mortal picture; it is necessary to be careful in this regard. Hydatid cyst cases that develop intraabdominal rupture may have recurrence in time; patients should be warned and closely monitored.

TJS. 2018;34(Suppl-1):S541.

PP-0647 [Hepatobiliary Surgery]. Stone Treatment with Percutaneous Hepatolithotomy with Minimal Dilatation in Patients Having Multiple Hepatolithiasis

Mehmet Metin Belviranlı ¹, Faruk Aksoy ¹, Ahmet Öztürk ², Mehmet Giray Sönmez ², Mehmet Aykut Yıldırım ^1,^✉, Süleyman Bakdık ³, Tevfik Küçükkartallar ¹, Mehmet Erikoğlu ¹

Intrahepatic stones cause serious morbidity and mortality. Apart from open surgical methods for the purpose of treatment, biliary decompression, endoscopic or percutaneous methods are used to remove stones in the bile ducts. It is very difficult to apply a new surgical procedure after repeated treatment interventions. Therefore, we aimed to demonstrate that intrahepatic stones can be removed with hepatolithotomy by interventional radiology guided percutaneous penetration to the bile duct, inspired by the application of percutaneous nephrolithotomy to reduce the complications.

Hepatolithotomy procedure was applied to 2 male and 1 female patients aged 26, 39 and 77 who had previously undergone different surgical procedures due to hepatobiliary diseases. It was determined that the female patient at 2 months of age underwent Kasai operation and then cholecystectomy and percutaneous or endoscopic interventions due to recurrent cholangitis. Male patients were found to have undergone bilioenteric procedures for choledoch stone 3 and 10 years ago. It was seen in the controls that there were multiple stones proximal to the anastomosis.

It was decided to apply hepatolithotomy with percutaneous intervention with urology and interventional radiology departments with a multidisciplinary approach. Intrahepatic stones were imaged under general anesthesia with a Chiba needle inserted into the left intrahepatic duct and an 8F rigid or flexible pediatric cystoscope inserted. Subsequently, the stones were broken with pneumatic lithotripter and the canals were cleaned. Cholangiograms showed that the contrast passage was smooth and there were no stones in the canals. Biliary drainage catheter was placed for drainage and the procedure was terminated. Postoperative follow-ups showed that intrahepatic stones were completely removed and biochemical parameters were normal.

The purpose of hepatolithiasis treatment is to prevent the ongoing infections, recurrent cholangitis and hepatic fibrosis and the development of cholangiocarcinoma. The treatment to be applied in patients with symptomatic hepatolithiasis should be decided after careful examination of the age, performance status, general condition and stone location of the patient.

While hepatectomy was the main treatment method for these patients, it is not recommended as the first choice treatment method in patients undergoing surgery. Extracorporeal shock wave lithotripsy (ESWL) results in patients with hepatolithiasis are unsatisfactory. It has been reported in the literature that intrahepatic bile ducts of a few cases have been cleaned by percutaneous intervention, endoscopic instruments and various lithotripters (laser, electrohydraulic, pneumatic). The nephroscopes used are larger in diameter and rigid.

It is a safe and successful method to clean stones using small diameter instruments and pneumatic lithotripters by providing minimal dilation with percutaneous intervention in patients, whether having surgical history in bile ducts or not, with hepatolithiasis with excess stone load. We are of the opinion that application of the percutaneous hepatololithotomy procedure by surgeons, who are prone to percutaneous intervention and have gained experience in the field of percutaneous nephrolithotomy over the years, will reduce stonelessness and morbidity rates and increase surgical success.

The first case was presented as a video case presentation at the 21. European Society of Surgery (ESS 2017) congress.

In addition, it was presented with the title of “New surgical technique applied with urological instruments in bilobar multiple hepatolithiasis: Ultra-mini percutaneous hepatolithotomy” in the 2017; 43(3): 371–7 issue of Turk J Urol journal.

TJS. 2018;34(Suppl-1):S542.

PP-0648 [Hepatobiliary Surgery]. Approach to the Patient with Amphysematous Cholecystitis: Case Report

Yaşar Subutay Peker ¹, Oğuz Hançerlioğulları ¹, Emine Arıcı ^2,^✉, Mehmet Eryılmaz ¹, Orhan Kozak ¹

Introduction

Amphysematous cholecystitis is a rare acute cholecystitis having a gangrenous course with gas formation in the gall bladder. It is the result of the secondary infection of gas-producing organisms on the sac wall. Clinical findings are similar to acute cholecystitis, but the onset is faster and louder. Sepsis findings can be added to the diagnosis. Cholelithiasis is seen in about half of the patients and most of them are diabetic. The treatment necessitates emergent operation since perforation and peritonitis may develop in patients having a gangrenous course. In this case report, we aimed to present our approach to a patient with gangrenous emphysematous cholecystitis, which is a case which should be treated immediately and which may result in death if not treated.

Case

A 80-year-old female patient was admitted to our clinic due to complaints of abdominal pain, nausea, vomiting, and fever. The patient has hypertension and diabetes mellitus diagnosis. Wall thickness of the sac, leucocytosis and defense were detected in the abdomen. Medical treatment was preferred to invasive methods in the patient who was considered to have acute cholecystitis, because of her age and comorbidities. The patient was taken to emergent operation upon worsening of her clinic and laboratory findings, especially upon detection of increase of CRP and WBC The patient underwent open cholecystectomy and was discharged on the fifth postoperative day without any complication.

Conclusion

TJS. 2018;34(Suppl-1):S545.

PP-0654 [Hepatobiliary Surgery]. Place of Percutaneous Cholecystostomy in Acute Cholecystitis in Comorbid Patients

Gökçe Aylaz ^1,^✉, Emil Guseinov ¹, Hüseyin Yüce Bircan ¹, Serdar Ahmet Karaca ¹, Feza Yarbuğ Karakayalı ¹

Acute cholecystitis (AC) is among emergency conditions that general surgeons encounter frequently. The most appropriate treatment is laparoscopic cholecystectomy (LC); but other treatment methods may be applied in patients who cannot undergo surgery due to the high risk of morbidity and mortality. Percutaneous cholecystostomy (PC) is one of these alternative methods. This method can be used in cases where emergency surgery cannot be performed in patients in advanced ages and having comorbid diseases. Infection is controlled by drainage of gall bladder. Cholecystectomy can be performed in more favorable and elective conditions after percutaneous cholecystostomy. We present our experience of percutaneous cholecystostomy in elderly patients with high-risk, acute cholecystitis in this study. Medical records of all patients who underwent PC at our hospital between January 2012 and January 2018 were reviewed. Our study was approved by our hospital committee. Tokyo criteria for acute cholecystitis diagnosis and grading were used. Reasons for application of percutaneous cholecystostomy are comorbidities, age or duration of symptoms. PC application decision was made by the senior surgeon looking at the profit-loss ratio. All PC applications were performed by the same interventional radiologist with local anesthesia and ultrasonography. A total of 67 PC procedures were performed at our hospital during the specified study period. Thirty-eight of the patients (56%) were male and 29 (44%) of them were female patients and the mean age was 77.64 years (range, 41–96 years). All patients with percutaneous cholecystostomy were assessed as ASA values of 3 or 4. The success rate of percutaneous cholecystostomy was 100% and the complication rate was 2.4% (n=1). The drains were held in place for six weeks. Forty-two (62%) of 67 patients underwent surgery after drains were withdrawn in their follow-up. Only two (4.7%) of the surgeries were switched to laparoscopy. The remaining 25 patients (37.3%) were followed without surgery after the drains were withdrawn and there was no recurrence of any disease in their follow-up. PC can be safely applied when LC cannot performed in elderly patients being admitted in emergency conditions with comorbid diseases and poor general condition. LC can be performed in appropriate patients after withdrawal of the drain, under elective conditions with an acceptable rate of 4.7% conversion.

TJS. 2018;34(Suppl-1):S545.

PP-0655 [Hepatobiliary Surgery]. Laparoscopic Cholecystectomy Results in Geriatric Population

Gökçe Aylaz ^1,^✉, Emil Guseinov ¹, Hüseyin Yüce Bircan ¹, Feza Yarbuğ Karakayalı ¹, Serdar Ahmet Karaca ¹

Investigation of the incidence of morbidity and mortality following laparoscopic cholecystectomy in patients aged 65 years and older. Medical records of 297 patients aged 65 years and over who underwent laparoscopic cholecystectomy were retrospectively reviewed. A total of 297 patients, 202 males and 95 females, were included in this study with a mean age of 73.11 years. The indications for surgery were chronic cholecystitis in 237 patients (80%), acute cholecystitis in 43 patients (14.4%), cholecystokoledocholithiasis in 10 patients (3.3%) and biliary pancreatitis in 7 patients (2.3%). Eight patients (2.6%) required laparotomy. Patients with the American Anesthesiologists Association score III or IV had a higher postoperative complication frequency and longer hospital stay (p≤0.05) than patients with the American Anesthesiologists Association score I or II. Advanced age is not a contraindication to laparoscopic cholecystectomy and laparoscopic cholecystectomy can be safely performed in elderly patients. However, the incidence of postoperative complications and the length of hospitalization increase with the increasing scores of the American Anesthesiologists Association.

TJS. 2018;34(Suppl-1):S545–S546.

PP-0656 [Hepatobiliary Surgery]. Hemangioma: A Disease that Should not be Overlooked

Zeynep Altın ¹, Banu Ural ^2,^✉, Yusuf Atabay ¹, Can Akçura ¹, Ferda Uçkun ¹, Harun Akar ¹

A 39-year-old woman was admitted to the internal diseases outpatient clinic with complaints of lack of appetite for the last month, vomiting after each meal, weight loss and occasional fever. When the anemia and sedimentation elevation were detected in the routine examinations of the patient’s outpatient clinic evaluation, the patient was admitted to the internal diseases service for further examination and treatment. She had no chronic illness history. She had anemia since mid-twenties. She had smoking habit and was feeding cats and dogs at home. There was no known disease in her family history. Physical examination revealed no pathology other than scleras, pale icteric conjunctivas, and hepatomegaly in the patient. The values in her examination were; BG: 95, Urea/Crea: 20/0.6, AST/ALT: 26/22 Na: 134, K: 4.32, Ca:8.2, ALP/GGT:249/76, Bil(T/D):1.3/0.39, Alb/Glb: 3/4.2, Sedim/CRP/Procalcitonin: 140/171.6/0.17, Hgb: 6.5 Rbc: 2.71 Hct: 20 Mcv: 73.7 Mch: 20 ferritin: 8 B12: 378. Celiac marker was detected as negative. The patient having anemia and sedimentation elevation in routine examinations was examined in terms of anemia. Scopies were planned for GIS scanning due to iron deficiency. Gastroscopy was evaluated as” a mass compressing gastric mucosa, the usual antrum”. Serum Ig values in terms of anemia due to sediment elevation, inversion in the alb/globulin ratio, and myeloma were normal. There was no lytic lesion in the headgraphy. Bone marrow aspiration and biopsy were normal. The patient with fever and hepatomegaly were investigated for infectious agents. Laboratory examinations in terms of infections such as brucella, TORCH, Parvovirus, EBV, CMV, HSV1–2, Cyst HYDATIC HAV, HBV, HCV, HIV were performed. Ppd was checked. The patient was reevaluated with all the tests. No active infection was detected. CT for malignancy examination was conducted. Liver was bigger than normal(23cm) in abdominal CT. In the liver, a massive lesion consistent with hemangioma was observed with a heterogeneous internal structure of approximately 10 * 7.5 cm filling the left lobe. There was compression on the stomach from the anterior and the stomach had a collapsed appearance. The patient being reported as “Heterogeneous internal structure filling the left lobe of the liver, massive lesions with hemorrhagic foci in the internal structure, having signal characteristics consistent with hemangioma, multiple hemangiomas scattered in the right lobe of the liver with a tendency of combining with each other” was referred to the gastrosurgery council and the patient was taken over by general surgery for left hepatectomy. There were no malignancies in the pathology reports of the patient evaluated in outpatient clinic follow-ups after hepatectomy. The patients complaints regressed. Sedimentation dropped to normal values.

TJS. 2018;34(Suppl-1):S546.

PP-0657 [Hepatobiliary Surgery]. Başkent University Istanbul Health, Application and Research Center 5-Year Cholecystectomy Results

Gökçe Aylaz ^1,^✉, Emil Guseinov ¹, Hüseyin Yüce Bircan ¹, Serdar Ahmet Karaca ¹, Feza Yarbuğ Karakayalı ¹

A total of 918 patients undergoing laparoscopic cholecystectomy between January 2013 and January 2018 were examined. Age, sex, early and late complication rates, rate of switching from laparoscopic to open surgery, and switching reasons were determined. 810 patients had chronic cholecystitis (88.3%), 65 patients had acute cholecystitis (7.1%), and 43 patients had gall bladder polyp (4.6%). ERCP was performed in 94 patients due to mechanical incision. The rate of switching to Open surgery was 3.5% (32/918). The difficulty in dissecting the calot triangle and different anatomies were the main reasons switching to open surgery. The mortality rate was 0% and the morbidity rate was 7.7% (70/918). Incisional hernia occurred in four cases, and sac perforation took place during the operation in 65 cases (7.1%). There was a subcutaneous infection in 18 patients. Cholecystectomy can be safely performed with the condition of obeying the rules with open or laparoscopic methods.

TJS. 2018;34(Suppl-1):S546–S547.

PP-0658 [Hepatobiliary Surgery]. Management of a Spontaneously Perforated Liver Abscess Case Developed Secondary to Cyst Hydatid

Mehmet Selçuk Misirligil ^1,^✉, Kuzey Aydınuraz ¹, Çağatay Daphan ¹

Introduction

Cyst hydatid is a parasitic infestation caused by Echinococcus granulosus. Although the disease is usually asymptomatic, the development of abscess due to the connection with intrahepatic bile ducts especially in large cysts, and the rupture that can develop secondary to it are the causes of acute abdomen which must be kept in mind.

Case

Physical examination of a 62-year-old male patient who was admitted due to diffuse abdominal pain, impairment of general condition and mental fog had a blood pressure of 70/40 mmHg and a pulse of 144/min. There were tenderness, defense and rebound in all the quadrants of the abdomen. It is learned from his history that the patient was examined in the Department of Medical Oncology with a pre-diagnosis of malignant mass in the liver. The laboratory values of the patient were Hb 13 g/dL, leukocyte 10,600/mm3, platelet 272,000/mm3, ALT 20 U/L, AST 26 U/L, ALP 230 U/L, GGT 401 U/L, CRP 220 mg/dl. The patient was taken to the operation since right hemidiaphragm in the posteroanterior chest x-ray of the patient was elevated and computed tomography showed cystic lesions with a size 98x100 mm, in the right lobe of the liver in the posterior segment and with a size of 68x71 mm with thick wall in the anterior segment consistent with abscesses with occasional air values and due to observing diffuse intraabdominal free fluid and acute abdominal findings. It was observed intraoperatively that the cyst in the anterior of the right lobe was perforated. The germinative membrane and abscess material separated from both cysts were drained. Packing was performed to the pouches of both cysts because of the serious bleeding from the drained cystsç Intravenous meropenem therapy was initiated. The patient followed up entubated with an open abdomen in the intensive care unit and when the patient was taken to the operation again after 24 hours, it was observed that the bleeding stopped but there was significant bile drainage from both cysts. The cystic bile leaks that could be seen were sutured and pezzer drain was inserted into the cyst pouches. The patient in whom nasobiliary drain was placed due to lack of decrease in bile drainage, which was about 800 cc/day from the drains in the cyst, was discharged with healing on the postoperative 18 th day with mebendazol treatment.

Conclusion

Hydatid disease of the cyst is located in liver at a rate of 50–70%. Although most cases are recommended to be followed by medical treatment, there is indication of operation in cysts which are superficial and larger than 10 cm, including multiple daughter vesicles and having a risk of rupture spontaneously or due to trauma in liver, infected cysts, cysts related to bile duct, and cysts making compression to the peripheral organs. The probability of developing a biliary fistula is 2.6–28.6% in those treated with surgery. According to the records of the Ministry of Health, an average of 3257 hydatid cyst operations were performed annually between 1990 and 2005. The estimated number of operated cases is 0.87–6.6 in 100.000. Cyst hydatid should be considered in the prediagnosis in patients in whom mass is observed in the liver and abscess in the liver is suspected. It should not be forgotten that the large cysts are infected due to the connection with the bile ducts and may be transformed into the liver abscess. Damage control surgery approaches such as packing and intensive care follow up with open abdomen in the management of patients’ surgical treatment should be kept in mind.

TJS. 2018;34(Suppl-1):S547–S548.

PP-0659 [Hepatobiliary Surgery]. The Role of Drain in Shoulder Pain after Laparoscopic Cholecystectomy

Mahmut Said Değerli ^1,^✉, Leyla Zeynep Tigrel ¹, Yusuf Emre Altundal ¹, Gamze Çıtlak ¹, Mürşit Dincer ¹, Sercan Yüksel ¹, Ekrem Ferlengez ¹, Orçun Alpay ¹, Büşra Ekinci Biçkici ¹, Alp Ömer Cantürk ¹, Şeref Erdoğan ¹, Muzaffer Akıncı ¹

Objective

Laparoscopy and minimally invasive surgical techniques are preferred in our clinics for many reasons, and less pain in the postoperative period is one of the most important factors in accelerating the healing process. Laparoscopic cholecystectomy is a frequently performed surgical procedure in the general surgery clinic practice, but post-operative abdominal pain and shoulder pain are common symptoms. The aim of this study was to investigate whether the development of abdominal and shoulder pain after laparoscopic cholecystectomy is associated with parameters such as the amount of gas remaining in the abdomen and the use of drains after the pneumoperitoneum.

Material and Methods

Patients, who underwent elective laparoscopic cholecystectomy in the General Surgery Department of the Health Sciences University Haseki Training and Research Hospital between March 2017 and June 2017, were included prospectively consecutively without randomization after obtaining the approval of the Haseki Training and Research Hospital Ethics Committee. The patients were divided into 3 groups postoperatively according to drain usage. Group 1 was the patients for whom drain was used, Group 2 was the patients using aspirative drainage, Group 3 was the patients for whom free drainage was performed. All patients were evaluated preoperatively with Lovibond’s Depression Anxiety Stress Scale (DASS). All patients underwent surgery with pneumoperitoneum applied under 14 mmHg pressure under standard general anesthesia. Demographic data, height, weight, ASA scores, duration of operation, pneumoperitoneal time, comorbid diseases, complications of all the patients and whether additional analgesic except routine analgesic treatment was needed or not, duration of hospital stay and peroperative surgical findings were recorded. All patients received standard analgesic treatment after surgery. Shoulder and abdominal pain of the patients were defined separately at the 6th and 24th hours postoperatively using Visual Analog Scale (VAS). The patients’ data were recorded by the assistants, and the operators of the cases were not informed about the data.

Results

The mean age of the patients was 49.9±12.7 and the F/M ratio was 75/23. Mean duration of operation was 62±27, pneumoperitoneal time was 48±24. There were 31 patients in Group 1, 35 patients in Group 2, and 32 patients in Group 3. There were no significant differences between the 3 groups in terms of age, gender, BMI, duration of operation, duration of pneumoperitoneum, surgical findings (degree of difficulty), and DASS scores. No difference was detected between the 3 groups in terms of 6th hour abdominal pain, 24th hour abdominal pain and 24th hour shoulder pain. The 6th hour shoulder pain scores was lower in the group without drain and the difference was statistically significant.

Conclusion

Shoulder pain after elective laparoscopic cholecystectomy is a common finding. According to the results of this study, it was determined that shoulder pain was less seen in patients who did not use drains regardless of the type of drain. We believe that postoperative pain control should also be considered when deciding on indications for drain use.

TJS. 2018;34(Suppl-1):S548.

PP-0660 [Hepatobiliary Surgery]. Incidental Portal Vein Aneurysm: Case Report

Hüseyin Bakır ^1,^✉, Osman Şimşek ¹, Salih Pekmezci ¹

Introduction

The portal vein aneurysm was first defined by Barzilai and Kleckner in 1956, and fewer than 200 cases have been reported since that date. Portal venous aneurysms are rare, usually asymptomatic, and are detected incidentally in routine imaging studies. They constitute approximately 3% of all venous system aneurysms. While most of the aneurysms are extrahepatic, they are rarely found in intrahepatic branches. The etiology of portal vein aneurysms is not fully understood, but two forms are defined as congenital and acquired. Acquired aneurysms are more frequent and are often associated with hepatic cirrhosis and portal hypertension. In our study, intrahepatic portal venous aneurysm originating from the portal vein left branch incidentally diagnosed in ultrasonography (USG) due to dyspeptic complaints in a 59-year-old female patient was presented.

Case

A lesion with a suspicion of portal venous aneurysm was observed in the USG performed for a 59-year-old female patient with dyspeptic complaints and nonspecific abdominal pain. The patient underwent computed tomography (CT). In CT, a lesion consistent with portal venous aneurysm was detected in liver segment 4 having a size of 52 * 31 mm. Aneurysmal filling was confirmed with simultaneous Doppler USG. Abdominal magnetic resonance (MR) imaging revealed an aneurysmatic dilatation in the size of 53 * 37 mm originating from the left portal vein. It has been seen that left segmental branches of the portal vein are continuous with aneurysmatic dilatation. CT sections of the lesion. There was no evidence of portal hypertension or liver cirrhosis in terms of clinical, radiological and laboratory findings. The patient was evaluated at the Hepatobilier Surgical Multidisciplinary Council conservative treatment decision was made and the follow-up for the patient started. Currently, most of the information in the literature on portal venous aneurysms constitutes case reports or small series and is not based on evidence-based studies. Most of the portal vein aneurysms are detected incidentally and one third of them is asymptomatic. Approximately 50% of patients present with nonspecific abdominal pain complaints. Less than 10% of cases may present with symptoms such as gastrointestinal bleeding, portal hypertension or abdominal distension due to the compression of adjacent organs, and jaundice. The incidence of portal venous thrombosis can be up to 20%. The conservative approach in treatment is the best choice for most patients. Although surgery may be considered in postoperative rupture, thrombosis, or other symptomatic complications, post-operative mortality is quite high. Moreno et al. Recommend surgical treatment for extrahepatic aneurysms larger than 3 cm without thrombosis. Nevertheless, there is no definite evidence or comparative study confirming the indication for surgery.

Conclusion

Portal venous aneurysm is a rare vascular pathology. There are no controlled studies in the literature in terms of follow-up and treatment approaches of the cases. However, the general view is conservative approach and careful monitoring in asymptomatic patients. For this reason, patients diagnosed with portal venous aneurysm should be directed to specialized hepato-biliary centers and should be followed and treated here.

TJS. 2018;34(Suppl-1):S548–S549.

PP-0661 [Hepatobiliary Surgery]. Choledochal Cyst: A Disease not to Be Forgetten in Acute Cholecystitis Surgery

Oğuz Hançerlioğulları ^1,^✉, Mustafa Tahir Özer ¹, Mustafa Tanrıseven ¹, Rahman Şenocak ¹, Şahin Kaymak ¹

Introduction

Acute calculous cholecystitis is the leading cause of bile duct disease requiring urgent surgical intervention. Patients frequently present with right upper quadrant pain, nausea, vomiting and distention to the emergency service. Although surgical intervention is often completed laparoscopically, open surgery should not be avoided when necessary. Here, we wanted to present the case being admitted with acute calculous cholecystitis picture and who was seen to have 2 choledochal cysts during surgery and to summarize the literature of similar cases.

Case

A 76-year-old male patient presented with recurrent cholangitis history and pain on the right hypochondrium for approximately 6 months. Liver function tests revealed that normal serum total bilirubin level (1 mg/dL) and liver enzymes (serum AST, 58 IU/L, serum ALT, 46 IU/L, serum ALP, 125 IU/L) were elevated. Bile duct involvement and acute cholecystitis were detected in USG. The white blood cell level was 14.600. Emergency laparoscopic cholecystectomy was planned. It was observed at the exploration that the gall bladder was rudimentary, making intense adhesions to the omentum and stomach. When the dissection was continued, as the anatomical structures could not be revealed completely, it was switched to the open surgery. It was observed that the patient had a type 2 cyst in the choledoch. Cholecystectomy, choledoch cyst excision and primary repair were performed and the operation was terminated. The patient did not tell us but as far as we learned later, a stone was observed in the external center the patient was admitted with jaundice, right upper quadrant pain and cholestasis findings. The patient underwent ERCP and stone extirpation from the choledoch with sphincterotomy. In the meantime, the patient had juxtaposed papillary diverticulum and requested MRCP. However, the images of these examinations of the patient could not be obtained.

Conclusion

Accurate diagnosis and surgical treatment of choledochal cysts is important to reduce the risk of bile duct injury in acute cholecystitis emergency surgery, complete resection only takes place with surgical treatment. Long-term follow-up is necessary for postoperative risk of malignancy.

TJS. 2018;34(Suppl-1):S549.

PP-0662 [Hepatobiliary Surgery]. A Rare Polypoid Lesion of Gall Bladder: Adenomyomatosis

Bilal Turan ^1,^✉, Serdar Acar ¹, İsa Karaca ¹, Sezai Kantar ¹, Mustafa Tevfik Bülbül ², İbrahim Barut ¹

Introduction

Adenomyomatosis; is a hyperplastic disease of unknown etiology of gall bladder. Local muscle hypertrophy is present with intramural mucosal diverticulum formation (Rokitansky-Aschoff sinuses) which penetrate muscle layer of the gall bladder accompanied by thickening of the gallbladder wall or not. It is usually asymptomatic unless accompanied by a known illness. Ultrasonography (USG) is very valuable in differential diagnosis. The exact diagnosis is made only histopathologically. In this case report, we aimed to present a 42-year-old case with literature, in whom adenomyomatosis over 1 cm was detected in USG, with right upper quadrant pain and dyspeptic complaints

Case

A 42-year-old female patient was admitted to the outpatient clinic due to complaints of right upper quadrant pain and dyspeptic complaints. There was no pathological examination finding in the right upper quadrant except for minimal tenderness. Ultrasonography examination of the abdomen revealed a polypoid lesion with cystic areas in the gall bladder fundus, 12x8 mm in size adjacent to the wall, causing the appearance of comet-tail artifact. Laboratory tests were normal. The patient’s polyp diameter’s being 1 cm was asymptomatic in addition to increasing the risk of malignancy so the surgery decision was made. Laparoscopic cholecystectomy was applied to the patient. No complication occurred during the operation. The patient was discharged on the postoperative first day with healing by arranging diet. The diagnoses of chronic cholecystitis and adenomyomatosis localized in the gall bladder fundus were established as a result of histopathological examination.

Conclusion

As a result of the widespread use of abdominal ultrasound (USG), incidental detection of gall bladder polyps has increased. It occurs in about 5% of the population and can be premalignant lesion for gall bladder cancer in 3–8% of cases. Recently, the treatment of bile duct polyps has been decided by determining the polyp diameter ultrasonographically. While polyps larger than 1 cm are treated with cholecystectomy because of the risk of malignant transformation; polyps smaller than 1 cm are followed by clinical and recurrent USG. Ultrasonographic examination should be considered in the differential diagnosis because bile duct adenomyoma can be confused with malignant polyps.

TJS. 2018;34(Suppl-1):S549–S550.

PP-0663 [Hepatobiliary Surgery]. 3D Model Application to Reduce Damage Risk in Gall Bladder Interventions

Mehmet Asım Özer ¹, Kamil Erözkan ², Safa Vatansever ^2,^✉, Ezgi Güler ³, Figen Gökmen ¹, Özgür Fırat ², Mustafa Harman ³, Sinan Ersin ²

Objective

Difficulties in the operations of patients may emerge in pathologies in gall bladder and bile ducts requiring surgical interventions due to anatomical variations. Manifesting bile duct patterns and forming a personalized treatment option, are important in terms of innovative operational strategies and preoperative planning. The treatment protocol may change according to the location, level and size of the pathology. For this reason, it was aimed to form 3 dimensional (3D) bile duct models of the patients and evaluate its possible contribution to the surgeon.

Material and Methods

3D biliary drainage structures obtained by computed tomography imaging of 5 patients with different bile flow patterns were modeled three dimensionally using 3D modeling software.

Results

3D modelling of the patients having variations in intrahepatic and extrahepatic bile ducts was made. In these models, the type of opening of each drainage type, shape, vascular characteristics, proximity to vascular structures were revealed on 3D models. Each of these features was used as an intraoperative reference. The patient was then operated and the intervention took place. The operation was thus observed to be more comfortable, shorter in duration, and the interventions were more controlled. 3D models have been instrumental in guiding the surgical planning of our patients and providing the control of the patient’s condition.

Conclusion

Patient-specific biliary tract models increase the dominance of surgeons in complex anatomy and facilitate operations. It helps to evaluate the geometric change that the bile flow variation creates in the organs by creating individual patient models,. 3D anatomical patient models can be used in new approaches in surgery, innovative operation strategies and preoperative planning.

TJS. 2018;34(Suppl-1):S550.

PP-0664 [Hepatobiliary Surgery]. A Case Report of a Rare Benign Liver Lesion: Foregut Cyst

Yavuz Selim Kaşıkçı ^1,^✉, Murat Çakır ¹, Mehmet Aykut Yıldırım ¹, Selman Alkan ¹

Liver foregut cyst is a rare congenital, solitary, non-neoplastic, and epithelial cyst of the liver. It is more common in males and usually asymptomatic. A 61-year-old female patient underwent laparoscopic right hemicolectomy due to right colon malignancy. Laparoscopic metastasectomy was performed upon detection of a lesion in the liver which was thought to be metastatic radiologically when she was followed by the medical oncology due to adjuvant therapy.

Pathologic evaluation was reported as foregut cyst. The differential diagnosis of foregut cyst, a benign liver lesion rarely seen, in our case is shared in the context of literature information.

TJS. 2018;34(Suppl-1):S550–S551.

PP-0665 [Hepatobiliary Surgery]. Conservative Approach to Biliary Duct Injury: Case Report

Şahin Kaymak ^1,^✉, Rahman Şenocak ¹, Salih Hamcan ², Ahmet Uygun ³, Mustafa Tahir Özer ¹

Introduction

Laparoscopic cholecystectomy is still widely used in elective surgeries and laparoscopic surgeries of the general surgery. Laparoscopic cholecystectomy is an operation that can easily be done in almost every center today. The rates of biliary duct injury after laparoscopic cholecystectomy are inversely proportional to the experience of the surgeon. In this study we wanted to share our experience with a case in whom biliary duct injury was considered after laparoscopic cholecystectomy.

Case

A 31-year-old female underwent laparoscopic cholecystectomy under elective conditions at the external center. The drain placed in the sac pouch was withdrawn on the 3rd postoperative day upon observing no content coming from the drain and the patient was discharged. The patient was admitted to the same center with complaints of abdominal pain and distention. Mild bilirubin elevation (1.61) and slight elevation in transaminases were detected in laboratory tests. Magnetic resonance cholangiopacreatography (MRCP) was performed upon absence of pathologic findings in the abdominal ultrasonography of the patient having WBC of 12300. It was reported in MRCP that the proximal of the choledoch was visualized but the distal part was not visualized. The patient who was thought to have bile duct injury was referred to our clinic. After the patient was hospitalized in our clinic, abdominal ultrasonography performed showed diffuse free fluid in Douglas. A percutaneous drainage catheter was then placed in the patient and the patient had approximately 1500 cc biliary fluid coming from the drain. Then endoscopic retrograde cholangiopacreatography (ERCP) was performed in the patient. It was observed in the ERCP that the opaque given in ERCP did not pass to the proximal and also the guide wire went out of the bile duct and a full thickness or partial biliary tract injury was considered as the preliminary diagnosis. The decision to place a percutaneous transhepatic catheter (PTC) in the patient was then made. It was entered to the duodenum with a transhepatic catheter placed percutaneously in the patient in the interventional radiology. One percutaneous catheter was placed in the same session to the lateral of the liver. The bile contents from the PTC of the patient increased while the bile from the drains of Douglas and liver lateral reduced and cut. Choledocheal stent over PTC was placed with ERCP in the patient who was followed almost 3 weeks. The treatment process of the patient, whose drain has been withdrawn, still continues in our unit.

Conclusion

Bile duct injuries are injuries requiring a multidisciplinary approach. We believe that unnecessary surgeries can be avoided in appropriate centers selected by multidisciplinary approach in experienced centers.

TJS. 2018;34(Suppl-1):S551.

PP-0666 [Hepatobiliary Surgery]. Very Rare Case; Pancreatic Schwannoma

Ali Önder Devay ^1,^✉, Nilüfer Avcı ¹, Sadık Kılıçturgay ¹

The clinical picture and the operations performed due to gallstone disease have an important role in daily surgical practice. Gall bladder stones, which are determined incidentally, can become symptomatic at a rate of 20–25% in 10 year follow-up. Symptomatic gallstone disease can lead to some complications, especially acute cholecystitis in patients. The term ‘difficult cholecystectomy’ refers to the increased surgical risk compared to standard cholecystectomy, inability to reveal biliary anatomy clearly (acute/chronic cholecystitis) or insufficient provision of surgical exploration (obesity, chronic inflammation). The cholecystectomy operation, which can be performed as standard in almost every hospital in our country, is a serious source of morbidity and mortality due to lack of equipment, lack of surgical experience and/or inevitable intraoperative complications. We examined the outcomes and effectiveness of subtotal cholecystectomy surgery which we applied in cases where we can use the concept of difficult sac in our hospital and we find beneficial for prevention of intraoperative complications.

Material and Methods

The data of 95 patients who were operated electively with the diagnosis of symptomatic cholecystitis and operated emergently with the diagnosis of acute cholelithiasis in Kars Harakani State Hospital between May 2014 and February 2018 were screened retrospectively.

Results

The mean age of the patients was 54±5 and the female/male ratio was 3.5. Laparoscopic cholecystectomy was performed due to lack of response to elective surgery in 79 patients and to medical treatment applied after hospitalization with the prediagnosis of acute cholecystitis in 16 patients. Our surgical indications in the patients with acute cholecystitis were the absence of improvement in the clinical picture despite medical treatment, the presence of palpable painful distended bile duct lesion in the right subcostal region, and elevation in BK and CRP levels. All patients were scheduled for surgery with a standard 4-port laparoscopic approach. Of the 95 patients, 82 of them had laparoscopic cholecystectomy, 13 patients had surgical dissection difficulty, and conversion cholecystectomy due to the failure to reveal the Callot triangle. Four of the 13 cases in whom it was switched to open surgery could be completed by cholecystectomy wheras subtotal cholecystectomy was performed in 9 cases because of the failure to obtain a “safety angle” in operative exploration and the inability to advance in Callot dissection. Subtotal cholecystectomy was performed in 3 male and 6 female patients. None of these 9 patients had a mechanical icterus picture and ERCP procedure. Seven of the nine patients had medical treatment resistant acute cholecystitis and two patients were in the elective surgery group. Reconstitutional type subtotal cholecystectomy was performed in 7 patients and fenestran type subtotal cholecystectomy was performed in 2 patients. No postoperative surgical complication, biliary leakage and mortality were observed in 8 patients who underwent subtotal cholecystectomy in the postoperative follow-ups, whereas one male patient was discharged with medical treatment applied after development of postoperative pulmonary thromboembolism.

Conclusion

Subtotal cholecystectomy can often be performed as definitive surgery if biliary anatomy can not be revealed. Subtotal cholecystectomy was performed as a primary therapeutic treatment in cases where difficult cases were forced to total cholecystectomy, considering the potential morbidity and mortality of a possible biliary injury for the patient.

TJS. 2018;34(Suppl-1):S554.

PP-0671 [Hepatobiliary Surgery]. Correlation of Ratio of Neutrophil Lymphocyte Ratio in Mild Biliary Pancreatitis

Hakan Çakıt ^1,^✉, Muhammed Taha Demirpolat ¹, Hüseyin Kerem Tolan ¹, Tolga Canbak ¹, Aylin Acar ¹, Fikret Ezberci ¹

Objective

Increase in the number of neutrophile and decrease in lymphocyte counts are associated with sepsis and bacteriemia. Neutrophile lymphocyte ratio is widely used to evaluate the development of surgical stress and development of inflammation. In this study, we aimed to evaluate the correlation between neutrophile lymphocyte ratio and Ranson values in patients with mild acute biliary pancreatitis.

Material and Methods

Patients with mild acute biliary pancreatitis being admitted to the general surgery department between January 2012 and December 2015 were evaluated retrospectively. Ranson values, neutrophil count, lymphocyte count and neutrophil/lymphocyte rates were calculated at the arrival and 48th hour of the patients. Chi-square test was used for statistical analysis and p <0.05 was evaluated significantly.

Results

221 patients were included in the study. Forty-eight patients (22%) were male and 173 (78%) were female. Median age was 52 (range 18–94). Admission ranson was 0 in 84 patients, 1 in 70 and 2 in 67 patients. Ranson 48th hour value was 0 in 81 in patients, 1 in 69 patients and 2 in 71 patients. The mean number of neutrophils at admission was 7.58, the mean number of lymphocytes was 2 and 48 th hour mean number of neutrophils was 5.18 and the mean number of lymphocytes was 1.66. When the neutrophil lymphocyte ratio was evaluated, the admission mean neutrophil lymphocyte ratio was 6.33 and 9.56 at 48th hour (p=0.02). Mean neutrophil and lymphocyte counts decreased while mean neutrophil lymphocyte ratios increased at 48th hour of the patients.

Conclusion

The neutrophil lymphocyte ratio can be used practically in the follow-up of acute mild biliary pancreatitis.

TJS. 2018;34(Suppl-1):S554–S555.

PP-0672 [Hepatobiliary Surgery]. Should Patients Be Followed after Cholecystectomy in Terms of Liver Fattening?

TJS. 2018;34(Suppl-1):S559–S560.

PP-0680 [Colon and Rectum Surgery]. A rare Acute Abdomen Cause: Ogilvie Syndrome

Semra Demirli Atıcı ^1,^✉, Hüseyin Esin ¹, Dilek Kuzukıran ², Cengiz Aydın ¹, Levent Uğurlu ¹, Yasemin Kırmızı ¹

Introduction

Ogilvie syndrome, also known as acute colonic pseudo-obstruction; is a syndrome that produces extreme dilatation and obstruction findings of the colon without organic obstruction. Although the etiology is not completely known, it has been associated with past surgical operations, trauma and cardiac diseases in which sympathetic innervation imbalance plays a role in pathogenesis.

Case

A 58-year-old male patient was admitted to the emergency department with the complaint of inability to defecate for ten days. It was observed that the patient had meningitis and orthopedic multiple operation history and he was admitted to the emergency service for several times. There was widespread tenderness and abdominal distension in the physical examination and the rectum was detected as empty in digital rectal examination.

In laboratory tests; WBC was 11,700 and the patient had no pathology except (85% neutrophil dominance). A diffuse air fluid level was detected in the direct abdominal radiography in standing position. It was observed in the abdomen CT that colonic loops were dilated and cecum diameter was 15 cm. The patient was considered to have an Ogilvie Syndrome at first, and was urgently operated taking into account the possibility of microperforation. Subtotal colectomy and endoostomy were performed. Postoperative service follow-up was made. Oral intake of the patient, whose ostomy was working, was initiated and as he tolerated oral intake it was increased. The patient was discharged with healing after withdrawing the drain on the postoperative 7th day. Ogilvie Syndrome is a multifactorial disease, with past surgical interventions, trauma (especially retroperitoneal), infection, and heart diseases being thought to play a role in etiology. Studies have shown that about 95% of cases are related to medical or surgical conditions and the rest are idiopathic. Today, the specific treatment of the disease is conservative approach and colonoscopic decompensation if practice is available. Surgical intervention should be performed in patients who have peritoneal irritation findings and who do not benefit from colonic decompression. Diagnosis in patients with Ogilvie syndrome is based on the assumption that non-specific signs and symptoms for mechanical obstruction may be due to Ogilvie syndrome. These patients have diffuse abdominal distension and usually have a comorbid pathology. There is not any specific laboratory finding for establishing diagnosis. Standing direct abdominal radiograph and the whole abdominal CT among anamnesis and imaging methods are helpful in diagnosis. Oral intake is discontinued in patients with no peritonitis requiring immediate operation or no evidence of abdominal free air and nasogastric decompression, intravenous fluid therapy, rectal tube and enema are applied conservatively. The most important complication that can develop during conservative follow-up is cecum perforation. The incidence of cecum perforation was reported to be 3–40% and related mortality was 40–50%. Surgical intervention should be performed without delay in patients with untreated or acute signs of medical treatment. Subtotal colectomy and end ileostomy should be preferred as surgical intervention.

Conclusion

Diagnosis in Ogilvie syndrome is based on the assumption that non-specific signs and symptoms for mechanical obstruction may be due to Ogilvie syndrome. Conservative follow-up is recommended in patients without peritoneal irritation finding. The most important complication that can develop during conservative follow-up is the cecum perforation and the patients should be followed closely.

TJS. 2018;34(Suppl-1):S560.

PP-0681 [Colon and Rectum Surgery]. Comparison of CR-POSSUM, Original ACPGBI and New ACPGBI Scoring Systems in Colon Rectum Surgery

Ömer Faruk Özkan ^1,^✉, Ali Güner ², Ümit Kaya ², Can Keçe ², Erhan Resi ², Sevgi Kesici ³

Objective

The purpose of this study was to compare the effectiveness of the new Association of Coloproctology of Great Britain and Ireland (ACPGBI) scoring system and the original ACPGBI and to evaluate the efficacy of Colorectal Physiological and Operative Score for enumeration of Mortality and Morbidity (Cr-POSSUM) on postoperative mortality after colorectal cancer surgery.

Material and Methods

The Cr-POSSUM, original ACPBGI, and new ACPGBI scores of 105 patients who underwent colorectal cancer surgery were retrospectively calculated. The data were obtained from the patients’ medical records and surgical notes. Mortality was defined as death within 30 days of surgery. Scores were verified as calibration and discrimination. Calibration was assessed using the Hosmer-Lemeshow goodness of fit test and corresponding calibration curves. The discriminative ability of the models was assessed using (ROC) curve analysis.

Results

The observed mortality rate was 4.8%. The estimation of mortality of Cr-POSSUM, original ACPGBI and new ACPGBI was 9.92%, 7.35% and 4.20%, respectively. The areas under the curve (AUC) for Cr-POSSUM, original ACPGBI, and new ACPGBI scores are 0,792, 0,844 and 0,801, respectively.

Conclusion

The Cr-POSSUM, the original ACPGBI and the new ACPGBI scoring systems are effective methods for determining mortality rates and estimating the risk of death in individual patients. The new and original ACPGBI scoring systems performed slightly better than the Cr-POSSUM scoring system.

This study was published in Chirurgia (Bucur). 2014 Nov–Dec; 109 (6): 800–5.

TJS. 2018;34(Suppl-1):S560–S561.

Treatment in aggressive angiomyxoma is surgical resection to achieve a negative surgical margin. The recurrence rate in these patients ranges from 25 to 47%, with 85% of recurrences occurring within 5 years (1). Gonadotropin releasing hormone agonist (GnRH-α) and aromatase inhibitors are used in treatment. It has been reported that recurrence with radiotherapy is not observed for 2–3 years (2). We think that long-term follow-up of these patients is appropriate.

References

1.Sutton BJ, Laudadio J. Aggressive angiomyxoma. Arch Pathol Lab Med. 2012;136:217–21. doi: 10.5858/arpa.2011-0056-RS. [DOI] [PubMed] [Google Scholar]
2.Suleiman M, Duc C, Ritz S, et al. Pelvic excision of large aggressive angiomyxoma in a woman: irradiation for recurrent disease. Int J Gynecol Cancer. 2006;16(suppl 1):356–60. doi: 10.1111/j.1525-1438.2006.00218.x. [DOI] [PubMed] [Google Scholar]

TJS. 2018;34(Suppl-1):S564–S565.

PP-0688 [Colon and Rectum Surgery]. Trocar Entry Site Metastasis in Colon Cancer

Sami Doğan ¹, Mehmet Fuat Çetin ¹, Erman Yekenkurul ^1,^✉, Dilek Yekenkurul ²

Introduction

In colorectal cancer cases, the incidence of metastasis in trocar sites in laparoscopic surgery has been proven to be low by studies. In this case, we wanted to describe the postoperative trocar entry site metastasis (TESM) of a case with the diagnosis of adenocarcinoma, which did not exceed the colon serosa and the surgical margin was intact.

Case

A 29-year-old female patient was admitted to the infectious disease outpatient clinic with complaints of abdominal pain, diarrhea and weight loss. The patient stated that she had two months of abdominal pain localized in the lower left quadrant and she had sometimes black stool. She had ability to defecate and there was sensitivity in the lower left quadrant. Blood tests were normal. Colonoscopy revealed rectosigmoid junctional ulcer, vegetating lesion, and biopsy resulted in adenocarcinoma. It has been reported that there was a mass in the rectosigmoid area in CT, but no metastasis. Laparoscopic low anterior resection was planned. A massive lesion was observed in the sigmoidal distal, proximal to the rectum, but not exceeding the serosa, and the liver and other intestinal segments were natural. The mass was excised; descending colon-rectum anastomosis was performed. The pathology result was grade two, invasive to the muscular layer, without lymphatic invasion, intact distal surgical margin, and adenocarcinoma without metastatic lymph node. The patient was referred to oncology department, and according to the pathology report, it was said that there was no need for CT. The patient was admitted again with abdominal pain and nausea after five months. The patient was hospitalized with the pre-diagnosis of ileus and colonoscopy was performed. Stenosis was seen in the rectum and bougie dilation was performed. Biopsy was taken, the result of the pathology was reported as granulation tissue. The patient applied again with abdominal pain two months later. Metastases were seen in trocar sites in the examination. Diagnostic laparoscopy was performed; metastases were seen in the omentum and in the trocar entrance sites. Therefore it was switched to laparotomy. Omentum and masses metastasized to the anterior wall of the abdomen were excised. Widespread tumor implants were seen in pelvic and rectum. But it was not suitable for resection. He was discharged on the sixth postoperative day.

TESM developed after laparoscopic colorectal surgery was first reported in 1993. In the literature, it has been observed that there is no difference between the trocar site and incisional line in open or laparoscopic surgery in colecteral cancer cases in terms of recurrence and incidence is 1%. In recent years, although decreasing TESM is rare. In one study causes of TESM have been suggested as direct implantation, transmission from instruments, aerosolization of tumor cells, surgical technique, tumor manipulation and hematogenous spread. Measures to be taken to prevent TESM are to place trochanter vertically in the peritoneum to minimize the tissue trauma, to perform trocar detection and to prevent carbon dioxide leakage, to minimize the touch of the tumor tissue and not to cut the tumor tissue, to cut the tumor from the distal, to remove the tumor tissue from the abdomen in the bag, to use adequate training and technical equipment, and the right patient choice.

Conclusion

It should be taken into consideration that newly detected masses in areas such as anterior abdominal wall trocar entry site in patients operated due to colorectal cancer may be metastatic lesions.

TJS. 2018;34(Suppl-1):S565.

PP-0689 [Colon ve Rectum Surgery]. Manometrical Pre- and Post-Operative Examination Results of Anal Sphincter Tonus of Sphincteroplasty Patients

Uğur Topal ^1,^✉, İsmail Cem Eray ¹, Ahmet Rencüzoğulları ¹, Orçun Yalav ¹, Ömer Alabaz ¹

Objective

Fecal incontinence is defined as recurrent and uncontrolled fecal material passage in individuals over 4 years of age for at least 1 month. Anal sphincter damage may develop after an obsteric or surgical trauma. Surgical treatment of fecal incontinence should be performed in patients who do not respond to medical treatment or who have proven anatomic defect. Different sphincter repair options are available in the literature. Preoperative diagnosis of anal sphincter repair and anal manometry and ultrasonography in its postoperative follow-up are frequently used as anorectal physiologic tests.

Material and Methods

Our study included patients who underwent overlapping sphincteroplasty by the proctology unit between January 2015 and August 2017. Manometric examination was performed preoperatively and 6 months postoperatively. Sphincter squeezing pressure data of patients were reviewed retrospectively from file and electronic records.

Results

In our study 3 of the patients were male and 5 of them were female. The mean age was 38.75. According to etiologic reasons, 5 patients had obstetric trauma related sphincter damage and 3 patients had sphincter damage after surgical trauma. All patients underwent preoperative and postoperative manometry. 33% of the patients had decreased sphincter pressures and 67% of them had increased sphincter pressures compared to the preoperative period.

Conclusion

Anatomic sphincter injuries caused by trauma due to obstetric, operative or external factors of the perianal region are the most common correctable causes of anal incontinence surgically. Neurological pattern accompanies the picture in incontinence usually having multifactorial etiology. The chances of success after sphincteroplasty becomes lower, especially in obstructive traumas because pudendal nerve accompanies them at a certain rate. Anal manometry is an anorectal physiology test that can be used in objective evaluation of detection of sphincter pressures after sphincteroplasty.

TJS. 2018;34(Suppl-1):S566.

PP-0690 [Colon and Rectum Surgery]. The Results of the Comparison of the Rates of Sphincter Defects in Endoanal USG of Patients with or without Obstetric Trauma among Patients being Admitted with Fecal Incontinence

Uğur Topal ^1,^✉, İsmail Cem Eray ¹, Ahmet Rencüzoğulları ¹, Orçun Yalav ¹, Ömer Alabaz ¹

Objective

Fecal incontinence is defined as the inability of controlling anal excretion of bowel content at the appropriate time and place. There are many specific tests to determine the underlying mechanism of fecal incontinence. The possible etiologic factor, the severity of the symptoms, the effect on the quality of life and the age of the patient are effective in the selection of the diagnostic test. Fecal incontinence is mostly seen as a result of obstetric injury. Although fecal incontinence in one-tenth of postpartum women and sphincter damage in only 10% of vaginal births are apparent, occult damage occurs in other women as well. Postnatal ultrasonography studies have shown sphincter damage in 30% of women after first vaginal delivery. Anal Endosonography is useful in evaluating the structural integrity and thickness of external and internal anal sphincter muscles, and showing cicatrization, sphincter dilation, muscle tissue loss and other local pathologies.

Material and Methods

Seventy four female patients who were admitted to the proctology unit due to fecal incontinence between January 2015 and August 2017 were included in our study. Clinical histories of the patients were questioned. The patients were divided into two groups, as those with and without obstetric trauma. The endoanal USG results of the patients were examined retrospectively from file and electronic records.

Results

There was no obstetric trauma in 54 patients in our study. 29 (53.7%) patients had sphincter defects in endoanal USG performed. Of the patients 20 of them had the history of obstetric trauma. Sphincter defect was detected in 16 (80%) of these patients.

Conclusion

Anal endosonography is a simple and inexpensive method of showing anal sphincters and is currently preferred for examining anal sphincter morphology. The results of these tests are guiding for further investigation and treatment. 80% of the patients with birth trauma had sphincter defect in USG and 53% of the patients without birth trauma had sphincter defect. Birth trauma significantly increased the incidence of sphincter defects in patients. If we look at the rate of detection of sphincter defects in patients without obstetric trauma, sphincter damage may be found in patients who have normal vaginal delivery regardless of the trauma history of the patients, so anal endoscopy should be performed.

TJS. 2018;34(Suppl-1):S566–S567.

PP-0691 [Colon ve Rectum Surgery]. The Role of Crp and Procalcitonin Values in Early Diagnosis of Anastomotic Leakages in Colorectal Surgery: An Experimental Study

Cenk Yazkan ^1,^✉, Özcan Dere ¹, Okay Nazlı ¹

Post-operative anastomotic leakages after intestinal anastomoses can lead to very high mortality and morbidity rates. Difficulties in early diagnosis of anastomotic leakages increase these mortality and morbidity rates. As a result, considerable mortal complications such as peritonitis, sepsis and septic shock can develop in patients. In many retrospective studies on humans, it has been shown that levels of CRP and procalcitonin in the blood may be significant in the early diagnosis of anastomotic leaks. However, prospective studies in this area seem to be inadequate.

Homogeneous studies are required when working on people due to the conditions such as age, sex, comorbid diseases, surgical techniques used, and differences in postoperative treatments, and difficulties are encountered in obtaining accurate results. For this reason, in homogeneous groups, there is a need for experimental studies in which the same surgical technique is applied and the levels of CRP and procalcitonin, are to be effected with least variability. Our aim in this study is to investigate whether there is a statistically significant and usable difference in the blood values of the control and study groups of blood CRP and procalcitonin levels on postoperative 1st and 5th day by creating a controlled anastomosis in rats. Twenty male, Wistar Albino rats, were divided into two groups as 10 control groups and 10 study groups. All applications were carried out by the same research team. End to end single layer colocolic anastomosis was applied using 8 sutures in control group and 4 sutures in study group after a few cm of full thickness incision from the distal of cecum. Literature data were used for the anastomotic leakage model. Blood samples were taken from the control and study groups on the first postoperative day and the values of CRP and Procalcitonin were analyzed. All rats were followed in separate cages and blood samples were taken again on postoperative 5th day and the values of CRP and Procalcitonin were analyzed. The colonic segment undergoing anastomosis was excised and sacrificed. As a result, significant anastomotic leakage was detected in rats undergoing anastomomosis with 4 sutures and no significant anastomotic leakage was detected in rats undergoing anastomosis with 8 sutures. Blood CRP and Procalcitonin values were found to be significantly higher in the group which underwent anastomosis with 4 sutures and anastomotic leakage was seen. Control and study group CRP and procalcitonin values were statistically analyzed. There was a statistically significant difference between postoperative 1st and 5th day values. Explosion pressures were measured by excising the colonic segment undergoing anastomosis. The results of explosion pressures were evaluated in rats with intact anastomosis line. According to the results of the study, positive predictive value of CRP and Procalcitonin in the early diagnosis of anastomotic leakages was determined.

TJS. 2018;34(Suppl-1):S567.

PP-0692 [Colon and Rectum Surgery]. Presacral Epidermoid Cyst Resected by Paracoccygeal Approach

Emrah Şahin ^1,^✉, Arife Şimşek ¹, Abuzer Dirican ¹, Mustafa Ateş ¹

Introduction

Presacral (retrorectal) masses are often asymptomatic and incidentally detected during imaging performed for other reasons. The target in their treatment is complete excision. Selection of the surgical approach in the complete excision of the presacral masses is important. Anterior (abdominal), posterior (sacral-coccygeal-perineal) or combined approaches may be preferred. Sacroctomy/coccyxectomy may or may not accompany mass excision. In this study, resection of a retrosectal cystic mass that was symptomatic with paracloxigal approach was presented.

Case

Results

Seven cases developing anastomotic stricture after low anterior resection were included in the study. Five cases were male and two cases were female. The mean age was 55.2 (37–84). Four cases were operated due to rectum adenocarcinoma, one case due to rectal polyp, and two cases due to endometriosis invasive to rectum. Anastomotic stricture developed in 4.1 months (2–12 months) on average. The use of anastomosis in three cases, radiotherapy in two cases, and use of staples in two cases were suspected in the etiology. The procedure was successful after single session bougie dilatation in 4 cases. Bougie dilatation failed in two cases. The stome opened after anastomotic stricture could not be closed in one of these cases.

Conclusion

Benign anastomotic strictures can produce undesirable results after colon-rectal surgery. In some cases, diverting stomas may become permanent stoma. Treatment is especially difficult in anastomotic strictures due to anastomotic leakage and radiotherapy. Endoscopic dilatations are primarily applied in the treatment of anastomotic strictures. Surgical treatment may be an option in endoscopically unsuccessful cases. However, the success rate of relapsarotomy is also low in these cases. As a result, the management of benign anastomotic strictures after colon-rectal surgery can be difficult. Patients may be condemned to permanent stomach after a benign cause in anastomotic strictures that may develop after anastomotic leakage and/ or radiotherapy. The negative aspect of this study is the low number of cases. However, the number of experienced centers in the management of these cases after anastomotic stricture is not much. We think that bougie dilatation is more effective than balloon dilatation in anastomotic strictures in line with the data of this study.

TJS. 2018;34(Suppl-1):S570–S571.

PP-0700 [Colon and Rectum Surgery]. Our Laparoscopy Experience in Colorectal Cancer

Ömer Avlanmış ^1,^✉, Buşra Burcu ¹, Gürhan Işıl ²

Objective

Laparoscopic resection in colorectal cancer surgery is considered an alternative to conventional surgery in the last two decades. Not having major wound incisions, reducing surgical stress, short-term mobilization and minimizing hospitalization time are among known advantages of it and it facilitates fast-track surgery.

In this study, we aimed to investigate the short term results of patients who underwent laparoscopic resection due to colorectal cancer at Private Çamlıca Erdem Hospital between 2014 and 2017.

Material and Methods

84 patients with the diagnosis of preoperative colorectal cancer who was operated between 2014 and 2017 were examined retrospectively.

Results

Of the 84 patients, 66 patients were male and 33.3% were female. The ages ranged from 40 to 93 with a mean of 60.76±11,64 years. The first defecation took place in 35±0.65 days on average. The mean time of first oral intake was 2.13±0.37 days. Reoperation rate is 1.2%. The mean hospital stay was 4.70±1.25 days. Complications occurred in 4,8% of the cases, surgical site infections in 1.2%, leakage in 1.2%, eventration in 1.2%, and hemorrhage in 1,2%. The case with leakage underwent low anterior resection and the stoma was not opened. Complaints were treated conservatively except hemorrhage. Anastomoses were performed extracorporeally with Phenensteil or supraumbilical- incision. Protective ileostomy was performed at a rate of 8.4% and distant metastasis was observed in 2.4%. When localization is examined; it was observed in ascending colon in 32.2% of them, in descending colon in 22.6% of them, in sigmoid in 20.2% of them and in rectum in 25.0% of them. The histology was in the form of adenocarcinoma in all cases. The diameter of the tumor varies between 1.5 and 9 cm with a mean of 3.39±1.30 cm; the number of lymph nodes dissected ranged from 10 to 94, with a mean of 22.71±12.14. There was no statistically significant difference between the number of lymph nodes dissected according to localization (p> 0.05) and it was remarkable that the number of lymph nodes dissected in the descending colon group was lower than the other groups. The complication was seen in 3 male cases who were over 50 years old. The tumor localization of two cases was sigmoid and one was rectum. Mortality was not observed.

Conclusion

The first laparoscopic colonic resection was performed by Jacobs M, Verdaja JCand Golstein HS in 1999. Senagore reported that he performed medial-lateral mobilization and vessel laparoscopy in 2004. The resection and anastomosis were extracorporeal. Port site metastasis in 1994 was 21% in 1994 and was acceptable at 2.4% in 2010. There was no significant difference between it and conventional surgery in terms of anastomotic leakage. Although it is thought that should not be applied in T4 tumors there are also studies in the literature with acceptable oncological results. The lymph nodes dissected in stage 3–4 were 10–67 (mean: 23) in this study and no local recurrence was observed. As the rate of protection of sphincter increases, it is observed that leakage also increases. Protective stoma is a frequently applied method and has not been found effective in many studies. Leakage was seen at a rate of 1.2% in this series, which was not high compared with conventional method. The conversion rate was found to be 4–30% in the literature. No conversion was observed in our series. Laparoscopic resection of colorectal cancer is now accepted as the gold standard. We also think that laparoscopy can be performed safely.

TJS. 2018;34(Suppl-1):S571–S572.

PP-0701 [Colon and Rectum Surgery]. Laparoscopic Resection in Colonic Schwannoma: Case Report

Ömer Avlanmış ^1,^✉, Buşra Burcu ¹, Gürhan Işıl ²

Introduction

Schwannomas are tumors originated in Schwann cells in the neural sheath and observed frequently in head, neck and extremities. It is very rare to see a primary schwannoma in the colon and rectum unrelated to Von Recklinghausen. They-constitute 2–6% of all gastrointestinal tract submucosal tumors. It is difficult to have preoperative diagnosis and its treatment is radical excision. Schwannomas occur at a rate of 83% in the gastrointestinal tract and ata a rate of 12% in the small intestine. Colorectal location is relatively rare. They are benign encysted tumors, growing slowly. Local and distant metastasis rates are 30% and 2%, respectively. The incidence is the same in both men and women, and the age of onset is 60–70.

Case

A 67-year-old male patient presented with complaints of fatigue in our clinic. There was no feature in his medical history. There was no abnormality except his hemoglobin (Hb) 5.8 g/dl and hematocrit (Hct) 28.8%. Colonoscopy was performed with the appearance of a 3.5 × 4 cm polypoid mass at the level of cecum and the ascending colon in abdominal computed tomography (CT). The almost 3 cm polypoid ulcerated lesion at the level of the ascending colon in the colonoscope was interpreted as being GIST. The result of the biopsy was reported to be lymphoma or leomyoma. Laparoscopic right hemicolectomy was applied to the patient. Complication was not observed in the patient with a hospitalization time of 5 days. Pathology result was a tumor of 4 × 3.8 × 3 cm in size with no invasion, Ki-67 4% and mitotic index was <1. CD 117, CD 34, desmin negative, and S 100 positive and was reported as schwannoma.33 lymph nodes were sampled and metastasis was not detected. The patient, who is on the 5th day of the follow-up, has a course without any problem.

Conclusion

Schwannom was first reported by Verocay in 1910 [4]. It is mostly originated from Aurbach’s plexus in the gastrointestinal tract and has a structure of sessile polyp growing towards lumen. It has an appearance of pediculated polyp when they originate from Meisiner’s plexus [2]. Its diagnosis is usually made with post-operative immunohistochemical examination. Although Schwannoma is a benign tumor, malignant transformation can occur if left untreated. It leads to symptoms such as abdominal pain, obstruction and rectal bleeding caused by other polypoid lesions [5]. It has been detected in our case diagnosed by anemia but it has not been encountered in the literature. Schwannomas accepted among subtypes of gastrointestinal stromal tumors (GIST) are separeted by immunohistochemical examination. CD117 (KIT), CD34, CKs, SMA and are desmin negative. S 100 protein and vimentin generally show positive staining [5]. The Ki-67 proliferative index being ≥5% and the tumor diameter’s being greater than 5 cm, enhance the probability of malignancy. In addition, the rate of mitotic activity being> 5 is a parameter increasing the risk of metastasis and recurrence. Ki-67 was present in 4% of the patients, the tumor was 4 cm in the widest site, and the mitotic index was <1. The general opinion in the treatment is complete local excision. Today, laparoscopic colectomies are widely used without increasing complication risk, less hospital stay, less postoperative pain and cosmetic superiority. We did not encounter any complications or recurrences in the patients. As a result schwannomas are post-operatively diagnosed tumors and their treatment is resection. The laparoscopic approach can be applied safely as it is in other gastrointestinal tumors.

TJS. 2018;34(Suppl-1):S572.

PP-0702 [Colon and Rectum Surgery]. Cecal Neuroendocrine Tumor: Case Report

Fatih Dolu ^1,^✉, Anıl Koçman ¹, Erkan Hazar ¹, Hatice Özer ², Kürşat Karadayı ¹

Introduction

Case

The 72-year-old female patient was admitted with RP having a non-reducible, undiagnosed mass on the tip of it 3 days ago. The 25 cm column was prolapsed. Biopsy was performed at the external center thinking that the mass might be CT and the patient was discharged 3 days ago. It was observed at the admission that the prolapsed part was edematous and bleeding was observed. There was no necrosis and it was attempted to be reduced manually. She was taken to the operating room for reducing under anesthesia due to pain. The patient not being reduced in any condition and was suspected to have CT underwent open anterior resection. A 4-cm diameter difference was observed between the invaginated distal part and the normal proximal colon in the laparotomy. The incarcerated part could be withdrawn to the abdomen by perforating the colon. Hartman was applied due to diameter difference and clinical condition. The pathology was specified as adenocarcinoma. There was no involvement in the removed lymph node (LN). There was no problem in the 30-month follow-up. RP significantly reduces the quality of life. Rectum may be prolapsed with defecation or independently. The rectum mucosa is mostly edematous and fragile. Ulcerated regions can be seen, and it tends to bleed. It can usually be reduced with hand. Strangulated RP occurs with severe pain and bleeding. Necrosis and perforation may develop if strangulation is not intervened early. In our case, the strangulated part was edematous, with bleeding and severe pain. Necrosis and perforation were not seen, even though they could not be reduced by hand or under anesthesia. After laparotomy, it could be reduced into the abdomen by providing immediate perforation from the proximal of the tumoral region. A rare cause in RP etiology is intussusception associated with CT. Sun et al have suggested that the most common cause of RP is 61% long rectosigmoid colon in the young population. In the case, colo-colic intussusception dragged the tumoral structure as precursor point to the tip of the prolapsed column segment and edema and pain have made it impossible to reduce the prolapse. Reduction is recommended under sedation and analgesia in situations where there is no strangulation, and in cases where there is no reduction. Even in anesthesia the case could not be reduced. If there is no possibility of an additional evaluation for the mass at the tip of the prolapsus and there is not a pathologic diagnosis, we think that the diagnosis should be evaluated as CT and the procedure should be applied according to the tumor. We planned open sigmoidectomy for adequate mesenteric and LN excision due to tumoral mass in our cases. Reporting the mass as adenocarcinoma supports the procedure we used. Although colostomy seems to be an aggressive approach, colo-rectal anastomosis is seen as risky.

Conclusion

RP is rare in anorectal emergencies. It should not be forgotten that one of the reasons for RP may be CT. The biopsy should be taken and colonoscopy should be performed if it can be done in patients with RP after colorectal masses. The surgery to be selected changes according to the time of arrival of the patient and the facilities of the hospital. In cases of emergency where there is no pathological diagnosis, if the mass is present, it can be evaluated as CT and appropriate emergency surgery can be performed.

TJS. 2018;34(Suppl-1):S575.

PP-0708 [Colon and Rectum Surgery]. Hyperplastic Polyp Case in Appendix

Barış Tırman ^1,^✉, İsmail Alper Tarım ¹, Ayfer Kamalı Polat ¹

Introduction

Serrated adenomas of appendix are considered more aggressive than serrated adenomas of colon and rectum. Serrated polyps are divided into three subgroups histologically: hyperplastic polyps, sessile serrated adenoma, traditional serrated adenoma. Hyperplastic polyps of appendix are rarely seen and resemble hyperplastic polyps at the morphological colon. In the pathological evaluation of this case, acute appendicitis was reported to be compatible with hyperplastic polyps. Appendix hyperplastic polyps may be with acute appendicitis, as well as occasionally incidental. The presence of adenocarcinomas in the large intestine and the presence of mucosal hyperplasia in the appendectomy necessitate advanced tests for exclusion of colorectal neoplasias.

Case

A 62-year-old male patient was admitted to the emergency service with a complaint of abdominal pain starting three days ago. There were rebound and defense in the right lower quadrant of the abdomen and acute abdomen symptom was detected. Preoperative abdominal ultrasound examination showed the appendix with a diameter of 8 mm, thick wall and echogenic, and it could be compressed very little. Thinning of the wall at the tip and wall discontinuity were observed. Findings were reported to be consistent with perforated acute appendicitis and the patient was operated. Appendectomy was performed. The patient was discharged on the postoperative 2nd day. An appendectomy material of 4 cm in length and a diameter of 0.6–0.9 cm having with some periappendicular, necrotic appearance fat tissue on it was observed in the macroscopic examination of the surgical specimen, and the material was obliterated with lumen having fecaloid content and histopathologic examination was reported as an appearance consistent with acute appendicitis and hyperplastic polyp. No polyp was detected in the colon in colonoscopic examination performed in order to exclude the possibility of synchronous adenocarcinoma in the colon in the first postoperative month. While hyperplastic polyps of appendix are frequently encountered incidentally, it can sometimes be confronted with an acute appendicitis clinic as in our case. Coexistence of hyperplastic polyps of appendix with adenocarcinomas in large intestine is important and appendectomy specimens should be absolutely investigated histopathologically. Appendicular malignancies are very rare. 0.5% and 1.4% of the appendectomy specimens are diagnosed with primary appendix cancer. Tumors are rarely suspected preoperatively. Carcinoid is the most common one in appendix cancers, and it constitutes 50% of primary lesions of the appendix. Although very rare, granular cell tumor, paraganglioma, neuroma and neurofibroma can be seen in appendix. Malignant lymphoma may be localized in appendix, and metastases in the gastrointestinal tract, breast and female genital organs have been reported as well. In a recent review, the incidence of incidental malignant tumors in the histopathological examination of appendectomy materials was reported as 0.3%. For this reason, histopathologic examination must be performed for the material obtained in the appendectomy.

Conclusion

PP-0713 [Colon and Rectum Surgery]. Neutropenic Enterocolitis in Oncologic Patient Groups: Presentation of 4 Cases

Server Sezgin Uludağ ^1,^✉, Emre Tunç ¹, Osman Şimşek ¹, Mehmet Velidedeoğlu ¹, Salih Pekmezci ¹

Ileocecal syndrome, neutropenic enterocolitis, also known as typhlitis; immunosuppression is defined as the inflammation of the cecum and surrounding tissues seen in patients. Typhlitis, first described in leukemic pediatric patients is the most common gastrointestinal complication in leukemic patients. Although the pathogenesis is not fully understood, neutropenic enterocolitis is thought to be due to bacterial invasion with neutropenia and mucosal injury in immunosuppressed patients. Despite the detection of gram negative rods, gram positive cocci, enterococci, fungi and viruses in damaged mucosa, these are not considered as a diagnostic criterion. Chemotherapeutic agents cause direct mucosal injury and decrease intestinal motility, leading to distention and necrosis which causes neutropenic enterocolitis. Although leukemic infiltration could not be histologically demonstrated in neutropenic enterocolitis cases formed before chemotherapy regimen in acute myeloid leukemia, the existence of other histological findings (mucosal ulcers, intramural hemorrhagic necrosis) show that leukemic involvement plays an important role in the pathogenesis of neutropenic enterocolitis. Despite the fact that neutropenic enterocolitis cases were detected after the taxan group chemotherapeutic agents at the beginning, cases were reported after cytosine arabinoside, gemcitabine, vincristine, doxorubicin, cyclophosphamide, leucovorin and daunorubicin. In this study, four cases of neutropenic enterocolitis were followed and treated at Cerrahpaşa Medical Faculty Hospital between 01/08/2017 and 01/02/2018. Neutropenic enterocolitis is a major cause of mortality and morbidity in immunosuppressed patients. In the cases examined, the disease was observed to be symptomatic when the patient’s neutropenia was deepened. Patients were first seen to have fever and abdominal pain, and when they were symptomatic, there was no reproduction in the gaita cultures sent. It was seen that the patients were not suitable for operation because of their deep neutropenia when the patients were symptomatic and that they can be followed by expanding antibiotherapies and cutting oral intake, daily physical examination and laboratory control and intermittent radiographic imaging. The inadequacy of the literature on neutropenic enterocolitis has led to the necessity of further studies on this subject.

TJS. 2018;34(Suppl-1):S578–S579.

PP-0714 [Colon and Rectum Surgery]. Giant Juvenile Polyp in Adult Patient

TJS. 2018;34(Suppl-1):S582.

PP-0719 [Colon and Rectum Surgery]. Colon and Rectum Surgery with Hand-Assisted Laparoscopy (HALS)

Koray Baş ^1,^✉, Emre Turgut ¹, Burak Dede ², Gürsoy Erdoğan ¹

Minimal invasive applications in colon and rectum surgery have become increasingly widespread and HALS (Hand Assisted Laparoscopic Surgery) method has begun to find a place for itself in this area with the advantages it offers. In addition to less cosmosis and postoperative pain, the contribution of the tactile sensation to the video image facilitates the identification and dissection of the tissues and thus increases the safety of the operation. It has also been reported in the literature that it also reduces the rate of switching to open surgery and the length of stay in the hospital. In this report, we presented the cases who underwent hand-assisted laparoscopic colon and rectum surgery due to invasive cancer. The mean age of our 5 patients (2 male) was 67,8 (50–84) and the mean BMI was 32,1 kg/m2 (29,2–34,6). Extended right hemicolectomy, right hemicolectomy and low anterior resection operations were respectively performed by HALS method in the patients whose tumor locations were in transverse colon, hepatic flexure, rectosigmoid junction (two patients), and upper rectum. Three patients with rectosigmoid junction and upper rectum-localized tumors underwent colonic stenting with SEMS (self-expanding metallic stent) by a surgeon who performed the operations at an average of 11 days before surgeries (8–14) due to tumor-related acute intestinal obstruction and bridging was performed to the elective surgery. For the hepatic flexure tumor with a small tumor size, safe distal border marking was conducted by the surgeon performing colonoscopy with carbon stain in the preoperative period. Ports to be used for removing the resected surgical material out of the abdomen for hand assistance were placed in the suprapubic area with a standard 8 cm transverse incision. Trocar sites for camera and work tools were selected according to tumor localization. Energy devices for surgical dissection and plastic and metallic clamps for vasculer closure were used. Anastomoses were extracorporeally performed at the hand port site using linear and circular staplers. No patient had diverting stoma applied for preventive purposes. The mean duration of surgery was estimated to be approximately 153 minutes (140–165). There were no surgical complications in our patients. A patient undergoing low anterior resection died on the second postoperative day due to cardiac arrest associated with AMI. In our extended right hemicolectomy patient, additional morbidity was not observed except for the conservative treatment with blood products for bleeding as a postoperative leakage. Although no scoring system was used in the controls of the patients, it was observed that their satisfaction in terms of surgical pain and cosmosis was very high. It was confirmed that resections were performed in accordance with the oncological principles and pathology results. We think that hand-assisted laparoscopic colon and rectum surgery applications with this limited case series are safe, compatible with oncologic principles and patient satisfaction is better than open surgery with cosmetic results.

TJS. 2018;34(Suppl-1):S582–S583.

PP-0720 [Colon and Rectum Surgery]. Multidisciplinary Approach to the Fournier Gangrene and the Importance of Colostomy

Dilek Yekenkurul ¹, Abdulkadir Yığman ², Erman Yekenkurul ^3,^✉

Introduction

Fournier gangrene; is a necrotizing, infectious, polymicrobial disease that spreads through the fascia starting from the perineal and genital regions and progresses rapidly with high mortality and morbidity. Urgent diagnosis and treatment is necessary since delay in treatment increases mortality considerably. Predisposing factors such as vascular disease and obesity, especially DM, do not only increase the susceptibility but also cause difficulty in treatment. Here, we aimed to examine the fournier gangrene case with DM diagnosis who was bed dependent due to prosthetic infection and CVA with multidisciplinary approach.

Case

A 65-year-old male patient presented with a complaint of drainage at the prosthesis site. While the patient with known DM and previous CVA was able to walk with support, he had implantation of prosthesis to left hip joint nine months ago, and he had second CVA during operation and right hemiparesis developed, followed by compression of the sacral area due to immobilization. The patient presenting to the orthopedic outpatient clinic with current complaints had urinary catheter and pyuria was also observed in urinalysis. The patient was hospitalized with physical examination and analysis results, and with the diagnoses of urinary tract infection, prosthetic infection and fournier gangrene in the sacral area and he was taken to emergent operation. In the operation intervened by orthopedics and general surgery, the prosthesis of the patient was removed, deep debridement was performed in the sacral area with Fournier gangrene, and colostomy was performed to prevent gaita contamination. Wide spectrum antibiotherapy was administered by infectious diseases department, insulin was regulated by the department of internal medicine because the patient had uncontrolled diabetes. The patient with white blood cell count of 16600/mm3, CRP 40 mg/dl, sedimentation 99 mm/h was followed by applying dressing, debridement and occasionally negative pressure wound treatment. Although debridement was performed with preservation of the anal sphincter, the entire perianal region was resected in the following debridements. Antibiotherapy was reviewed again according to the results of deep tissue and urine culture. He received broad spectrum antibiotic treatment for approximately 24 days. The patient whose leakage ceased and who had tissue healing, white blood cell count dropped to 8500/mm3, CRP 4.5 mg/dl, sedimentation 39 mm/h was discharged by suturing the wounds and recommending moxifloxacin 400 mg tb 1x1. Aggressive resuscitation, broad spectrum antibiotic use, early surgical drainage, and glucose control in patients with DM are important in the treatment of Fournier’s gangrene. Prevention of wound and stool contamination is beneficial for wound healing; so colostomy may be needed in some cases. There are studies in the literature that report a decrease in dressing numbers and hospital stay with negative pressure wound dressings.

Conclusion

Fournier’s gangrene, which requires immediate diagnosis and treatment necessitates follow-up by infectious diseases, surgical units and internal diseases in case of comorbidities. We wanted to present this case in order to show how important the multidisciplinary approach is in the fournier gangrene, with mortality of about 16–40%, which is difficult to follow in a secondary health care institution, where there is not a microbiology laboratory, and the culture taken is sent by vehicle to the central state hospital.

TJS. 2018;34(Suppl-1):S583.

It should not be forgotten that lymphoid tissue hyperplasia and tumors among the causes of acute appendicitis are rare. The pathology result of the patients should be absolutely followed in the post-appendectomy period, which is one of the most frequent emergency conditions of the general surgery.

TJS. 2018;34(Suppl-1):S585.

PP-0724 [Colon and Rectum Surgery]. Atypically Localized Appendix: Video Presentation

Turan Acar ¹, Feyyaz Güngör ^1,^✉, Nihan Acar ¹, Araz Babayev ¹, Mehmet Hacıyanlı ¹

Video shows appendix detected in neighborhood of gall bladder during exploration in the patient for whom elective laparoscopic cholecystectomy was planned with the diagnosis of cholelithiasis. Since the complaint of right upper quadrant abdominal pain that the patient had experienced before the operation was thought to be related to this appendix with atypical location, it was decided to perform laparoscopic appendectomy after cholecystectomy in the same session. Appendix was suspended with a grasper to reveal its meso. Meso was cut by coagulating with energy device. The appendectomy was then completed by closing the appendix stump with two plastic polymer endoclips.

TJS. 2018;34(Suppl-1):S585–S586.

PP-0725 [Colon and Rectum Surgery]. Differences between Characteristic, Histopathologic and Cancer Morphology of Right and Left-Side Colon Cancer Patients

Turan Acar ^1,^✉, Nihan Acar ¹, Fevzi Cengiz ¹, Erdinç Kamer ¹, Halis Bağ ¹, Ercüment Tarcan ¹, Mehmet Hacıyanlı ¹

Objective

One million people are diagnosed with colon cancer (CC) every year in the world, and this type of cancer constitutes 9% of all cases. Recent reports indicate that left and right-sided colon cancers display distinct clinical and biological features. In particular, it has been found that right-sided colon cancer is predominantly present in women and young patients, and left-sided cancers predominate in men and elderly patients. Although the demographic, hereditary and environmental characteristics of the patients were examined, no definitive data was available on the cause of this condition. It is assumed that it may be dependent on biological behavior of the tumor. There is no study in our country about this issue. In this study, we aimed to classify patients diagnosed with colon cancer according to the localization of the tumor, to determine whether there is age and gender relation and to reveal the differences between clinical symptoms, cancer invasion depth, cancer morphology and histology.

Material and Methods

493 patients who were operated due to colon cancer in our Department of General Surgery between January 2011 and July 2017 were included in this retrospective study.

Group 1 (Right colon located tumors): Cecum, ascending and transverse colon tumors
Group 2 (Right colon-located tumors): Splenic corner, descending and sigmoid colon tumors

Patients’ files were reviewed retrospectively. Demographic data (gender, age), medical histories, admission symptoms and findings, laboratory and radiological data, preoperative staging scores, tumor localizations, lymph node dissection numbers and positivity rates, hospitalization durations, recurrence and survival of the patients were evaluated.

The patients included in the study:

Patients diagnosed with colon cancer
Patients undergoing surgical treatment
Epithelial malignancies (Adeno- squamous carcinoma)

The patients excluded from the study:

Benign tumors
Metastatic patients
Patients with synchronous tumors
Patients undergoing only endoscopic submucosal dissection (ESD)
Non-epithelial malignancies (such as lymphoma, carcinoma)
Appendicular carcinoma, rectum and anal tumors

Results

Of the 493 patients who were included in the study, 200 of them were in Group 1 and 293 of them were in Group 2, 61.5% of them were male and 38.5% of them were female. The demographic and clinical data of the patients are given. There was a statistically significant difference between the groups in terms of gender, age distribution and admission symptoms. Tumor localization distribution of patients is given. According to this, there were patients with ascending colon at most in Group 1 and patients with sigmoid colon tumor at most in Group 2. Histological and morphological differences between the groups are given.

Conclusion

According to our study; although the right colon tumors are seen at younger ages than the left colon tumors, the presence of poor histological type and mucinous component are more frequent. Depending on these, their prognosis are worse.

TJS. 2018;34(Suppl-1):S586.

PP-0727 [Colon and Rectum Surgery]. Appendicitis Mucinous Cystadenoma: A Rare Case Report

TJS. 2018;34(Suppl-1):S588.

PP-0731 [Colon and Rectum Surgery]. Approach with Laparoscopic Anterior Resection: A Rare Case of Lipoma Obstructing Colon

Eyüp Murat Yılmaz ^1,^✉, Ahmet Ender Demirkıran ¹

Introduction

Gastrointestinal lipomas originate from the fatty tissue of the intestinal wall. In the gastrointestinal tract, lipomas are frequently localized in the colon, along with the esophagus and small intestine. The causes of obstruction are quite rare. We will present a sigmoid colon lipoma that causes obstruction in this case.

Case

Seventy-eight year old female patient applied to our General Surgery outpatient clinic with complaints of intermittent abdominal pain and difficulty to defecate. The patient stated that she had difficulty to defecate for a few weeks and used her finger from the rectum. She had no history of weight loss and bleeding. While there was tenderness in the left quadrant in the physical examination, there was no defense and rebound and the voice of the bowel was hypoactive. Biochemical pathologic findings were not found in blood values and hemogram values were normal. Diffuse gas was observed in the standing direct abdominal graph performed. The patient underwent rectoscopy and it was observed that the color of the lumen became dark (melanosis coli?) and a smooth, mobile mass 4x5 cm in size and the base of which could not be clearly evaluated, and did not permit passage of scopes at 35 cm from the anal canal (polyp ?, lipoma?). Resection was decided in the patient, whose biopsy results was evaluated as lipoma, due to obstruction findings and laparoscopic anterior resection was performed. The patient taken to the postoperative service was discharged on the 4th day postoperatively.

Conclusion

Gastrointestinal lipomas are well differentiated and slowly growing mesenchymal tumors originating from the fatty tissue in the intestinal wall. Lipomas more frequently observed in females than males peak in the 5th and 6th decades. Lipomas have submucosa origin in about 90% of cases. Rarely, they can also originate from the subserosal area. Their size is very variable and they may reach a diameter of 20–30 cm in some patients. The most common site where lipomas are observed in the colon is ceum and ascending colon. These are followed by transverse colon, splenic flexure, descending colon, sigmoid colon and rectum respectively. In our case, it was evaluated as a 5 cm lipoma which obstructed the sigmoid colon. While follow-up is sufficient in the ones that are small and asymptomatic, endoscopic segmental resection is recommended for a size of 2cm and laparoscopic segmental resection is recommended if they are larger and cannot be removed. We also preferred laparoscopic anterior resection because we were not successful endoscopically. Occlusive colon polyps are rare cases and treatment and follow-up should be planned accordingly.

TJS. 2018;34(Suppl-1):S589.

PP-0732 [Colon and Rectum Surgery]. Laparoscopic Left Partial Nephrectomy Case with Simultaneous Laparoscopic Sigmoidectomy

Erdinç Kamer ^1,^✉, Sacit Nuri Görgel ², Yiğit Akın ², Fevzi Cengiz ¹, Mustafa Peşkersoy ¹

Introduction

Renal angiomyolipoma is a benign neoplasm originating from mesenchymal elements and was first reported in 1951. Angiomyolipoma is also called ‘hamartoma’ because of its varying composition including fat tissue, smooth muscle and blood vessels. On the other hand, Jacobs et al. reported the first laparoscopic colectomy at the beginning of the 1990’s. Laparoscopic colorectal surgery has some potential advantages when compared to open surgery. In our study we aimed to present the results of simultaneous laparoscopic left hemicolectomy and left partial nephrectomy in the patient with sigmoid colon carcinoma and angiomyolipoma in the left kidney synchronously.

Case

A 64-year-old female patient underwent colonoscopy because of fecal occult blood. In colonoscopy, a vegetarian mass causing a narrowing of the colonic lumen 5–6 cm in length 20 cm from the anal canal was seen and a biopsy was obtained from the suspicious lesion. Biopsy pathology was reported as moderately differentiated adenocarcinoma. A computerized tomography for the purpose of staging of the patient showed irregular mucosa-wall thickening- luminal obstruction in the sigmoid colon and a 8.5 cm angiomyolipoma (6 cm in length) originating from the left renal upper pole. MR was applied for the features of the kidney upper pole. Simultaneous laparoscopic sigmoidectomy and left partial nephrectomy were planned in the same session. Ports were placed for classic laparoscopic sigmoidectomy. Medial dissection was completed by attaching A and V mesenterica inferiorly. After the lateral dissection was completed, the splenic corner was lowered. Thus, the left kidney lodge was reached. Urology team was also involved in the operation. Left partial nephrectomy was performed without additional port. Laparoscopic sigmoidectomy was then completed. (Picture). The patient’s pathology was moderately differentiated adenocarcinoma (T3N0T0) and angiomyolipoma. The patient was discharged without any complication on postoperative 5th day. No problems were encountered during the first and third month follow-up. Postoperative adjuvant treatment was not considered.

Conclusion

Increased use of cross-sectional imaging revealed an increase in incidentally detected angiomyolipomas. Renal angiomyolipomas can cause spontaneous bleeding at a a rate of 15% and hemorrhagic shock at about 10%. Preservation of renal function is important in patients with renal angiomyolipoma. Nephron protecting surgery should be considered for this reason. A council was established with general surgery, urology, radiology and medical oncology to plan the operation in the preoperative period because the patient had to undergo mandatory surgery due to sigmoid colon tumor and to be operated in the left retroperitone. The council concluded a simultaneous operation decision. We have not seen such a case in the literature. In conclusion, we believe that simultaneous laparoscopic left hemicolectomy and left partial nephrectomy in cases with sigmoid colon carcinoma and synchronous angiomyolipoma in the left kidney are applicable procedures in centers with laparoscopic surgery experience.

TJS. 2018;34(Suppl-1):S589–S590.

PP-0733 [Colon and Rectum Surgery]. Relationship Between Diverting Ostomy and Anastomotic Stricture in Lower Anterior Resections

Hayyam Babayev ^1,^✉, Wafi Attaallah ¹, Cumhur Yeğen ¹

Objective

Loop ileostomy or loop colostomy are opened to protect the anastomosis in risky patients undergoing lower anterior resection. Patients wait for some time to close the diverting ostomy. Stenosis in the anastomosis can be observed in control colonoscopies before the ostomy is closed. In this study, rectal anastomosis stenosis rates were investigated in patients with diverting ostomy. It was also investigated whether there is a correlation between the anastomotic stricture and the expected time for ostomy closure.

Material and Methods

The information of the patients who had diverting ostomy with lower anterior resection in a single center was retrospectively reviewed. The demographic characteristics of the patients, whether they had received chemoradiotherapy, and the control colonoscopy reports after the index operation were examined. Patients who did not undergo colonoscopy were called by telephone and physical examination and colonoscopy procedures were performed. Anastomotic stricture rates were calculated as the primary outcome. Anastomotic stricture was assessed in cases where it could not be passed from anastomosis with colonoscopy. We investigated whether there was a correlation between the anastomotic stricture and the expected time for ostomy closure as secondary outcome.

Results

Sixty one patients underwent diverting ostomy with lower anterior resection between 2009 and 2016. The control colonoscopy reports of 38 patients were reached before the ostomy was closed. The median age of the 38 patients included in the study group were 63 (28–78) and twenty of them (53%) were male patients. All of the patients were treated with rectum tumor. Seven (18%) patients received neoadjuvant, and nine (24%) patients received adjuvant radiotherapy. 22 (58%) patients received adjuvant chemotherapy. Seven (18%) patients underwent laparoscopic resection. 26 (68%) patients had loop ileostomy, and 12 (32%) patients had loop colostomy. Median follow-up time from index operation to control colonoscopy was 12 (3–23) months. Seventeen (45%) patients had anastomotic stenosis in the control colonoscopy. There was no significant correlation between the anastomotic stenosis and the expected time for ostomy closure.

Conclusion

Patients who underwent lower anterior resection and deflector ostomy to protect the anastomosis were observed to have a high rate of anastomotic stenosis. No significant correlation was found between the anastomotic stricture and the expected time for ostomy closure. In this study, it has been shown that there is no effect of the time passed till closure of ostomy on anastomotic stenosis rate.

TJS. 2018;34(Suppl-1):S590.

PP-0734 [Colon and Rectum Surgery]. Our Experiences with Hemorrhoidectomy in Our Hospital Which is an Training and Research Hospital

Ekrem Ferlengez ¹, Fazilet Erözgen ¹, Gamze Çıtlak ¹, Leyla Zeynep Tigrel ^1,^✉, Mürşit Dincer ¹, Muzaffer Akıncı ¹

Objective

Hemorrhoidal disease is one of the reasons of admission to surgical clinics of many individuals. Although treatment is usually medical, surgery is considered in cases where treatment is not responsive. In this study, we wanted to share the results of hemorrhoidectomy we performed in or clinic.

Material and Methods

We retrospectively reviewed the data of 375 patients who underwent hemorrhoidectomy between January 201 and January 2013 in Department of General Surgery of our hospital. The findings were evaluated in terms of the demographic characteristics, hemorrhoid stage, surgical technique, and postoperative complications.

Results

It was detected that the surgical technique (Ferguson, Milligan-Morgan, Band Ligation, Ligasure hemorrhoidectomy), performed in the patients who underwent hemorrhoidectomy and were in the hemorrhoid stages of grade 2–3-4 did not have a difference in the postoperative recovery period of hemorrhoid stage however hemorrhoidectomy performed with Band Liga significantly shortened the duration of surgery compared to other surgical techniques.

Discussion

Hemorrhoidectomy is an intervention with successful results in patients with hemorrhoid disease who are still unresponsive to medical treatment. Although the application techniques change, there has been no difference except the change of duration of operation in terms of the results.

TJS. 2018;34(Suppl-1):S590–S591.

PP-0736 [Colon and Rectum Surgery]. Renocolic Fistula and Sinistral Portal Hypertension Caused by Xanthogranulomatous Pyelonephritis

Bakhtiyar Chakhalov ^1,^✉, Nilay Tuğba Uzunay ¹, Samir Aghalarov ², Deniz Tazeoğlu ¹, Alper Ötünçtemur ², Fazıl Sağlam ¹

Introduction

Fistulas between the GIS tract and the kidney are rare. Nephrocolic fistulas are the most common in nephroenteric fistulas and more than 130 cases have been reported. Xanthogranulomatous pyelonephritis (XGP) is seen as a rare disease; about 400 cases have been reported in the literature up to 1980. Approximately 1/3 of cases of XGP are associated with complications such as abscess and fistula. Here we present a case of renocolic fistula and sinistral portal hypertension caused by XGP.

Case

A 50-year-old male patient with complaints of left-side pain, high fever, and fatigue did not have a known chronic disease. Left upper quadrant tenderness was present in physical examination, blood and urine in laboratory tests had high inflammatory values. Stones largest of which was 17 mm and many other smaller ones were observed in left renal pelvis in USG. Left kidney parenchyma thickness increased by 4.8 mm. Splenomegaly in contrast-enhanced CT has completely lost the morphological appearance of the left kidney and was larger than normal and parenchyma became thin. Numerous multiple calculations were observed in the left kidney calyx and left ureter, and these calculi appeared to cause obstruction in the distal of left ureter. Air densities in the left kidney parenchyma were consistent with emphysematous pyelonephritis and the appearance of an abscess forming air-liquid level was noted. Perirenal fatty tissues were eradicated. Percutaneous abscess drainage was performed in the patient, and imaging by giving contrast material from the drain revealed fistulization with the descending colon and contrast material spread to the colon. Left nephrectomy + left hemicolectomy operation was performed by giving a surgical decision to the patient whose inflammatory values did not regress despite drainage. It was observed that the left kidney formed portal hypertension due to splenic vein pressure peroperatively and omentum vessels were dilated secondary to this. The postoperative period was stable. There were varices in the stomach fundus in the gastroscopy performed in the postoperative period. The patient was continued to be followed by outpatient control.

Conclusion

PP-0740 [Colon and Rectum Surgery]. Case Report: Perineal Rectosigmoidectomy in the Treatment of Strangulated Rectal Prolapse

Akın Çalışır ¹, Sefer Durucan ^1,^✉, Halil Kirazlı ¹, Enes Şahin ¹, Mustafa Şahin ¹

Introduction

Full-thickness rectal prolapse is a state of protrusion of rectum wall from the anus with all its layers. Although the exact incidence cannot be predicted clearly, it is usually seen in the elderly population and 80–90% of the cases are females. The pathogenesis of rectal prolapse remains controversial. Full-thickness prolapse may be a sliding defect in the pelvic fascia, or it may occur as a complete progression of internal rectal intussusception to full thickness. The mucosal prolapse may also occur due to the weakness and looseness of the connective tissue ties of the rectum. Although the treatment is surgical, there is no definite consensus on what is the optimal surgical procedure, and many surgical procedures have been defined in this regard. If the surgical technique is roughly classified, it can be classified into two sub-groups as abdominal and perineal procedures. We aimed to present the case of full-thickness rectal prolapse without reduction in this case report.

Case

A 42-year-old male patient was admitted to the emergency service with the complaint that anus protruded after a strong strain. Our clinic was consulted with pre-diagnosis of rectal prolapse. It was learned from the patient’s history that he had rectal prolapse during defecation that could be reduced with hand and occasional incontinence in his childhood. No abnormal findings were found in the vital signs of the patient. Abdominal examination was comfortable. A rectal prolapse of about 20 cm in diameter which was painful, edematous and non-reducible, was detected in rectal examination. The patient was taken to the operation. He was prepared under the general anesthesia in lithotomy position. Reduction was attempted at the operation table but could not be successful. On top of this, perineal rectosigmoidectomy (altemeier procedure) was decided. A full-thickness incision was made around the prolapsed colon wall under dentat line. The mesorectum and mesosigmoid vessels were then ligated and the meso was separated. The prolapsed rectosigmoid tissue was resected and coloanal anastomosis was performed by one with sutures that could be manually 2/0 absorptive. No protective ostomy procedure was performed in the patient, so oral intake was not initiated until the third postoperative day. Gaita discharge occurred on the fifth postoperative day. There was no problem in the anastomosis of the patient on the 6th day postoperatively, and the patient was discharged. The patient came to the outpatient clinic control 1 week and 1 month after discharge. No complications were encountered in the follow-ups of the patient.

Conclusion

Perineal operations in surgical treatment of rectal prolapse are more applicable approaches because of less invasiveness, especially in elderly patients, compared to abdominal surgery. Perineal rectosigmoidectomy was first defined by Mickulicz, but its use was limited due to studies reporting high recurrence rates. Later, thanks to better results published by Altemeier, reuse has increased. Complications were defined at a rate of 10–12% after Altemeier operation. The most common serious complication is the anastomotic leakage. Other complications are pelvic abscess, urogenital dysfunction, and anastomosis stenosis. In conclusion, perineal rectosigmoidectomy operation is a safely applicable alternative in case of inccarcerated rectal prolapse, which is a rare surgical emergency.

TJS. 2018;34(Suppl-1):S594.

PP-0741 [Colon and Rectum Surgery]. Perianal Paget’s Disease: Case Report

Şükrü Çolak ^1,^✉, Sevgi Kurt Yazar ², Ufuk Oğuz İdiz ¹, Ekrem Çakar ¹, Hasan Bektaş ¹

Paget’s disease is a neoplastic disease primarily seen in the breast. Paget’s disease seen in the perianal region is defined as a subgroup of the Extramammary Paget’s Disease (EPH). EPH is most commonly seen in the vulva, periscrotal, and perianal regions. We aimed to present the clinical findings, diagnosis and surgical treatment of the rare primary Perianal Paget’s disease (PPH) case which was seen in the General Surgery Department of the Health Sciences University Istanbul Training and Research Hospital in December 2017. A seventy-seven-year-old female patient’s history included surgery due to hydrocephalus and previous cerebrovascular disease. The patient complained of a red colored, elevated wound in the perianal region for approximately 3 years. Topical treatments were started at the external centers but the complaints were not relieved. As a result of admission of the patient in the dermatology clinic of our hospital, the patient was diagnosed as extramammarian Paget disease in the perianal region as a result of the examinations and biopsy. The patient was interned for surgery. MR imaging of the lower abdomen revealed no thickening of the rectum mucosa immediately above the anal canal and upon this finding no feature was detected in the colonoscopy performed. The patient’s surgery was performed by a team of general surgery and plastic surgery. The lesion in the perianal region of the patient in prone position, extending to the vulva was excised with a 2 cm intact margin. Then, while the defect in the coccyx region was repaired with transposition fleps prepared from the gluteal region, Ying-Yang flaps prepared from both sides of the defect were sutured into the anal canal mucosa by placing drain into the lodges for anal canal reconstruction. Laparoscopic sigmoid loop colostomy was performed after switching to supine position. Wound infection and wound dehiscence developed on postoperative 7th day when the patient was followed up in the service. The patient was discharged applying serial dressings on the postoperative 39th day. Pathological result of the resected specimen was reported as Minimal Invasive Extramammary Paget’s Disease. Perianal Paget’s disease (PPH) is a subgroup of EPH that develops within the perianal skin and is examined in two categories according to the tissue it originated from. While primary PPH is caused by apocrine glands in the perianal region or carcinoma of underlying tissues, secondary PPH is associated with malignancy in the distal regions. Secondary PPH is more common and has a worse prognosis. Due to its rare occurrence, it occasionally took its place as case presentations. Although the exact incidence of PPH and the survival rate are unknown, the treatment strategy is not yet standardized.

TJS. 2018;34(Suppl-1):S594–S595.

PP-0742 [Colon and Rectum Surgery]. Transanal Endoscopic Microsurgery (TEM) Application with SILS Port

Koray Baş ^1,^✉, Hakan Öğücü ¹, Emran Kuzey Avcı ¹, Yahya Çapkis ¹

Transanal endoscopic microsurgery (TEM) is becoming increasingly common in modern rectal surgery as a good alternative to radical resections of surgical excisions of rectal tumoral structures that can not be excised by colonoscopic methods. Initial work in this area began with G. Buess et al.’s animal experiments in the early 1980s, and the same group published the first patient series in 1985 as “transanal endoscopic microsurgery”. The original technique of the transanal approach is the use of a rigid proctoscope with an external diameter of 4 cm, which may lead to severe morbidity, such as decreased anal sphincter pressure and associated incontinence after the procedure. In this study, we share a case in whom we performed TEM as an alternative method through the SILS port. A 66-year-old male patient underwent colonoscopy for the purpose of screening and a polypoid mass with sessile-based mass, measuring approximately 4x3 cm in size with a left lateral wall location starting in the rectum at 6.cm and an endoscopic punch biopsy was reported as an adenoma showing moderate dysplasia. Synchronous lesions were not detected in other segments of the colon. Pelvic magnetic resonance imaging confirmed the absence of wall invasion and peripheral pathologic lymphadenopathy and excision of the lesion with TEM was decided.

Technique

One 10 mm and two 5 mm trocars were used over the SILS port placed into anal canal in the left decubitic position under general anesthesia. 10mm and 5mm 30 degree angle optical cameras were prepared. In the presence of conventional laparoscopic instruments and energy devices, the lesion was excised with a circumference of 1 cm intact margin deepening into the circular muscle layer in the base. The mucosa defect was closed endoscopically by suturing. The patient was discharged on the 2nd postoperative day. It was confirmed that adenoma with moderate dysplasia without invasive focus in specimen histopathology and the negativity of all borders were confirmed. There was no pathological finding in the field of resection in the 6 month control rectosigmoidoscopy. AlthoughTEM for rectal adenomas is a recommended method because it offers the advantages of minimally invasive surgery, we think that this procedure can be performed with less traumatic instruments such as the SILS port as well as classical rigid proctoscopy.

TJS. 2018;34(Suppl-1):S595.

PP-0743 [Colon and Rectum Surgery]. Sigmoid Colon Perforation Due to Multiple Myeloma

Evren Besler ¹, Mehmet Taner Ünlü ^1,^✉, Mustafa Fevzi Celayir ¹, Hakan Mustafa Köksal ¹, Mehmet Uludağ ¹

Objective

Stercoral perforation of the colon is an uncommon and unexplained emergency surgery. Although spontaneous colon perforation due to various causes is defined in the literature, the information about the subject is limited. In this report, we aimed to present spontaneous sigmoid colon perforation in a patient under multiple myeloma treatment.

Material and Methods

Characteristics of the case (complaints, history, clinical and laboratory findings, treatment and prognosis): A 64-year-old female patient presented with a complaint of abdominal pain to the emergency service for 1 week. There were ischemic heart disease, congestive heart failure, stenting in coronary arteries, appendectomy, segmental cesarean section, undiagnosed spastic colon, multiple myeloma and associated vertebral metastases under treatment. The patient was on chemotherapy-corticosteroid therapy for multiple myeloma in the hematology-oncology unit. Physical examination of the patient revealed significant tenderness and rebound findings in the lower quadrants of the abdomen. Nausea-vomiting and fever were absent. The patient had spontaneous defecation. Intestinal voices were hypoactive. Laboratory values were Wbc: 4,67 10 ^ 3/uL, Neu: 53%, CRP: 96 mg/L. In ultrasonography, anechoic free fluid was observed minimally in the subhepatic area in the abdomen and it was more apparent in the right lower quadrant. Computerized tomography revealed free air and dirtiness around the rectosigmoid colon, and appearance consistent with fecalomas in various parts of the colon. The patient was taken into operation with the prediagnosis of hollow organ perforation - acute surgical abdomen. In the operation, intraabdominal purulent fluid, fecalom, located in the rectosigmoid corner of the colon, which corroded and thinned this part of the colon wall, a rectosigmoid colon segment with impaired feeding, and petrified fecalomas in other colonic segments were observed. The patient underwent segmental rectosigmoid colon resection, intracolonic fecaloma emptying and end colostomy. The patient was admitted to the intensive care unit for 1 day postoperatively and was taken to the clinic. Gas-gaita discharge occurred from the colostomy on the postoperative 2nd day and oral intake was initiated and the patient was discharged on the 8th postoperative day with surgical healing. The patient’s pathology was reported as colon perforation, serosal peritonitis, edema, mixed type inflammatory cell infiltration.

Conclusion

Stercoral column perforation is an emergency surgical condition which is not understood with its various clinical conditions. This case of multiple myeloma-related stercoral perforation is the second case reported in the literature. We believe that dehydration and associated constipation occurred secondary to suppressed immune system due to patient’s being under intense chemotherapeutic agents and corticosteroid treatment and plasma with increased viscosity and perforation occurred secondary to intestinal wall ischemia. There is a need for more extensive research to understand the cause of stercoral perforation.

TJS. 2018;34(Suppl-1):S595–S596.

PP-0744 [Colon and Rectum Surgery]. Our Acute Appendicitis Cases in Geriatric Age Group

Eyüp Gemici ^1,^✉, Ahmet Sürek ¹, Murat Çikot ¹, Hakan Seyit ¹, Osman Köneş ¹, Bahadır Kartal ¹, Mehmet Abdussamet Bozkurt ¹, Menmet Emin Güneş ¹

Objective

The purpose of this study is to detect the effect of advanced age on surgical management, postoperative follow-up, and surgical field in patients undergoing appendectomy due to acute abdomen and to discuss the results of our case series.

Material and Methods

Sixteen cases who were taken to operation with the prediagnosis of acute abdomen and underwent appendectomy in Bakırköy Dr. Sadi Konuk Training and Research Hospital Department of General Surgery until 01.01.2018. In this retrospective study, demographic data, leukocyte count, alvarado scoring, presence of imaging methods, complication development and duration of hospitalization in the geriatric age group (≥80) were questioned.

Results

Eight male (50%) and eight female (50%) cases underwent surgery. The mean age was 83 (min: 80-max: 96). Patients were admitted with an average of 2.6 day (1–5) abdominal pain complaint. Complaints were accompanied by loss of appetite in all cases. There was no fever in any case. It was reported that in only 1 case the pain changed place and the pain was in all quadrant being more on the right, in all other cases. Leukocytosis was not detected in 6 cases. The mean leukocyte level was measured as 13356/mm3 (4500–21200). Alvarado score was determined between 5 and 8 in all cases. Ultrasonography was performed in all cases before the operation. In only 3 cases (16%) appendicitis could be detected. Whole abdominal CT scans were performed in all cases whose ultrasonography did not give information. All appendicitis cases were reported in the radiologist’s evaluation of the tomography. Laparoscopic appendectomy was performed in 12 cases. The operation was completed by switching to open surgery. Open surgery was started in 1 case. Perforation was detected in 8 cases (50%). Intraabdominal abscess developed in 2 cases (12.5%) postoperatively. It was drained by a percutaneous catheter, which did not require major surgery. The mean hospital stay was detected as 4.3 days (1–12). It was observed that the surgical area was without any problem in the outpatient clinic controls of the patients after their discharge. Malignancy was not found in pathology reports.

Conclusion

Although acute appendicitis in the geriatric age group is rare, it should come to mind immediately in cases of newly started pain. Leukocytosis and fever may not be seen in the advanced age group. Cross-sectional methods are recommended to diagnose when ultrasonography is inadequate. Postoperative hospitalization durations are longer than in younger patients with frequently seen appendicitis.

TJS. 2018;34(Suppl-1):S596–S597.

PP-0746 [Colon and Rectum Surgery]. A Rare Cause of Psoas Abscess: Appendicular Mucinous Carcinoma

Melih Can Gül ¹, Mehmet Zafer Sabuncuoğlu ¹, Ayfer Şen ¹, İsa Karaca ^1,^✉

Introduction

Psoas abscess (PA) is a rare, usually lately diagnosed, disease with a high mortality and morbidity. Psoas muscle has neighbourhood with organs such as appendix, colon etc. Related infections can spread to psoas muscle. Its findings are fever, abdominal pain and low back pain. Psoas abscess is classified as primary and secondary. The etiology of primary psoas abscess (pPA) is unclear. Secondary Psoas abscesses (sPA) constitute 70% of the cases and they occur as a result of local spread from surrounding infected tissues. The choice of appropriate antibiotic in treatment of psoas abscess is open or percutaneous abscess drainage. It was prepared as a case since the pathology result of the appendectomy material due to interpretation of the last imagings of the recurrent right psoas muscle abscess prediagnosis of our patient in favor of psoas muscle abscess secondary to appendix perforation was obtained as appendiceal mucinous carcinoma and that it was not common in the literature.

Case

A 84-year-old male patient was admitted to the emergency service in our hospital 3 months ago with the diagnosis of right side pain, nausea, fever, and 8x4 cm abscess at the right psoas level in USG. The patient had diagnoses of diabetes for 14 years and chronic renal failure for 3 years and was using short and long acting insülin, metaprolol and norvasc. Laboratory findings were as such: BUN: 30mg/dL, creatinine: 2.39mg/dl, Na: 142mmol/L, K: 4.49mmol/L, Hemogram: WBC: 12100/μL and urinalysis was normal. A drainage catheter was inserted in the patient by interventional radiology department. Discharge of the patient who was treated with appropriate antibiotic treatment according to reproductions in his culture in the follow-ups was planned due to association of the current picture with diabetes, complete regression of abscess pouch and improvement of current clinical picture after exclusion of other secondary psoas muscle abscess causes including tuberculosis and brucella. The abdominal USG performed in the patient who was hospitalized in our clinic upon recurrence of previous picture after discharge of him 1 month later and was examined again, revealed that appendix formed a wall thickness all along originating from cecum and formed a continuity with the predefined abscess in distal and wall integrity of distal end was impaired. The operation decision of the patient was taken. It was observed that the distal of the appendix was adhered to the psoas muscle after withdrawal of the appendix from cecum. The patient underwent appendectomy and the wall of the abscess cavity was cured. The patient was discharged with healing on the 4th postoperative day. The patient underwent right hemicolectomy upon obtaining the pathology result as appendiceal mucinous carcinoma.

Conclusion

Psoas abscess is a rare, infectious disease that is characterized by severe complications with difficulty of treatment, and lethal disease, which do not have typical clinical findings and require advanced imaging techniques for diagnosis. 30% of psoas abscesses are classified asprimary and 70% of them are classified as secondary. Crohn’s disease takes the first place (60%) in the literature as sPA. It is followed by pott disease, previous intra-abdominal surgeries, kidney stones, brucella, and diabetes. As an etiology, although the above-mentioned causes are prioritized we are of the opinion that reviewing the conditions of the intraabdominal neighboring organs would help to establish diagnosis. In this respect, it was understood that malignancy was on the ground of pathology of the patient who was operated with the prediagnosis of perforated appendicitis.

TJS. 2018;34(Suppl-1):S597.

PP-0747 [Colon and Rectum Surgery]. Comparison of Postoperative Pain and Recurrence Rates in Open and Closed Lateral Internal Sphincterotomy

Melih Can Gül ^1,^✉, Mehmet Zafer Sabuncuoğlu ¹, Mahmut Bülbül ¹, Nesime İnci Eryılmaz ¹

The rise of internal anal sphincter pressure, the anatomic position of external anal sphincter and ischemia are accused in anal fissure formation. Lowering the pressure in the anal canal is targeted in lateral internal sphincterotomy. It was detected that pressure decreased at a rate of 40–50% in patients with high anal canal pressure after lateral internal sphincterotomy, and in parallel anal fissure healing was detected. In this study, postoperative pain levels and postoperative recurrence rates were compared in Open and Closed Lateral Internal Sphincterotomy. Twenty patients were included in the study in both groups formed as prospective and randomized groups. The operation of all the patients was performed with the presence of spinal anesthesia and petidine HCl (aldolan) was administered 1mg for 1 kg intramuscularly in a 6-hour period in the postoperative period. In the postoperative period, both groups of patients were planned to discharge with stopping analgesics at 24 th hour. The peripheral oxygen saturation, respiration rate, heart rate, and non-invasive arterial blood pressures were recorded in our clinic by on duty teams at the 4th, 8th, 12th and 24th hours in the postoperative period. There were no significant differences in terms of age, gender, weight, ASA and duration of operation between the two groups. There was no difference in the anamnesis findings of postoperative pain levels at any working hours. Patients were followed for 9–13 months with intervals of 21 days. In both groups, recurrence was observed in one patient and sphincterotomy was performed again. Although no difference was detected in terms of postoperative pain levels in the first 24 hours in Open and Closed Lateral Internal Sphincterotomy recurrence rates were found to be equal and low. Both methods were found reliable in terms of pain and efficacy.

TJS. 2018;34(Suppl-1):S597–S598.

PP-0748 [Colon and Rectum Surgery]. Laparoscopic Total Colectomy Ileal Pouch Ileoanal Anastomosis Diverting Terminal Loop Ileostomy: Experience Between 2015–2017

Esra Dişçi ^1,^✉, Mehmet İlhan Yıldırgan ¹, Yavuz Albayrak ¹, Sabri Selçuk Atamanalp ¹, Ufuk Memiş ¹, Mustafa Yeni ¹

Objective

Stapler-assisted total colectomy performed due to ulcerative colitis (UC) and familial polyposis coli (FPC) becomes an applicable surgical method with an increase in laparoscopic equipment and experience. Laparoscopic surgery is superior than open surgery because of less pain after surgery, shorter hospitalization duration, earlier return to work and better cosmetic results.

Objective

Regional lymph node metastasis in colon cancers is an important prognostic factor. Different results have been reported in studies on the number and distribution of normal lymph nodes in mesocolon. Our aim is to investigate the number and distribution of lymph nodes according to the anatomical regions of the mesocolon in patients who underwent surgery due to colon cancer in our clinic.

Material and Methods

Ten colon cancer patients operated in our clinic with conventional method between August 2017 and February 2018, were taken into the study. Operations and pathologic examinations were performed by a single surgeon and a single pathologist. During surgery, mesocolon vascular structures were connected with high ligation technique and total mesocolic excision was performed. The lymph nodes in the mesocolon after resection were separated by the surgeon according to epiclonic, paracolic, intermediate and main colic lymph node stations and histopathological examination was performed according to these stations.

Results

Of the 10 patients who were operated on due to colon cancer, 5 were male and 5 were female and the mean age was 71.6 (51–87 years). Five of the patients underwent right hemicolectomy and five underwent left hemicolectomy. In 10 patients, 258 lymph nodes were examined and the mean number of lymph nodes was 25.8 (7–49). The mean number of lymph nodes in right hemicolectomy patients was 34 (15–49). The mean number of lymph nodes in the epiclonic region was 0.6 (0–1), the mean number of lymph nodes in the paracolic region was 18.5 (8–36), and the mean number of lymph nodes in the intermediate region was 15.2 (7–28). Metastatic lymph node rates were 4.39% (4/91) in the paracolic area, whereas metastatic lymph nodes were not found in other areas. The mean number of lymph nodes in patients who underwent left hemicolectomy was 17.6 (7–31). The mean number of lymph nodes in the epiclonic region was 0.2 (0–1), the mean number of lymph nodes in the paracolic region was 11.8 (3–24), the number of lymph nodes in the intermediate region was 4.8 (4–6), and the number of lymph nodes in the main colic region was 1(0–2). The rates of metastatic lymph nodes detected were 22% (13/59) in the paracolic area and 4.2% (1/24) in the intermediate area, whereas no metastatic lymph node was found in other areas.

Conclusion

The distribution and number of lymph nodes in the colon meso and metastatic lymph node distributions may be important in predicting surgical resection width.

TJS. 2018;34(Suppl-1):S599–S600.

PP-0752 [Colon and Rectum Surgery]. SEMS (Self-Expandable Metal Stent) Applications in the Occluding Colon and Rectum Tumors

Koray Baş ^1,^✉, Gizem Kılınç ¹, Hüseyin Esin ¹, Lütfi Mutlu ¹, Avni Şamlı ¹

The first application areas of endoscopic stents that can be placed endoscopically were biliary and esophageal obstruction pathologies. Nowadays, they have begun to be used more widely as an alternative method for the palliation of duodenal and colonic advanced obstructive lesions. In recent years, they are used especially in the left colon and rectum obstructive tumors, for the purpose of bridging the patients to elective surgery. Emergency surgery treatment of colonic obstructive lesions are practices with high morbidity and mortality. Endoscopic colonic stenting in appropriate cases may protect the patient from emergency surgery due to obstruction.

With removal of luminal obstruction by stent;

-Dilation of the dilated colonic loops in the proximity of the obstruction decreases and thus normalizes the intestinal vascular perfusion. So, the probability of necrosis and perforation is reduced
-Impaired fluid and electrolyte balance can be returned to normal in the third cavity due to liquid leakage
-Luminal bacterial translocation is reduced and septic picture control becomes easier
-Decreased distension reduces intra-abdominal pressure and prevents possible abdominal compartment syndrome
-General anesthesia risk is reduced because the patient’s vital parameters are improved
-Histopathologic diagnosis of the tumor can be achieved by dissolving the urgency of the patient
-Advanced imaging studies can be used for cancer staging; for example, if a locally advanced rectal cancer is detected, the patient may be given neoadjuvant chemo-radiotherapy
-Surgery can be performed more appropriately with oncologic principles in the resection of distension-resolved colonic loop
-The chance of using laparoscopic and robotic surgery for resection surgeon is increased
-Since proximal and distal colonic lumen diameters will approach each other, the likelihood of providing intestinal continuity with anastomosis increases
-Anastomosis safety is increased by performing surgery on condition that the patient and the surgery are more optimal.

In this report, we share our experience in 4 cases we bridged from emergent surgery to elective surgery by applying SEMS due to the left colon and rectum occlusion lesion. The mean age of the patients were 65.8 (50–84) Occupational tumoral lesions of two male and two female patients were located in the upper rectum, rectosigmoid junction (two patients) and distal sigmoid colon. In the procedures, semi-coated self-expanding colonic stents with external diameters of 25 mm and lengths of 80 and 100 mm were used through colonoscopy lumen under direct view. There was perforation during the procedure in our patient who had a solid tumor with advanced sigmoid location and the patient was operated and the Hartman procedure was applied. Our other 3 patients’ surgeries were performed 14, 8 and 11 days later. All three patients underwent low anterior resection with hand-assisted laparoscopic surgery (HALS) under elective surgery conditions. Diverting stoma for anastomosis protection was not applied. One patient was lost for non-surgical reasons. We believe that with this limited case series, SEMS applications may protect the obstructive colonic tumoral lesions at appropriate cases with high morbidity and possible mortality caused by emergency surgery.

TJS. 2018;34(Suppl-1):S600–S601.

PP-0753 [Colon and Rectum Surgery]. The Case of Pseudomyxoma Peritonei Presenting with Port Hernis

Serkan Karaıslı ^1,^✉, Atahan Acar ¹, Feyyaz Güngör ¹, Kemal Atahan ¹

Introduction

Pseudomycasoma peritonei (PP) is a rare tumor that occurs at a frequency of approximately one in a million. It is often associated with appendicular mucocele or mucinous overt tumor. PP, can be frequently inguinal and rarely presents with hernia. In this article we aimed to present the diagnosis and treatment process of a patient with the diagnosis of PP secondary to mucinous tumor of appendix presenting with laparoscopic port hernia.

Case

A 72-year-old male patient with a history of type-2 diabetes, hypertension, and laparoscopic cholecystectomy 10 years ago was admitted to the department of general surgery with abdominal swelling for two months and increased swelling in the area of the old incision scar on the umbilicus. Sensitivity was detected in the right lower quadrant in the physical examination except distension and umbilical protrusion. Laboratory parameters were within normal limits. While a 1.5 cm fascial defect was observed in the umbilicus superior in superficial ultrasonography, computed tomography was reported as a multiloculated cystic mass with a size of approximately 19x13x16 cm, with a mesenteric location at the level of the terminal ileum level and partially herniated at the superior part of the umbilicus. The patient was scheduled for laparotomy with an intraabdominal mass. It was seen that the intraabdominal diffuse gelatinous fluid leading to the protrusion in the region having port hernia and a mass of 6x5x4 cm in the distal part of the appendix. For example, the frozen examination of the sample sent from the liquid was reported as a liquid having mucinous character considering PP. Right hemicolectomy, ileotransversostomy and peritoneal debridement were performed. Cytoreductive surgery or intraperitoneal hyperthermic chemotherapy were not considered in the patient with poor overall performance. The patient was discharged without any problems on the 6th postoperative day. Pathology result was reported as a mucinous tumor of the appendix. No surgical complication was observed in the 1-month follow-up of the patient. The patient who did not accept additional surgery was referred to the medical oncology unit.

Conclusion

In the literature, cases of PP that are rarely presenting with inguinal, femoral, incisional or umbilical hernia have been reported. However, the PP case, which presents with port hernia, has not been defined before. In the case of port hernia, which is a very rare event, the possibility of PP should be kept in mind in case of increased abdominal distension, and whole abdominal imaging should be performed.

TJS. 2018;34(Suppl-1):S601.

PP-0754 [Colon and Rectum Surgery]. The Role of Diverting Colostomy in the Treatment of Fournier Gangrene

Fevzi Cengiz ^1,^✉, Emine Özlem Gür ¹, Kemal Erdinç Kamer ¹, Cengiz Tavusbay ¹, Ahmet Atasever ¹, Necat Cin ¹, Gülden Ballı ¹, Mehmet Hacıyanlı ¹

Objective

Fournier’s gangrene (FG) is a disease characterized by necrotizing fasciitis developing associated with perineal, genital or synergistic polymicrobial infection of perianal regions. FG has high mortality with insidious clinic, requiring urgent surgical intervention [1]. In fact, it is a disease in conditions of existing low-virulence bacteria and pathological conditions such as local trauma causing destructive and rapid spreading tissue destruction by frequently triggering synergistic effects with comorbid systemic disease. Deaths with FG cause have fallen from 80% to 40% in the last 15 years to below 20% today [2]. Despite surgical debridements, broad spectrum antibiotics, improved wound care products and intensive care facilities, diverting colostomy is still controversially recommended. The purpose of our study is to investigate the place of the diverging colostomy in the treatment of FG.

Material and Methods

Thirty three patients who had undergone FG surgery due to only perianal region in the İzmir Katip Çelebi University Atatürk Education and Research Hospital Department of General Surgery between 2014 and 2017 were included in the study. The patients were divided into two groups as the group undergoing diverting colostomy group (Group I, n=17) and the group not undergoing diverting colostomy group (Group II, n=16). Demographic data of the patients, Uludag Fournier Gangrene Severity Score (UFGSI), debridement numbers and postoperative local care (vacuum assisted closure systems-VAC) were retrospectively scanned from prospectively recorded records in the hospital database. All of the study group was assessed within the timeframe until post-operative discharge. Fisher exact test and Mann-Whitney U test were used for statistical study.

Results

Five of the patients (21.2%) were female and 26 (78.8%) were male. There was no gender difference in the demographic data of the groups, whereas the patients who had colostomy were found to be statistically younger. It was observed that patients with diverting colostomy had statistically high numbers of UFGSI score and debridement. There was no statistical difference in VAC treatment between groups and mortality.

Conclusion

The purpose of the diverting colostomy is to prevent the stool from passing through the infected area for wound healing. However, prolongation of operation period is the cause of morbidity. In our study, colostomy appears to be applied to the patients with worsening physical parameters and wider wounds. Although this group was younger and had a higher number of debridements, there was no difference in local treatment and mortality rates compared to elderly and less debridized patients. In our choice of colostomy, we believe that when considering the general condition of the wound and the patient, they have to be applied less considering that they do not change the number of debridement and mortality and they cause the functional and aesthetic disturbances, and there will be a necessity of secondary surgery.

References

1.Erkan O, Dilek Ş. Using negative pressure therapy for improving skin graft taking on genital area defectsfollowing Fournier gangrene. Turk J Urol. 2017;43:366–70. doi: 10.5152/tud.2017.92845. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Tuncay Y. Fournier’s gangrene: insidious, lethal, but treatable disease. Journal of Colon Rectum Diseases. 2012;22:45–9. [Google Scholar]

TJS. 2018;34(Suppl-1):S602.

PP-0755 [Colon and Rectum Surgery]. ASA 3 Colon Cancer Patients Operated under Emergency Conditions

Fevzi Cengiz ^1,^✉, Kemal Erdinç Kamer ¹, Turan Acar ¹, Hızır Taner Coşkun ¹, Halis Bağ ¹, Atahan Acar ¹, Mehmet Hacıyanlı ¹

Objective

Emergency surgery is required in approximately 15–30% of patients with colon cancer. In this case, there are many treatment options such as ostomy, resection + ostomy or resection + anastomosis. There are studies in the literature suggesting performing only ostomy, and studies suggesting that resection can be done as well. The purpose of our study is to investigate the surgical interventions and outcomes of ASA-3 patients, whose daily activities are not affected due to severe systemic disease in the scoring system by American Society of Anesthesiologists (ASA), requiring emergent intervention due to colocteral cancer.

Material and Methods

ASA 3 patients who underwent emergency colon cancer surgery between 2010 and 2017 were included in the study. Patient demographic data, operative indications, operative information, operative time, operative complications and mortality were retrospectively scanned from prospectively kept records in the hospital database. Complications were assessed according to Clavien-Dindo classification. All of the study group was evaluated within the first 30-day time-period. The results were obtained by statistical comparison of the data of the died and living patients. We used the Chi Square exact test for the rXc tables and the t test for the numerical variables as categorical variables in the statistical study.

Results

The study was conducted on 133 patients within the specified time period. There was no statistically significant difference in the demographic and surgical indications of the groups. There were no statistically significant differences between the operations performed and the duration of surgery. Anastomosis leakage requiring emergent intervention was observed in two patients who underwent anastomosis after resection in an emergency condition and did not undergo ostomy and mortality was not observed in these patients. There was no statistically significant difference in grade>2 observed surgical complication rate between the two groups according to Clavien-Dindo classification (21.0%, 17.8%, p=0.577).

Conclusion

In our study, it was found that the surgical interventions of ASA 3 colon cancer patients under emergency conditions and the related operation time did not make any statistical difference in terms of morbidity and mortality observed in the short term. However, it is known that the long-term outcomes of patients who undergo surgery under urgent conditions are worse than those of elective patients at the same stage. In this case, if possible we believe that it is appropriate to perform the elective surgical intervention. Furthermore, the fact that the proportion of patients who died and lived in our study group is high affects the statistical results, and we believe that the results may change with wider series.

TJS. 2018;34(Suppl-1):S602–S603.

PP-0756 [Colon and Rectum Surgery]. An Unusual Cause of Intestinal Obstruction in an Adult Patient: Anal Atresia-Rectovaginal Fistula: Case Report

Rifat Mert Gülmez ^1,^✉, Sinan Efe Yazıcı ¹, Yusuf Alper Kılıç ¹

Introduction

Anorectal malformations are congenital defects observed one in 5,000 live births that define a range of anatomical abnormalities of the rectum and anus. Since it is easy to diagnose, they are usually diagnosed within the first 24 hours after birth and treated surgically in the early period. Nevertheless, there have been reports of untreated cases until adulthood in developing countries. In this presentation, we present a case of anal atresia-rectovaginal fistula who did not receive treatment until an advanced age due to low level of socioeconomic status, and then was admitted to the hospital due to intestinal obstruction.

Case

A 32-year-old female patient with no comorbid internal disease presented with complaints of defecation from the vagina from birth and intestinal obstruction following chronic constipation. There was no anal penetration on the patient’s examination and a fistula was seen between the rectum and the vagina. In the routine MRI examination of the patient without a pathology laboratory examination, it was observed that the anal canal became a thin band all the way from the localization to the 3 cm proximal from the anal penetration, the luminal structure, internal and external sphincter were not observed and fistula tract associated with vagina in the dentate line region was observed. In computerized tomography, the pelvis was fully padded with 13x29 cm size stool. It was seen that the descending colon and sigmoid colon of the patient who was taken to the operation was completely padded with stool and she was distended. The stools were emptied by performing enterotomy and then a short segment of the colon was resected to prevent development of a motility disorder and the end colostomy was opened from the descending colon level. The patient whose oral intake started on the postoperative 2nd day was discharged on the 12th postoperative day in order to plan reconstructive surgery.

Conclusion

Anal atresia in advanced age is a rare condition; however, treatment may be delayed until old ages if the urethra is fistulized to the uretrea, bladder and vagina as in our case. Imperforated anus is a condition that requires emergency surgery unless it is a fistula tract. Perineal anoplasty or colostomy may be applied in surgical treatment. It has been reported in current studies that performing colostomy first for the adult patients and then performing a posterior sagittal anorectoplasty in the second stage is the most effective method. The mentioned prospective reconstructive surgery options in patients with congenital anorectal malformation should be kept in mind.

TJS. 2018;34(Suppl-1):S603.

PP-0757 [Colon and Rectum Surgery]. Effects of Adipose Tissue Derived Stem Cell Application on Immunosystemically Suppressed Rats with Everolimus on Colon Anastomosis: Experimental Study

Emre Karakaya ^1,^✉, Aydıncan Akdur ¹, Tugan Tezcaner ¹, Alev Ok Atılgan ², Çağrı Uysal ³, Huriye Eda Özturan Özer ⁴, Sedat Yıldırım ¹, Mehmet Haberal ¹

Objective

Anastomotic leakage after gastrointestinal surgery causes severe mortality and morbidity. There are many factors that affect the safety of anastomosis. Although MTOR inhibitors have stronger immunosuppression, they have side effects such as wound healing, infertility, pneumonia and thrombocytopenia. Mesenchymal stem cell therapy has a positive effect on wound healing due to differentiation into multiple tissues and increases the formation of new blood vessels.

Investigation of the effect of adipose tissue-derived stem cells on wound healing in immunosuppressed rats with mtOR inhibitors.

Material and Methods

In this study, 56 Sprague-Dawless male rats were used and divided into four groups. Group 1 (control, colon anastomosis), group 2 (colonic anastase + stem cell), group 3 (colonic anastomosis + immunsuppression), group 4 (colonic anastomosis + immunsuppression + stem cell). Anastomoses were performed in the descending colon in all groups. The third and fourth groups’ immune systems were suppressed with the everolimus every day 7 days before the laparotomy. In the second and fourth groups, subserial adipose tissue stem cell injection was performed in the anastomotic region. One of the subgroups of each group was sacrificed on the fourth day and the others were sacrificed on the seventh day. In each group, adhesion, colonic anastomosis burst pressure, tissue hydroxyproline level measurement, fluorescence microscopy, histopathological and stem cell detection were performed.

Results

Adhesion was most commonly seen in group 3 and caused the adhesions of stem cell application to appear less in group 4. On the seventh day, higher levels of tissue hydroxyproline were detected than on the fourth day (p<0.001). Immunosuppression was found to cause a decrease in tissue hydroxyproline level. Stem cell application caused an increase in hydroxyproline level in group 2 (p<0.001), while group 4 did not cause the same effect. On the fourth and seventh day of the anastomosis, the highest bursting pressure was found in the pressure group 2 and in the lowest group 3. Although stem cell administration increased the bursting pressure in group 4 on the fourth day,the same effect was not seen on the seventh day. Histopathological examination revealed high vascular proliferation in the stem cell group (p<0.001).

Of the 30 patients in Group I, 16 (53.3%) were found to have a good quality of life, discharge continued in 11 (36.6%) of the patients, and 3 (10%) patients were re-drained due to having an abscess. Of the 26 patients who came to the control examinations, 12 (40%) were found to have no complaints after drainage and 11 (42.3%) patients had definitive surgical intervention with drainage after fistula. 11 patients (73.3%) had a good quality of life in the group of 15 patients who came to control in Group II. Three patients who lived with seton and did not accept the operation were followed up with minimal discharge. It was observed that recurrent abscesses occurred in one patient with rupture of seton and the quality of life was “bad”. The setons of 7 (46.6%) patients changed into cutting seton after an average of 6 weeks after the operation, and 4 (26.6%) patients had definitive surgical intervention. There was no recurrence.

Conclusion

In the series presented, the quality of life was good in 40% in group I and 73.3% in Group II. Abscess recurrence in group I was 23.3% while it was 6.6% in group II. The need for definitive surgery was 36% in Group I, and 26% in Group II. We think that the application of seton in abscess drainage in addition to fenestration prevents the development of recurrent abscesses, reduces the need for definitive surgery and increases the quality of life.

TJS. 2018;34(Suppl-1):S609–S610.

PP-0768 [Colon and Rectum Surgery]. Comparison of Quality of Life Scores for Patients Who Underwent Low Anterior Resection and Abdominoperineal Resection Due to Rectum Tumor

Material and Methods

A 64-year-old female patient was admitted to our emergency department with nausea, vomiting and abdominal pain in the lower right quadrant. The pre-diagnosis of acute appendicitis was established and the laparotomic exploration decision was made. A mass obstructing appendix root was detected in the operation.

Results

The adult patient presented with complaints of pain, nausea and vomiting on the lower right side of the abdomen since 3 days. The patient did not have a chronic illness and there was no regular use of medication in her history. No family history of gastrointestinal cancer was found in the first degree relatives. There was sensitivity only in the lower right quadrant in the examination.. The examination of the other systems was evaluated as normal. The patient’s laboratory values were WBC: 9900 K / u (4X103-10x103), CRP: 3.95mg / dL (<0.5). Computerized tomography (CT) showed a 28x24 mm contrast enhancement in the cecum and a large and inflamed appendix due to the pressure of the cyst. Appendectomy and cecum wedge resection were performed for the patient. The pathology report was reported as poorly differentiated adenocarcinoma. For this reason, the patient was followed up and she underwent right hemicolectomy one month later and pathology was reported as mixed adenoreuroendocrine carcinoma.

Conclusion

Neuroendocrine neoplasias (NENs) arise from endodermal cells. These cells have common characteristics, such as the production of biogenic amines and polypeptide hormones. Sometimes NEN contains malignant exocrine glandular cells, when it represents at least 30%, it is called MANEC. These tumors are characterized by nonspecific symptoms, usually occurring in the fifth or sixth decade of life. MANEC is a malignant tumor prone to distant metastases. Therefore, it is usually diagnosed late and at the metastatic stage. If the diagnosis is made at an early stage, surgical resection may be therapeutic.

TJS. 2018;34(Suppl-1):S611–S612.

PP-0772 [Colon and Rectum Surgery]. Total Removal of the Mesh due to Mesh Erosion in a Rectocele Case who Underwent Transperineal Repair with Polytetrafluoroethylene (ePTFE) Mesh

Fatma Ayça Gültekin ^1,^✉

The erosion of mesh which is a complication of repairs with mesh in the pelvic organ prolapses is a feared condition among surgeons especially due to medicolegal problems it creates. This causes different mesh types to be used during repairs. Some of the existing meshes have severe fibrosis, high-grade erosions and low recurrence rate, whereas some cause complications such as poor fibrosis, high recurrence and mesh rejection. The video demonstrates the operation of extracting the mesh due to mesh rejection in the rectocele case, in whom transperineal mesh repair was conducted with polytetrafluoroethylene (ePTFE) mesh. Video: In the operation performed in the lithotomy position under full intestinal cleansing and spinal anesthesia, 2/3 of the mesh was found to be rejected but there was not a finding in favor of the infection. In order to remove the rest of the mesh, the rectovaginal septum was dissected and mesh was extracted totally by opening weak adhesions with gentle blunt dissections. The rectum was controlled by rectal touché and flexible rectosigmoidoscopy. Finally, rectum was controlled in terms of rectovaginal fistula having a size that could escape from the eye in rectal touche and flexible rectosigmoidoscopy by filling with methylene blue. After the control, no pathology was found in the patient and the lodge was abundantly washed with serumphysiological. The perineum and vagina were closed with 3/0 vicryl sutures.

It may be necessary to use mesh in the repair of pelvic organ prolapse. In such a case, the choice of mesh and the way in which the selected mesh will be used has critical importance.

TJS. 2018;34(Suppl-1):S612.

PP-0773 [Colon and Rectum Surgery]. A Rare Case: Perianal Involvement in Lymphoma

Özhan Albayrak ^1,^✉, Bünyamin Gürbulak ¹, Şükrü Çolak ¹, Ekrem Çakar ¹, Hüsnü Şevik ¹, Hasan Bektaş ¹

Introduction

Lymphomas are malign diseases that originate from lymphoreticular cells. They are divided into 2 groups as Hodgkin’s lymphoma and non-Hodgkin’s lymphoma. Lymphoreticular cells are found especially in the lymph nodes, so the tumor growth of the lymph nodes is often the leading clinical symptom but the symptoms may vary according to the locations where they are seen. Lymphoma is a disease that must be included in the differential diagnosis of perianal lesions. In this study, it is aimed to present a case of a lymphoma which is interned with the pre-diagnosis of perianal abscess.

Case

A 55-year-old non-comorbid female patient was admitted to the emergency room with a complaint of pain in anus in the last week. During the patient’s admission, physical examination revealed swelling in the perianal region and the patient was operated with the pre-diagnosis of perianal abscess. Drainage could not be achieved because the abscess pouch could not be reached. The patient underwent colonoscopy in her follow-ups. Colonoscopy revealed a mass lesion involving edematous necrotic areas and a segment of approximately 3 –4 cm, narrowing the lumen all around at 3 cm in the rectum. Patient underwent lower abdominal CT and lower abdominal MR. The pelvic mass was first identified as a hematologic tumor image. The patient underwent reoperation after the ileus picture developed in her follow-ups. The patient’s operation showed an unresectable mass completely filling the pelvis. Pathology material was taken from this mass and loop colostomy was opened. The patient complained of swelling on the cheeks in his follow-ups and paranasal sinus and maxillofacial CT were applied and neck and facial MR was performed. A biopsy was taken by the department of otorhinolaryngology on the basis of a mass image extending from the patient’s right maxillary to the mandibula. Upon reporting of pathologic examination result as high grade large B-cell lymphoma showing plasma cell differentiation, chemotherapy was started for the patient by the department of hematology. The patient with cardioplumonary arrest was lost on the second day of chemotherapy.

Conclusion

Perianal abscess is a disease that is thought to be originated from cryptoglandular epithelium in the anal canal and can be seen in ischiorectal, supralevatoric, transsphincteric and intersphincteric cavities. Although perianal abscess is considered in the first plan in the lesions presenting with hyperemia, temperature increase and fullness developing in the perianal region, in case features such as lymphadenomegaly, B symptoms and deterioration in hematological laboratory parameters are detected lymphomas with perianal involvement should be kept in mind.

TJS. 2018;34(Suppl-1):S612–S613.

PP-0774 [Colon and Rectum Surgery]. A Rare Fistula Localization after Rectum Surgery: Lower Extremity Fistulas

Ahmet Orhan Sunar ¹, Yusuf Emre Aytin ^1,^✉, İbrahim Ethem Cakcak ¹, Eyüp Kahya ¹, Doğan Albayrak ¹

It is known that rectal perforations very rarely cause Perineal Fournier gangrene. However, the development of necrotizing fasciitis spreading to the upper thigh and lower extremity is very rare. There are several ways in which faecal material can reach this area. Femoral canal, Obturator foramen and psoas sheath. Despite the presence of polymicrobial infection in this case, septic shock and mortality did not develop. Although the number of surgical procedures for hyperbaric oxygen has been shown to decrease mortality and morbidity, it could not be implemented in this case. There was also no complication in the lower extremity requiring amputation. Limb loss and even mortality can be avoided in these cases with frequent debridement, combined treatment of the abdomen and vac therapy applied to the lower extremities having a course of necrotising fasciitis.

TJS. 2018;34(Suppl-1):S614.

PP-0778 [Breast Diseases and Surgery]. A Rare Breast Tumor: Adenomyoepithelioma

Sönmez Ocak ^1,^✉, Ömer Faruk Bük ¹, Mehmet Celal Kızılkaya ¹, Zülay Kazak ¹

Adenomyoepithelioma (AME); is a very rare tumor characterized by biphasic proliferation of both epithelial and myoepithelial cells. It has a high recurrence rate when it is resected with inadequate surgical margin although it has mostly benign character. A 33-year-old female patient with a 12-week gestation was admitted to the general surgery department with a palpable mass complaint. BIRADS 4b lesion was detected in the left breast in ultrasound. A true-cut biopsy of the lesion was obtained. The mass was excised upon suspicious result of the biopsy. The final pathology was reported as adenomyoepithelioma. No local recurrence was found at postoperative 9th month.

TJS. 2018;34(Suppl-1):S615.

PP-0781 [Breast Diseases and Surgery]. The Predictive Value of Neutrophil/Lymphocyte Ratio and Thrombocyte/Lymphocyte Ratio on Recurrence in Patients with Idiopathic Granulomatous Mastitis

Ömer Arda Çetinkaya ^1,^✉, Süleyman Utku Çelik ², Serdar Gökay Terzioğlu ³, Aydan Eroğlu ⁴

Objective

Idiopathic granulomatous mastitis (IGM) is a rare chronic inflammatory disease of the breast with unknown etiology. Although IGM is a benign disease histopathologically, it is a clinical picture whose diagnosis and treatment is difficult since it has complications such as fistula and abscess and it is frequently repetitive. The aim of this study was to investigate inflammatory parameters such as neutrophil / lymphocyte ratio (NLR) and thrombocyte/ lymphocyte ratio (TLR) and the relationship between prognosis and recurrence of IGM.

Material and Methods

We retrospectively reviewed 31 patients who had not been diagnosed with malignancy or inflammatory breast pathology between January 2010 and April 2016 and who were treated with histopathological diagnosis of IGM. In addition to the demographic information of the patients, body mass index (BMI), pre- and postoperative complete blood count, comorbidities, and recurrence-related information were obtained from clinical records. Patients were evaluated pre- and postoperatively for NLR and TLR values. The predictive effect of pre- and postoperative NLR and TLR values on recurrence was then examined. The results were given as mean, median and frequency; the value of p <0.05 was accepted as statistical significance.

Results

All patients were female and their mean age was 35.0±7.3 (21–49) years. The mean follow-up duration of the patients was 18.1±14.2 (3–66) months. The mean BMI was calculated as 30.7±5.7 kg/m². During the follow-up period, 4 (12.9%) patients had recurrent CRM. Preoperative NLR, postoperative NLR, preoperative TLR and postoperative TLR were found as 3.8-3.3-161.8 and 151.3 respectively. There was no statistically significant difference between preoperative and postoperative NLR and TLR values (p=0.807 and p=0.824, respectively). There was no statistically significant relationship between age groups, BMI, preoperative TLR, postoperative TLR and postoperative LNR. However, preoperative LNR level was found to be significantly higher in recurrent IGM (p=0.02).

Conclusion

Although IGM is a chronic inflammatory disease of the breast, it plays an important role in the surgical practice with the reason of its confusion with carcinoma. Although the etiology is not fully known, the treatment is also controversial. In addition, IGM is a challenging disease for both clinicians and patients, with recurrences and complications during follow-up. The present study demonstrates that the use of NLR as an inflammatory parameter, obtained by a simple complete blood count, may be a guide in the determination of IGM prognosis and recurrence. For more meaningful results, however, multicenter studies involving more patients are essential.

TJS. 2018;34(Suppl-1):S615–S616.

PP-0782 [Breast Diseases and Surgery]. Metaplastic Breast Carcinoma: A Rare Subtype Chondroid Metaplasis Carcinoma

Semra Demirli Atıcı ^1,^✉, Semra Salimoğlu ¹, Yasemin Kırmızı ¹, Dilek Kuzukıran ², Cengiz Aydın ¹

Metaplastic breast carcinoma constitutes 1–2% of all malignant breast lesions and clinically is more aggressive than other breast cancer subtypes. There are five subtypes of metaplastic breast carcinomas according to the 2012 WHO classification; low-grade adenosquamous carcinoma, fibromatous-like metaplastic carcinoma, squamous cell carcinoma, spindle cell carcinoma, mesenchymal differentiation carcinoma (chondroid differentiation, osseous differentiation and other mesenchymal differentiation types). In this article, we present a case of chondroid metaplasia, a subtype of metaplastic carcinoma in a 55 year old female patient.

A 55-year-old female patient presented with the complaint of a palpable mass in the left breast and a stiffness that covered almost the entire breast. In the breast USG performed; a mass having the possibility of malignancy whose inner echo has solid heterogeneous calcifications in the mid low zone of the left breast with lobulated contours about 6x6 cm was found. True cut biopsy performed: Invasive Ductal Carcinoma Grade 2; Tumor Histological Grade 2, Nuclear Grade 2, ER 40% (+), PR (−), Ki67: 20%, CerB2: (−) EKADERINE: reported as (+). No distant metastases were detected in the preoperative thoracobdominal CT. Sentinel lymph node biopsy was sent for frozen analysis during the operation. The axillary dissection was not performed upon arrival of the frozen result as reactive lymphadenopathy. Then, Left Mastectomy was applied because of the mass covering the entire breast of the patient. The hemovac drain in the operation lodge was withdrawn and the patient was discharged on the third postoperative day. Although the optimal treatment strategies for metaplastic breast cancer are still unclear, there are studies that suggest performing mastectomy rather than lumpectomy for the patients with larger masses compared to invasive ductal carcinoma. However, studies have shown that there is no difference between general or disease free survival in patients with metastatic breast cancer treated with modified radical mastectomy or breast conserving therapy. Intraoperative SLNB was performed in this case since tumor covered most of the breast tissue. Mastectomy was performed upon negative SLNB and the operation was terminated. The patient was directed to the Department of Medical Oncology for further postoperative treatment. Metaplastic carcinomas are spread by hematogenous way and the most distant metastases are in the lung and bones. Despite large tumor sizes, lymph node involvement is less common than adenocarcinoma. The incidence of lymph node metastasis can range from 0% to 63%. Patients diagnosed with metastatic breast cancer tend to have a higher stage of disease than those with invasive carcinoma. In addition, chemotherapy shows lower response rates than other basal-like tumors in treatment. In short the prognosis of multiple metastatic carcinoma is worse than conventional invasive carcinoma. Hormone receptor negativity and histopathologic subcomponents of tumor are effective factors on prognosis and treatment.

TJS. 2018;34(Suppl-1):S616.

PP-0783 [Breast Diseases and Surgery]. A Rare Soft Tissue Tumor in Differential Diagnosis of Axillary Lymphadenopathy, Synovial Sarcoma

Semra Demirli Atıcı ^1,^✉, Değercan Yeşilyurt ¹, Emre Dikmeer ¹, Semra Salimoğlu ¹, Cengiz Aydın ¹

Synovial sarcoma is a soft tissue tumor with epithelial and mesenchymal differentiation. It is seen in 5.6–10% of all soft tissue sarcomas. Synovial sarcoma with an atypical location, rarely seen in the differential diagnosis of the axillary mass, should also be considered in patients presenting with a palpable mass in the axillary region.

A 68-year-old female patient presented with painless swelling complaints in the right armpit for the last two months. Physical examination of the patient without a chronic illness revealed right axillary conglomerate, fixed, rigid lymphadenopathy. Both breast examinations and abdominal examination were normal and there was no malignancy history in the family.

Right axillary lesion 4 cm in diameter with a lobulated lesion consistent with necrotic lymphadenopathy was reported in superficial tissue ultrasonography performed for examination purposes. There was a suspicious appearance in terms of metastasis. Breast USG and mammography were performed excluding breast carcinoma encountered mostly in female patients in the differential diagnosis of axillary lymphadenopathy in the preplan of the patient. A well-defined, hypoechoic BIRADS 4 malignancy suspicious solid lesion with hyperechogenic interseptal occurrences with millimetric cystic spaces in the right axilla 46x32 mm in size was observed in the USG and Mammography performed in the patient with no palpable detected mass. The patient underwent thoracoabdominal CT for malignancy screening and the result was reported as usual. A true-cut biopsy was taken from the axillary lymphadenopathy having malignancy suspicion in order to establish tissue diagnosis. The result of the biopsy was interpreted as biphasic lesion formed of epithelial and mesenchymal cells, but its primary formation could not be detected. For this reason, the total surgical excision of the mass was decided with the safe surgical margin with diagnostic purpose of the patient. Postoperative pathology was compatible with biphasic type synovial sarcoma histopathologically. The patient was directed to the oncology department for follow-up and treatment. Synovial sarcoma is a soft tissue tumor with epithelial and mesenchymal differentiation. It occurs in 5.6–10% of soft tissue sarcomas. Histologically, there are 3 subtypes, monophasic, biphasic and poorly differentiated. It is seen mostly in lower extremity especially around the knee and the third-fifth decades. In our case, there was a synovial sarcoma of advanced age, rare and atypical localization originating from the shoulder joint. The prognosis of the disease is poor and the 5-year and 10-year survival rates are 38–76% and 20–63%. Removal of the tumor with safe surgical margin is important for prognosis, and it is the most important factor in preventing local recurrence. There are studies indicating that performing neoadjuvant chemoradiotherapy preoperatively according to grade, size and localization in synovial sarcoma treatment, followed by surgery, and postoperative adjuvant chemotherapy treatment have a positive contribution to survival. In the axillary lymphadenopathy for which patients admit to the department of general surgery, atypically located, rare synovial sarcoma as well as diseases such as breast carcinoma, metastasis of solid organ carcinoma such as lymphoma, leukemia and stomach cancer, tuberculous lymphadenitis and cat scratch should be considered.

TJS. 2018;34(Suppl-1):S617.

PP-0784 [Breast Diseases and Surgery]. Evaluation of the Necessity of Surgical Excision in the Treatment of Intraductal Papillomas of the Breast

Yusuf Murat Bağ ^1,^✉, Marlen Süleyman ¹, Pelin Seher Öztekin ¹, Rüçhan Bahadır Celep ¹, Soykan Dinç ¹, Çağdaş Topel ², Serap Erel ¹

Objective

Papillary lesions of the breast refer to multiple lesions that may be benign, atypical, and malignant. There is a general consensus about excision of the lesion if there is malignancy or atypia in the result of image guided biopsy (IGB) in cases considered to have intraductal papillomas (IDP) in imaging methods. However, surgical treatment of benign intaductal papilloma is controversial. We aimed to investigate the necessity of surgical excision by examining the patients diagnosed with intraductal papilloma by various biopsy methods.

Material and Methods

In our study we retrospectively reviewed the records of 3368 patients who underwent image guided breast biopsy and incisional-excisional breast biopsy followed by different surgeons at Health Sciences University Ankara Education and Research Hospital between January 2011 and February 2017. Fifty one cases of IDP among the 67 reports that had “Intraductal Papillom” labeling in the pathology report, were included in the study. Demographic, clinical, pathological, radiological and surgical characteristics of these cases were examined.

Results

Definite pathological result of 13 of 35 surgically excised lesions (37.1%) were reported as atypical papilloma or papilloma along with ductal carcinoma insitu and 8 of these cases were interpreted as benign intraductal papilloma in the preoperative IGB. The incidence of atypical-malignancy was significantly higher in cases with solid mass without ultrasonographic dilatation (p=0.003) and with peripheral lesions (p=0.046).

There are many studies suggesting surgical excision, and close follow-up instead of surgical excision in the treatment of benign papillary lesions. In our study, definite pathological diagnosis of 8 patients (53.3%) of 15 patients with benign IDP and who underwent surgery was atypical papilloma or DCIS and atypical papilloma as a result of IGB was reported in only 2 out of 10 patients (20%) whose definite pathological diagnosis was atypical papilloma or DCIS and who underwent preoperative IGB. In previous studies, the age, being symptomatic, having simultaneous ipsilateral breast carcinoma, radiological dimension of the lesion, microcalcification as a result of imaging and IGB were evaluated as predictive factors for the diagnosis. When we looked at the ultrasonographic imaging features in our study, among the patients with benign IDP as a result of IGB, all of the 7 patients in the group with definite pathologic result of benign IDP had a solid mass and 5 patients had ductal dilatation. On the contrary, it was observed that there was a solid mass in all of the 8 patients in the group having definite pathology result of atypical papilloma or papilloma with DCIS however none of them was accompanied by ductal dilatation and the difference between the two groups was significant (p=0.007).

Conclusion

We conclude that surgical excision is necessary in cases with suspected İDP because the number of cases having definite pathological result of atypical papilloma or having papilloma with DCIS is high in both the study group and in cases considered to have benign IDP as a result of image guided biopsy. The possibility of atypical-malignancy increases in the cases with peripheral lesions seen as solid mass without ultrasonographic dural dilatation.

TJS. 2018;34(Suppl-1):S617–S618.

PP-0785 [Breast Diseases and Surgery]. Paget’s Disease of the Breast; 2 Different Case Presentations

Serap Ulusoy ¹, Fariz Hüseynov ^2,^✉, Mehmet Özer ¹, İbrahim Kılınç ¹, Şevket Barış Morkavuk ¹, Ömer Parlak ², Abdussamed Yalçın ², Ali Coşkun ², Mehmet Kılıç ²

Introduction

Paget’s disease is manifested by eczematous changes in the nipple as a preliminary finding of the cancer. Although it is rarely seen, it is associated with cancer at the rates between 92% and 100%. Patients with Paget’s disease admit to the dermatology departments and most of them are wasting their time trying to be treated like dermatitis. We aim to present 2 cases with different Paget’s diseases.

Case 1

A 45-year-old female patient was admitted to different dermatology departments for a scurfy, crusted, itchy lesion on the left nipple for about 1 year. Topical treatments were suggested. The patient, whose complaints did not regress, was directed to the general surgery department. An incisional biopsy was performed from the areola of the patient. The patient whose pathology result was Paget’s disease, was admitted to our clinic. The patient’s physical examination revealed a crusted, scurfy lesion covering the entire aerola of the left breast. A clear mass with a border and lymph node in the axilla were not palpable. There was no significant feature in the patient’s medical history. Breast MR was performed for the patient. A suspicious lesion under the nipple in a large area was detected. The patient was prepared preoperatively and operated. The sentinel lymph node was evaluated. Metastasis was not detected. The patient underwent simple mastectomy. As a result of the pathology, a carcinoma focus of 6 mm was detected within the 8 cm comedo necrosis carcinoma in situ. ER and PR was negative and c-erbB2 was positive. The patient was initiated paclitaxel and transtuzumab. There was no pathology in the 3rd month control.

Case 2

A 50-year-old female patient was admitted to our hospital’s dermatology department due to a lesion on her right nipple for 6 months. The pathology of the patient who underwent skin biopsy in dermatology department resulted in Paget’s disease of the breast. The patient was directed to our clinic. The physical examination of the patient revealed crusted, scurfy, and eczematous lesion that covered the entire right nipple. No mass with a border in the breast and lymph node in the axilla was found in the physical examination. No significant features were found in the patient’s medical history. Breast ultrasonography, mammography and breast MR were performed. No significant pathology was detected. The patient was informed, preoperatively prepared and taken to the operation. The sentinel lymph node was evaluated. Metastasis was not detected. The patient underwent simple mastectomy. Pathology resulted in Paget’s disease of the breast and benign breast tissue. No significant pathology was present in the 3rd month control of the patient.

Conclusion

Paget’s disease can be seen with invasive breast cancers. Early diagnosis and treatment planning is very important to prevent advanced stage cancer.

TJS. 2018;34(Suppl-1):S618.

PP-0786 [Breast Diseases and Surgery]. Stewart-Treves Syndrome: Case Report

Bahri Çakabay ^1,^✉, Abidin Tüzün ¹, Mehmet Ali Can ¹

Introduction

Stewart-Treves Syndrome is a rare malignant mesenchymal tumor that is caused by prolonged lymphedema. This tumor can be induced by lymphedema formed as a result of radical mastectomy and axillary dissection to treat breast cancer. In this study, we aimed to present a case of Stewart-Treves syndrome who was admitted to our clinic with a complaint of axillary mass.

Case

A 54-year-old female patient who was admitted to our clinic with a left axillary mass was operated due to ductal breast carcinoma. Left modified radical mastectomy and axillary lymph node dissection were performed 4 years ago. The patient who had chemotherapy and radiotherapy had complaints of lymphedema postoperatively. A swelling in the axillary region was added to this lymphedema for several months. Angiosarcoma was detected as a result of the biopsy result made from the mass in the axillary region. The patient was transferred to medical oncology upon detecting distant metastasis of the unresectable mass fixated in the chest wall in radiological examinations.

Stewart-Treves syndrome is used for angiosarcoma formed of chronic lymphedema developing due to reasons such as congenital lymphedema or mastectomy. Deterioration of the lymphatic flow results in increased protein-rich interstitial fluid. This destroys the immune system and the activity of the immune cells. The body tries to compensate this situation by trying to create collateral lymphatic and vascular circulation. However, neoangiogenesis can result in tumor formation due to current immunosuppression and it can manifest itself with a malignant mesenchymal tumor called Stewart Trewes Syndrome. Most of the cases consist of female patients operated due to breast cancer. It is presumed that this sarcoma leads to induction directly by radiation therapy or indirectly by causing sclerosis of the lymph nodes. The prevalence of this rarely seen sarcoma decreases by the increase of the conservative treatment of breast cancer, current surgical equipment and radiotherapy techniques. The mean age of the cases is 60 years and it is seen within an average of 10 years after breast surgery. Our case underwent breast surgery when she was 50 years old and angiosarcoma developed 4 years later. If the sarcoma is isolated on the extremity, it can be cured by amputation. However, chemotherapy and radiotherapy may be beneficial in cases where the R 0 resection is not possible, such as the axillary region, which we present in our case.

Conclusion

Stewart-Treves syndrome is a rare sarcoma associated with modified radical dissection and possibly radiotherapy applied in breast cancer. Clinicians should keep in mind that this sarcoma may develop in all patients who develop lymphedema. It is important to remember the importance of fighting lymphedema by compression pumps and physiotherapy in patients.

TJS. 2018;34(Suppl-1):S619.

PP-0787 [Breast Diseases and Surgery]. A Case of Desmoid Tumor Imitating Breast Cancer

Özkan Demiroğlu ^1,^✉, Abidin Tüzün ¹, Serdar Gümüş ¹, Mehmet Ali Can ¹, Yusuf Yağmur ¹, Bahri Çakabay ¹

Introduction

Breast fibromatosis is a rare benign tumor. It is characterized by proliferation of fibrous tissue originating from muscle aponeuroses. Generally, the pectoral muscle is derived from the fascia. It has a course with local invasions and recurrences, but it does not cause metastasis. They constitute 0.3% of solid tumors and 3.5% of fibrous tumors of the breast. We aimed to present a rare case of breast fibromatosis having similar physical examination and radiological features of breast cancer.

Case

A 34-year-old female patient presented with a mass on the right breast. There was no significant feature in her history. There was no history of trauma or previous breast surgery. A fixed mass with irregular margin having a diameter of 4cm was detected in the upper external quadrant of the right breast in the physical examination. Axillary lymph nodes were not found. Ultrasonography revealed a hypoechoic, solid, lobulated, irregular mass lesion in the upper external quadrant of the right breast. Benign changes, in which intense fibroblasts were observed, were detected in the true-cut biopsy. An unenhanced solid mass was seen on MR imaging of the breast. The mass was totally removed with the skin on it and the underlying pectoral muscle fascia. Pathologic examination revealed no malignancy and the lesion was detected to be breast fibromatosis. Breast fibromatosis (desmoid tumor) is a rare soft tissue tumor originating from breast tissue or underlying pectoralis major muscle, fibroblast originated, being able to imitate breast cancer clinically and radiologically. It is usually seen in the reproductive period. Etiopathogenesis is not fully known. Past trauma, surgical scars, silicone implants, hormonal factors and pregnancy may be the case. Coexistence of familial adenomatous polyposis (FAP) and Gardner syndrome have been shown. Clinically it can occur as palpable, painless, hard, irregular margin and can have findings of thickening of skin. Distinguishing it from the breast cancer is very difficult radiologically. Histologically, fibroblast and collagen rich, low-grade, hypocellular fusiform cells invasive to neighboring muscles are seen in the lesion. Malignant-benign separation cannot be made without histopathological examination. Large local excision should be performed in case surgery is considered. Recurrence is observed in 1/4 of the cases. Radiotherapy, chemotherapy and anti-estrogen therapy can help control or eradicate the lesion. It has been reported in some studies that nonsteroidal anti-inflammatory drugs and ascorbic acid and tamoxifen are used to prevent the growth of the desmoid tumor.

Conclusion

Breast fibromatosis can imitate breast cancer with clinical and radiological imaging features. Axillary involvement does not occur. These cases should be colonoscopically examined in terms of FAP and Gardner’s syndrome. The final diagnosis can only be made histopathologically. Total excision of the mass is the main treatment method.

TJS. 2018;34(Suppl-1):S619–S620.

PP-0788 [Breast Diseases and Surgery]. A Case of Metachronous Bilateral Breast Cancer with Macromastia; Inadequacy of Imaging Methods

Halis Bağ ^1,^✉, Hilmi Güngör ¹, Ahmet Atasever ¹, Mehmet Sercan Candan ¹, Yasin Peker ¹

Introduction

Breast cancer is the most common cancer type in women. The risk of developing cancer in other breast of the women with breast cancer increases. The incidence of bilateral breast cancer (BBC) in women is between 2% and 11%. The BBC is subdivided into two subgroups, synchronous and metachoronous, according to the time of appearance of the second tumor. BBC usually occurs as a second primary cancer. Breast cancer makes most common metastasis to bone. These metastases are mostly observed in thoracic and lumbar vertebrae. There are difficulties in examination and imaging methods in patients with macromastia.

Case

The patient in whom mass excision to the right breast was applied at the external center was admitted to our outpatient clinic on obtaining of pathological diagnosis of “invasive ductal carcinoma”. The patient had scarring on the upper external quadrant of the right breast in the examination. Diffuse inflammation was present in the breast. The patient had bilateral macromastia and obesity. Her height was 160 cm, weight was 116 kg and BMI was 45. A 4 cm diameter conglomerate lap was detected on the right axilla in control breast USG and mammography. Paraffin blocks were re-evaluated. It was stated that the tumor was 2 cm in diameter and that the surgical margin was intact. The chemotherapy (CT) decision was made in the breast council. Progression was seen in the patient’s CT period. Surgical decision was made. Right modified radical mastectomy (MRM) was performed in the patient. The pathology was evaluated as “sclerosing adenosis, fibrocystic changes, invasive ductal carcinoma metastasis and perinodal infiltration, 14/18 right axillary lymph nodes”. CT and radiotherapy (RT) decision was made at the council. The patient was taken to oncology treatment and follow-up. We were consulted again because of cellulitis in the left breast of the patient almost one year later. In the patient’s examination there was an important size increase and hyperemia in the breast.

There was no finding of malignancy on breast USG and mammography. There was no response to cellulitis treatment in the patient for 15 days. Balance problem occurred in the patient. The patient was informed and a mastectomy decision was made. The patient was treated and discharged when influenza developed. In this period, the left hip fracture occurred in the patient who fell in the house. The curettage material from the fracture site of the patient, who was operated by Orthopedics, was evaluated as “breast carcinoma metastasis”. Left MRM was applied to the patient one month later. The specimen was approximately 6 kg. The pathology was evaluated as “mixed type breast carcinoma (invasive ductal + invasive lobular carcinoma), carcinoma metastasis and perinodal infiltration, 19/19, left axillary dissection lymph nodes”. The council issued made a decision of CT+RT. During the follow-up of the patient for severe back pain, metastasis and mild myelomalacia were detected between T 4–9 in thoracic MR. The patient for whom an operation was recommended by Brain Surgery did not accept it. In the Palliative Support Clinic, while treatment and follow-up for comorbid diseases was going on, the patient died due to sudden cardiopulmonary arrest in postoperative 4th month.

Conclusion

There is difficulty in diagnosing breast cancer in patients with macromastia. Close follow-up is required by experienced teams in these patients after breast cancer is diagnosed. Surgery should not be delayed in patients who do not respond to conventional treatments.

TJS. 2018;34(Suppl-1):S620.

PP-0789 [Breast Diseases and Surgery]. Primary Solid Neuroendocrine Carcinoma of the Breast

Halim Kale ^1,^✉, Ömer Faik Ersoy ¹, Zübeyde İlke Narlı İnce ², Alpay Aktümen ², Harun Erol ²

Despite the presence of neuroendocrine tumors in many parts of the body, the existence of true carcinoid tumors in the breast is controversial. For this reason, it is very rare. A 77-year-old female patient was admitted to our outpatient clinic because of a palpable mass in the right breast. It was found that this patient was admitted to our hospital with a smaller size mass in the same breast and in the same localization 2 years ago and the true-cut biopsy was fibroadenoma. The patient, who did not come to the control follow-ups, was admitted again upon the rapid growth of the mass in the breast. In the breast ultrasonography performed, a solid mass lesion with 80mm*50mm size and regular margins, having a hererogeneous internal structure and involving locally cystic areas, filling the entire right breast was observed. Axillary pathologic lymphadenopathy was not observed. MR imaging of the breast revealed a solid and lobulated solid mass lesion sized 70mm*40mm*25mm filling the parenchyma in all areas of the right breast. The result of the true-cut biopsy came as a malignant epithelial tumor. The patient underwent radical mastectomy surgery. The patient’s pathology result was obtained as mucinous carcinoma + solid neuroendocrine carcinoma (mixed type invasive breast carcinoma). Synaptophysin and chromoginin were detected positively in the evaluation of the pathology specimen. While 25 lymph nodes were reactive, no metastatic lymph node was detected. As is well known, breast neuroendocrine tumors are very rare and standard treatment protocols have not yet been fully clarified. Local and distant recurrence rates are quite high.

TJS. 2018;34(Suppl-1):S620–S621.

PP-0790 [Breast Diseases and Surgery]. Rare Myofibroblastic Sarcoma Case in the Breast

Ahmet Gökhan Sarıtaş ^1,^✉, Cihan Atar ¹, Kubilay Dalcı ¹, Gürhan Sakman ¹, Kıvılcım Eren Erdoğan ²

Introduction

Myofibroblastic breast sarcoma, first described in 1887, is very rare. It can give symptoms with the palpable mass in the breast. Breast Ultrasonography (USG), Mammography and Breast Magnetic Resonance Imaging (MR) are used in the diagnosis. Treatment has different modalities including combination of surgical resection, radiotherapy and chemotherapy.

Case

A sixty-six-year-old female patient presented with a palpable mass complaint in the upper external quadrant of the left breast. She was operated due to a mass detected in the left breast during the screening and a malign mesenchymal tumor was detected. The patient did not continue the treatment after the operation and was admitted to our clinic due to palpable mass in the breast. A mass of 6x6 cm was detected in the left breast between the quadrant 1–5 hour. Breast USG, Mammography and MR imaging revealed a mass of 6.5x5.5 cm, having lobulated contour and microlobulations in the upper external quadrant of the left breast. No pathological image was found in the left axilla. Left simple mastectomy and sentinel lymph node biopsy were performed and the frozen biopsy was evaluated as reactive lymph nodes. Mastectomy material was evaluated as malign mesenchymal tumor and myofibroblastic sarcoma.

Conclusion

Breast myofibroblastic sarcoma is very rare, and there are a limited number of case reports and studies in the literature. Resection should be performed to provide a negative surgical margin surgically, and radiotherapy and/or chemotherapy options should be added to the treatment. It should also be considered that there may be a myofibroblastic sarcoma in the differential diagnosis of mass lesions in the breast.

TJS. 2018;34(Suppl-1):S621.

PP-0791 [Breast Diseases and Surgery]. Rabdomyosarcoma Metastasis to the Breast: Case Report

Bercis İmge Uçar ^1,^✉, Ertunç Altuntaş ², Akile Zengin ¹, Mehmet Korkmaz ³, Mustafa Şahbazlar ⁴

Rhabdomyosarcoma is a soft tissue sarcoma commonly seen in the pediatric age group and in adolescent age and constitutes 4–8% of all childhood malignancies. Rhabdomyosarcoma can usually originate from many places such as head, neck, orbita, genitourinary tract, retroperitoneum, extremities, trunk, gluteal region, mediastinum and gastrointestinal tract and its breast metastasis is very rare (6%). A 14-year-old female patient was diagnosed with rhabdomyosarcoma in the right cervical region 2 years ago, and upon detecting a suspicious mass in the upper external quadrant of the left breast and involvement of increased fluorodeoxyglucose (FDG) in the same region in Positron Emission Tomography (PET-CT), she was referred to us. The interventional radiologist performed ultrasonography-guided marking and then lumpectomy was performed to cover the marked masses. The lodge was marked by hemoclips and the process was terminated. Reoperation was planned upon obtaining the pathology report as surgical margins were positive mixed type (20% embryonal, 80% alveolar) rhabdomyosarcoma. The old lodge was extensively excised with the reotroareolar region to cover the muscle fascia. It was decided to perform modified radical mastectomy (MRM) with the approval of the relatives of the patient since the lesion of the frozen lesion was persistent at the medial, lateral, anterior surgical margin, there were suspicious invasion areas at the superior and inferior surgical margins, and no protection of the nipple for the anterior-negative surgical margin could be provided. As a result of peroperative oncology consultation, mastectomy was completed by deciding not to perform axillary lymph node dissection since lymphatic spread would not happen due to tumor’s being sarcoma. Pathologic outcome of MRM was reported as “Multiple foci of tumor cells were observed and embryonal type rhabdomyosarcoma foci were observed at 1 mm distance from lateral surgery. No tumor was seen in the medial, superior, inferior, posterior surgical margin. It was learned that right MRM was performed upon multifocal masses in the opposite breast of the patient under the follow-up of oncology and general surgery departments in the postoperative 9th month.

Although almost all of the adolescent age breast masses are benign, metastatic breast cancer should be kept in mind in patients with malignancy history. A close follow-up of outpatient clinic is very important in the patients in adolescent age group having especially rhabdomyosarcoma history, and breast examination should be a part of the physical examination.

TJS. 2018;34(Suppl-1):S621–S622.

PP-0793 [Breast Diseases and Surgery]. Breast Necrosis Case Developing After a True Cut Biopsy

Ozan Utku Öztürk ^1,^✉, Mustafa Uğur ¹

Introduction

One of the most important tools for diagnosis in patients with the mass diagnosis in the breast is the true-cut biopsy. The main complications are hematoma (2–10%), infection (4–6%) and pain (12–18%). The development of necrosis of the skin and breast tissue was not found in the literature. In this case report, a patient who developed necrosis of the skin and breast as a rare complication after true cut biopsy was presented.

Case

A 70-year-old female patient presented to our polyclinic with a palpable mass complaint in the right breast. There was no previous active breast complaint and no biopsy was performed. Her family had no ovaries or breast cancer stories. There were grade 3 ptosis in both breasts in the physical examination. There was a mobile mass having approximately 5cm size and with regular size in the upper internal quadrant of the breast. Breast ultrasound revealed heterogeneous area adjacent to aerola at 2 o’clock position in the right breast, diffuse calcifications in both breasts, and asymmetric density increase in the right breast (BIRADS 4A). It was decided to do a biopsy of the lesion with a true cut. Department of interventional radiology performed a true cut biopsy to the patient with a 14 G needle. Complications did not develop in the early period after the procedure. The pathology result was reported as “fibrocystic changes, adenosis, microcalcification”. After 15 days, the patient was admitted to the outpatient clinic with the right breast pain and color change. In the physical examination, there was a necrotic area in the right breast that started from the area where the biopsy was performed and covered the entire upper inner quadrant. The patient was operated urgently. Cadenectomy was performed to include necrotic skin and breast tissue. The patient was discharged on the 4th day without any postoperative problems.

Conclusion

True cut biopsy of breast lesions is widely preferred due to less invasive procedure and low complication rates. However, as in the case we presented it should not be forgotten that it is possible to develop ischemia and necrosis after taking a true cut biopsy from the masses of the patients with large size and droopy breasts and from the masses in the upper internal quadrant since they involve medial perforator vessels.

Less than 1% of all breast cancers occur in men. Breast cancer constitutes 0,17–1,5% of the cancers in men. Because of their rare occurrence, most of the information is based on single-center retrospective studies or studies of female breast cancer (CMC). The incidence of male breast cancer (EMR) increases with age. Because it is a rare case, bilateral male breast cancer is presented.

Case

A 74-year-old male patient was admitted with the complaint of breast swelling. He stated that the masses were small and painless at the beginning but they gradually grew. At the same time, he stated that he noticed palpable, painful and increasingly growing swellings under the left armpit. There were no trauma histories for both breasts in his medical history. His daughter had been operated due to breast cancer. In the physical examination, there was a protruding, hard lesion on the left breast and a pullout in the right nipple. A mass of 2.5 cm in size just below the right nipple and 5.5 cm in size of the left breast were found with palpation. Left axillary lymph nodes were palpated. The patient’s hormonal profiles were normal. CA15–3 level was 53.4 U / mL (N: 0–31, 3 U / mL). The patient refused to have genetic analysis for BRCA1 / 2 genes. Radiologically, both ultrasonography and Magnetic Resonance Imaging showed masses in the subareolar area of both breasts. In addition, there was no evidence of metastatic disease in chest radiography and liver ultrasonography. Preoperative F-18 fluorodeoxyglucose (18F-FDG) positron emission tomography / computed tomography (PET / CT) was performed and bilateral intake with cutaneous invasion in the SUVmax subareolar areas of the left breast and mild involvement in both axillas were detected. Invasive ductal carcinoma on the right breast and papillary neoplasia with in situ carcinoma on the left breast were detected in needle biopsy. Fine needle aspiration cytology of the left axillary lymph node was negative. Left modified radical mastectomy and right simple mastectomy and right sentinel lymph node biopsy (negative) were performed. Histopathological examination revealed invasive ductal carcinoma (maximal diameter 2.5 cm) in the right breast and intracystic papillary carcinoma (maximum diameter 5.5 cm) in the right breast. TNM classification was consistent with stage IIIa.

Conclusion

The diagnosis of male breast cancer can be made later than that of female breast cancer and it is at a more advanced stage at the time of diagnosis. The importance of advanced examination for early diagnosis of skin lesions developing and not healing in male patients was emphasized.

TJS. 2018;34(Suppl-1):S624–S625.

PP-0798 [Breast Diseases and Surgery]. A Rare Case of Juvenile Papillomatosis; Follow Up or Excision?

Abdullah Durhan ^1,^✉, Koray Koşmaz ¹, Marlen Süleyman ¹, Enes Cebeci ¹, Pelin Seher Öztekin ², Pınar Celepli ³, Gamze Durhan ⁴

Juvenile papillomatosis is a rare breast disease in young women. Etiology is unknown. There is often a breast cancer history in the family. It is associated with the risk of increased breast cancer. History, clinical and radiological findings help to diagnose. The aim of this case report is to discuss the rarely seen juvenile papillomatosis with clinical, radiological, pathological findings and surgical approach. A 26-year-old woman was admitted to our clinic with a palpable mass in the right breast. In her examination, there was an irregular mobile mass at the 6 o’clock position in the right breast. The current mass of the patient was followed by ultrasonography (US) at the external center for 5 years. US was asked again since the mass had irregular margins in the examination. In the US, a mass containing a large number of cysts at at 6 o’clock position in the right breast was observed, but also a vascularized solid component was observed. Magnetic resonance imaging (MRI) was also performed due to this solid component and the patient’s family history. The breast contained a large number of cysts within the mass defined on the MRI and showed a suspicious type 3 dynamic curve for malignancy. Fine needle aspiration biopsy was performed from the mass due to suspicious radiological findings. Pathology result was received as cyst content. However, when evaluated together with clinical, history and radiological findings, a preliminary diagnosis of juvenile papillomatosis in the patient was considered and the mass was excised with a clear surgical margin. Pathology result showed “Swiss Cheese” feature which is typical for juvenile papillomatosis, and papillomas were present in many cysts. One of the papillomas contained carcinoma in situ focus. Juvenile papillomatosis, a rarely seen and known phenomenon, is often confronted as lesions containing numerous cysts in tricenarian women who have positive family histories. Since clinicians and radiologists are also less aware of the lesions and can be followed for a long time as fibrocystic disease. Although these phenomena can be stabilized for a long time, excision of the lesions is recommended because the risk of developing breast cancer is increased in the following period. In our case, the case was followed for a long time but juvenile papillomatosis was considered when the clinical and radiological findings were evaluated and the lesion was excised. Pathology results also confirmed this diagnosis. Juvenile papillomatosis should be kept in mind in patients with complicated cystic lesions at a young age and should be evaluated together with history, physical examination and radiological findings. In these cases, thick needle biopsy should be preferred rather than fine needle aspiration biopsy and excision with clear surgical margin should be recommended in terms of possible synchronous tumor. However, extensive surgical resection or prophylactic mastectomy is not recommended. As a result, surgical excision can prevent breast cancer development in juvenile papillomatosis cases and early diagnosis and treatment can be provided.

TJS. 2018;34(Suppl-1):S625.

PP-0799 [Breast Diseases and Surgery]. A Rare Case Presentation; Mondor’s Disease of the Breast

Yeşim Akdeniz ^1,^✉, Ali Küçük ², Kayhan Özdemir ¹, Ahmet Tarık Harmantepe ¹, Enes Baş ¹, Belma Koçer ¹

Introduction

Mondor’s disease is a rare benign disease characterized by thrombophlebitis of the subcutaneous veins of the breast and anterior chest wall. It usually occurs in women between 30 and 60 years of age. The skin gives clinical signs of pain and stiffness in the superficial veins. In this case, we aimed to present our case, which we identified mondor’s disease.

Case

A thirty six-year-old female patient was admitted to outpatient clinic because she felt pain and stiffness in her right breast for two weeks. Superficial veins of the right breast could be observed by inspection in the breast examination of the patient with no chronic disease history, and venous structures starting from the anterior axillary line and surrounding aerola consistent with thrombophlephite were detected with palpation. The patient did not have any blow on this breast or operation history. Varicose lesions were present in the bilateral lower extremities. There was no routine medication taken by the patient followed by the cardiovascular surgeon for this reason. Hemogram, biochemical parameters, fibrinogen and D-dimer levels were normal. Bilateral breast ultrasonography revealed dilated superficial veins having a tendency of connecting with each other in the upper external quadrant of the right breast, with a size of 5.8 mm in the widest area. It does not respond to compression. The walls are thicker than normal. It was interpreted as being consistent with superficial thrombophlebitis in the breast. The patient was offered non-steroid anti-inflammatory tablets and hot compress treatment. It was found that after two weeks there was a marked decline in the visible thrombosed veins, a decrease in pain complaints, and a complete treatment at the end of 4 weeks.

Conclusion

Mondor’s disease was first defined by Henry Mondor in 1939. It is more common in middle aged women. The pathophysiological mechanism of the disease is uncertain. Superficial veins of the breast and anterior chest wall are involved. Breast biopsy, trauma, axillary metastasis, tightness of the clothes, or trauma exposed to that area are among the possible etiological causes. Diagnosis is usually made clinically, but diagnostic imaging is important to determine if a palpable mass is a thrombosed superficial venous cord. Doppler USG can be used in the diagnosis. It is also necessary to exclude possible malignancies. In treatment, hot compress is applied to the area with non-steroidal anti-inflammatory drugs (NSAID). We treated the patient with NSAII treatment as well as hot compress application. As a result; Mondor’s disease is a rare condition and clinicians should keep in mind that these signs and symptoms may be a mondor’s disease after malignancies have been excluded.

TJS. 2018;34(Suppl-1):S625–S626.

PP-0800 [Breast Diseases and Surgery]. A Rare Mass that Mimics Male Breast Cancer: Pilomatrixoma

Marlen Süleyman ^1,^✉, Yusuf Murat Bağ ¹, Kevser Uzunoğlu ¹, Pınar Celepli ², Pelin Seher Öztekin ³, Serap Erel ¹

Introduction

Pilomatrixoma is a benign tumor with deep dermal or subcutaneous localization and which originates from the matrix cells of hair follicles. It is usually seen in the first two decades of life, and rarely turns into pilomatrix carcinoma. It is most commonly found in the head and neck region and very rarely in the breast.

Case

A 43-year-old male patient was admitted to the hospital due to a palpable mass in the for two years. In the examination, a lobular mass with firm consistency was palpated on the upper external quadrant of the right breast.

A homogenous, hyperechoic solid mass lesion with microlobulations in the size of 30x12 mm, approximately 3 cm from the right breast nipple at the 2–3 o’clock position was observed in the USG. Microcalcifications were seen in the mass. There was no significant blood build up in the examination with CDUS.

Mammography: In the midline of the right breast, well-defined moderate fusiform densities with coarse calcifications and micro-calcifications in the size of approximately 3x2 cm were observed. A solid mass (BIRADS 4) in the right breast was evaluated as suspicious in terms of malignancy. Tru cut biopsy was performed upon radiologic findings had been evaluated as BIRADS 4, and pathologic results were reported as pilomatrixoma.

A total excision was performed and the patient was discharged on the first postoperative day. Histopathological examination revealed pilomatrixoma (Malharbe tumor) findings.

Conclusion

Pilomatrixoma is a rare benign soft tissue neoplasm that originates from the matrix of hair follicles. This lesion was first described by Malherbe and Chenantais in 1880 and was called as calcifying epithelioma. It mostly develops in the head and neck region, less in the trunk and extremities, and very rarely in the breast. A total of 15 papers on benign pilomatrixoma of the breast have been published.

They are usually subcutaneous hard masses that are less than 3 cm. In most cases, the lesion is adhesively attached to the skin, and the underlying mass stretches the skin and forms a nodular appearance. This pathognomonic finding was described by Graham in 1978 as “tent symptom”. It occurs as a single lesion, and multiple lesions might be seen among 2% of the cases.

Ultrasonography shows pilomatrixoma as an isoechoic, heterogeneous mass with well-defined, encapsulated, superficial, posterior acoustic shadowing. The multiple bright foci within the mass and capsule might give a hypoechoic image. In our case, the radiologist described a solid mass with micro-lobulations, homogeneously hyperechoic, with micro-calcifications and no evidence of blood build up.

On mammography they appear as pleomorphic coarse, nodular opacities with irregular calcifications (BIRADS IV–V).

In our case, suspected malignancy (BIRADS IV) with well-defined moderate fusiform densities with coarse calcifications and micro-calcifications was observed.

The treatment is surgical excision. Excision with appropriate surgical margins provide complete cure and recurrence is rare. Pilomatrixoma is benign, but it is important to remember that there may be malignant cases. Only one case with malignant pilomatrix breast carcinoma has been reported.

In conclusion, it is difficult to differentiate rarely seen breast localized pilomatrixoma from primary malignant lesions by radiological examination, but it is diagnosed with histopathologic examination. Pilomatrixoma should not be forgotten in the differential diagnosis of malignant lesions in the breast.

TJS. 2018;34(Suppl-1):S626–S627.

PP-0801 [Breast Diseases and Surgery]. Synchronous Breast and Stomach Cancer-A Case Report

Sevinç Dağıstanlı ^1,^✉, Nilüfer Bulut ², Mustafa Uygar Kalaycı ¹

Introduction

Synchronous tumors are difficult in terms of both diagnosis and treatment planning. The tumor that is asymptomatic at the time of diagnosis is likely to be overlooked. As there is no definitive treatment protocols in their treatment, we need to develop a special treatment strategy for the patient. In this case report, a synchronous gastric tumor was detected incidentally during scanning performed in order for staging in a patient with breast tumor.

Case

A 56-year-old female patient was admitted due to a mass of 7 mm in the right breast. In the examinations performed via MMG, a hypoechoic lesion with irregular spiculated contour on the right breast at 3 o’clock position 3cm from areola in size of 23x22 mm and a lymph node in the right axilla whose multiple part of the fatty hilus cannot be recognized were detected. Biopsy results performed from LAP on the right axilla and the mass on the breast were reported as invasive ductal carcinoma, axillary metastasis (Grade: 2, ER: +++ PR: ++ C-erb-b2:-Ki67: 30%). In PET-CT, which was performed for screening purposes of distant organ metastases, intense FDG uptake (SUVmax: 14.2) extending through the malignant process in the 8 cm segment that ends in the lower side of antrum and localized in the small curvature of the stomach corpus and localized second primary tumor in the size of 23x20 mm with increased FDG uptake (SUVmax: 14.2) at 2 o’clock position in the upper inner quadrant of the right breast (SUVmax: 2.9) and several 15 mm diameter LAPs in the right axilla at level 1 and level 2 with minimal FDG uptake (SUVmax: 3.1) were observed. In the endoscopy, a ulcerovegetan mass advancing to the corpus was detected along the small curvature starting right below the cardio-esophageal junction. Histopathological examination revealed a moderate differentiated adenocarcinoma (ER:-, PR:-, Cerb-b2:-in IHC). The oncology council decided to apply neoadjuvant chemotherapy (6 cycles of FAC) for breast tumor after operating on stomach tumor, and then operate the patient for breast tumor. The patient underwent total gastrectomy + D2 dissection. Post-operative gastric tumor pathology T3N2M0 (3/24 LN) was detected. Neo-adjuvant CT (6 cycles of FAC) was performed for breast tumor. Radical mastectomy was applied to the patient 4 months after gastric surgery. Post-operative breast tumor pathology T2N2M0 (9/13 LN, RCB3) was detected. The patient who did not develop complications after stomach and breast surgery was referred to radiation oncology for radiotherapy treatment for stomach tumor after breast surgery. No recurrence and/or distant metastasis were detected in the 3rd postoperative month imaging of the patient.

Conclusion

It should be kept in mind that a second tumor with different origin may be present in patients with malignancy. It should be considered that a synchronous tumor can be detected in systemic physical examination and in all imaging and laboratory tests performed. Given the fact that the stomach tumor in this case had been more aggressive compared to the breast tumor and this would have affected the survival of the patient, treatment with stomach tumor was prioritized.

TJS. 2018;34(Suppl-1):S627–S628.

PP-0802 [Breast Diseases and Surgery]. Glycogen Rich Clear Cell Carcinoma; Clinical Experience

Ahmet Karayiğit ^1,^✉, Mahmut Onur Kültüroğlu ¹, Mehmet Furkan Sağdıç ¹, Onur Can Güler ¹, Bülent Aksel ¹, Lütfi Doğan ¹

Objective

Glycogen-rich clear cell carcinoma (GRCCC) is a rare neoplasm of the breast, with an incidence of between 1.4% and 3% of all breast cancers (1). The GRCCC of the breast is defined as a carcinoma in which more than 90% of tumor cells have abundant amounts of clear cytoplasm containing glycogen and is considered as a separate histological variant (2).

Material and Methods

Retrospective screening of 4350 patients with breast cancer treated in our department between 2013 and 2018 showed that 5 patients had been diagnosed with GRCCC (0.1%). Clinical and pathological features of the patients were recorded, disease free and total survival periods were calculated.

Results

The average age of the patients was 53 (36–65). 4 of the patients (80%) were postmenopausal at the time of the diagnosis. Diagnosis was made by excisional biopsy in 40% of the patients. Mastectomy was applied to 80% of patients and breast conserving surgery was applied to 20% of patients. Sentinel lymph node biopsy (SLNB) was reactive in 2 (40%) of the patients. Two (40%) patients with SLNB positive were treated with axillary dissection. It was determined that 40% of the tumors were in the size of T1, 40% of the tumors were in the size of T2, 60% of the tumors were ER (−), all were PR (−) and 80% of them were cERBb2 score0. 80% of the patients were found to be grade III. The rate of patients receiving hormonotherapy was 20%. During an average follow-up of 13 months, no regional recurrence was seen in any patient and systemic recurrence was observed in 1 patient.

Conclusion

GRCCC is a rare tumor of the breast. However, it is the most common breast cancer with clear cell morphology (1). The GRCCC of the breast is defined as a carcinoma in which more than 90% of tumor cells have abundant amounts of clear cytoplasm containing glycogen and is considered as a separate histological variant (2). In 1985, in a study that had included 45 cases, Fisher et. al. reported that compared to commonly seen breast carcinomas the GRCCC of the breast is significantly lower (p=0.0038) in terms of disease-free survival. Morphology of the GRCCC of the breast is similar to lung, endometrium, cervix, kidney and salivary gland carcinomas. Metastasis of these tumors should also be kept in mind in differential diagnosis. It has been reported that the prognosis of the GRCCC of the breast is not favorable and may be similar or worse in terms of staging when compared to common invasive ductal carcinomas.

References

1.Markopoulos C, Mantas D, Philipidis T, Kouskos E, Antonopoulou Z, Hatzinikolaou ML, Gogas H. Glycogen-rich clear cell carcinoma of the breast. World Journal of Surgical Oncology. 2008;6:44. doi: 10.1186/1477-7819-6-44. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Mizukami Y, Takayama T, Takemura A, Ichikawa K, Onoguchi M, Taniya T. Glycogen-rich clear cell carcinoma of the breast: a case report. J Med Ultrasonics. 2009;36:39–43. doi: 10.1007/s10396-008-0200-4. [DOI] [PubMed] [Google Scholar]
3.Baslaim MM, Junainah EM, Ahmad HH, Semilan AF, Al-Ghamdi AO, Rahimuddin NO, Salman BA. Glycogen Rich Clear Cell Carcinoma (GRCC) of the breast may not havea poor prognosis. International Journal of Surgery Case Reports. 2017;33:92–6. doi: 10.1016/j.ijscr.2017.02.044. [DOI] [PMC free article] [PubMed] [Google Scholar]

TJS. 2018;34(Suppl-1):S628.

PP-0803 [Breast Diseases and Surgery]. Evaluation of Awareness in Surgeons’ Treatment Approach of Granulomatous Mastitte: A Survey Study

Sema Yüksekdağ ^1,^✉, Ömer Faruk Özkan ¹, Özgül Düzgün ¹, Ethem Ünal ¹, Fikret Ezberci ¹, Neşet Köksal ¹

Objective

Granulomatous mastitis is defined as a benign pathology of the breast. The debate about its etiology and treatment still continues. While consensus on many diseases has been achieved today, granulomatous mastitis treatment and approach algorithm have not been established. A 15-question questionnaire prepared for general surgeons in our study aimed to reveal the differences in the approach among physicians on granulomatous mastitis.

Material and Methods

A multiple-choice and categorical questionnaire consisting of 15 different questions prepared after obtaining the approval of the ethics committee from Ümraniye Training and Research Hospital, University of Health Sciences was directed to general surgery specialists. The collected data were loaded into the SPSS program for statistical evaluation. The results were evaluated according to percentiles.

Results

According to the results obtained from thirty participants in the early stage of the planned study for one hundred and fifty general surgery specialists, the number of experts who had between 5 and 10 granulomatous mastitis cases per year was 8 (26.6%) and the number of experts who had less than 5 cases was 16 (%53,3). The first treatment option of all participating specialists was medical. Of the medical treatment methods, the most preferred one was antibiotherapy (85%) and the most common surgical treatment method was abdominal drainage (70%). The majority of participants thought that not enough time is allocated for the discussions on granulomatous mastitis at the national meetings.

Conclusion

According to the early results of our study, in granulomatous mastitis patients, surgeons’ preliminary plan was medical treatment; antibiotherapy was the first choice in medical treatment and topical steroids were the second one.

TJS. 2018;34(Suppl-1):S628.

PP-0804 [Breast Diseases and Surgery]. Annihilated False Positivity of SLNB in Breast Cancer; A Clinical Evaluation

Semih Yaman ^1,^✉, Mustafa Şit ¹, Bahri Özer ¹, Oğuz Çatal ¹, Elif Yalçın ¹, Selçuk Köksal ¹, Muhammet Fatih Keyif ¹, Ferdi Bolat ¹, Özgür Kurtkulağı ¹, Mehmet Hayri Erkol ¹

From the spot where the tumor is located to the first lymph node where it will be drained, it is called the “sentinel”, which means guard, surveillant or messenger. Hypothetically, if the sentinel lymph node does not carry a tumor, it is considered that other lymph nodes in the bed are also tumor free. This eliminates the need for a regional lymphatic dissection, which results in eliminating vascular and neural damage, wound infections and high costs associated with the procedure. SLNB is successfully applied in many centers with low morbidity and over 90% accuracy in the axillary staging as an easily applicable technique in breast surgery. Several studies have shown that about 5–10% of SLNB is an effective and easily performed method with false negative result. In the intraoperative evaluation of LN, the accuracy rates of frozen section and cytologic examination are close to each other and they range from 80% to 99%. There is no or scarcely any false positivity. False negativity is reported as 9–52% for frozen section and 5–70% for cytological examination. For both methods, a significant portion of false negative results (75–90%) depend on micrometastases. In this retrospective study, false positivity of SLNB, which is known to be absent or scarcely present in the literature, was found to be observed in only 1 case. 52 patients who underwent SLNB were retrospectively reviewed. Clinical and radiological records of all patients were evaluated. Of 52 patients, uptake in SLNB was observed in 15 patients, and ALND was performed. In the remaining 37 patients, SLNB was negative. Of 15 patients who had positive SLNB in frozen section examination and were performed ALND, ALDN was negative in one patient. It has come to the conclusion that although the number of patients was not enough to give a percentage, it is useful since further studies are required in terms of absence or scarce presence of false positivity of SLNB in literature.

TJS. 2018;34(Suppl-1):S629.

PP-0805 [Breast Diseases and Surgery]. In the Long Term Follow-up Period of 37 Patients with Early-Stage Breast Cancer and who underwent SLNB with Negative results, Two Patients with Axillary Uptake

TJS. 2018;34(Suppl-1):S631.

PP-0810 [Breast Diseases and Surgery]. Encapsulated Papillary Breast Carcinoma; A Truly Innocent Tumor?

Cemal Kaya ^1,^✉, Pınar Yazıcı ¹, Ramazan Uçak ², Deniz Türkyılmaz Mut ³, Mehmet Mihmanlı ¹

Introduction

Encapsulated papillary carcinoma (EPC) is a rare breast carcinoma considered to be a variant of invasive ductal carcinoma. In studies conducted up to now, these tumors have been presented as benign behavior with excellent prognosis. In our study, we aimed to investigate the diagnosis and treatment approach of an EPC case with an aggressive course.

Case

A 68-year-old female patient was admitted to the center with a newly developed mass on the left breast 10 months before and was recommended follow-up upon a negative true cut biopsy result and imaging. The patient was admitted to our department due to the expansion of the mass in left breast and the newly formed mass on the sternum. On the physical examination of the patient, an 8 × 7 cm mobile mass with moderate rigidity filling the left breast inner quadrant and a 7 * 4 cm sized rigid mass in the sternum were palpated while the axilla was negative. In the mammography and advanced magnetic resonance imaging, a cystic mass with a 7.5 * 6 cm solid component in the left breast and a second mass associated with the first one with a necrotic character covering the majority of the sternum were detected. A large excision was made to the mass in the left breast upon the detection of a papillary tumor whose invasive character could not be determined in the biopsy performed on the left breast. The patient was discharged without any problems on the second postoperative day. Histopathological examination revealed an encapsulated papillary carcinoma with a solid component of 3 * 3 * 2 cm. Luminal A pattern was observed in the immunohistochemical evaluation of the mass with lymphovascular invasion. The patient was directed to oncologic treatment.

There is not sufficient evidence on papillary carcinoma of the breast in the literature because of its rare occurrence and it is described as a lesion with benign behavior in the diagnosis and treatment. EPK is a tumor that accounts for 0.5–1% of all breast cancers and is usually seen in postmenopausal women. There is a thin capsule that separates normal breast tissue from this tumor that originates from the mammary duct epithelium. These patients are admitted with large cystic masses in the breast. Surgical excision is recommended in the presence of atypia on core biopsy, presence of high-risk lesion, or radiology-histology incompatibility. Although our case exhibits typical symptoms that are mentioned above, the disease could only be detected in later stages due to the difficulty of differential diagnosis.

The treatment procedure includes lumpectomy or mastectomy (with sentinel lymph node/axillary dissection) followed by adjuvant radiotherapy +/− hormone therapy in appropriate cases. Although the 10-year survival rates are above 95%, there is a risk of recurrence and metastasis, especially in high-grade tumors. However, it should not be forgotten that aggressive behavior, independent from the tumor grade, may be seen in advanced stage cases that are detected late as in our case.

Conclusion

Papillary carcinoma should be kept in mind when imaging and biopsy results are inconsistent in elderly women and advanced examination and excisional biopsy of the mass should be kept in mind as a alternative.

TJS. 2018;34(Suppl-1):S631–S632.

PP-0811 [Breast Diseases and Surgery]. The Effect of Micropapillary Component Ratio of Invasive Micropapillary Breast Carcinoma Cases on the Prognosis

Cemal Kaya ^1,^✉, Ramazan Uçak ², Emre Bozkurt ¹, Sinan Ömeroğlu ¹, Kinyas Kartal ¹, Pınar Yazıcı ¹, Ufuk Oğuz İdiz ³, Mehmet Mihmanlı ¹

Objective

Invasive micropapillary carcinoma of the breast (IMPC) is a rare, aggressive variant of invasive ductal carcinoma. The prognostic significance of the ratio of micropapillary component (MPC) in these tumors is controversial. In this study, we aimed to investigate the effect of MPC ratio on the prognosis of these patients.

Material and Methods

The data of 47 patients with IMPC was reviewed retrospectively. The patients were divided into two groups: MPC-r, ≤ 75% (Group 1) and>75% (Group 2). The demographic characteristics, tumor histopathologic features and survival rates of the patients were compared.

Results

Demographic characteristics were similar between the two groups. There was no significant difference in tumor diameter, lymph node metastasis, lymphovascular invasion, histological grade, multicentricity, regional recurrence, distant metastasis and overall survival.

In the WHO classification of 2003, the IMPC was described as a subtype of ductal carcinoma of the breast but not a percentage of the MPC ratio was given because of the very rare occurrence of its pure form. Although later studies have suggested that generally accepted MPC’s being over 50% is necessary in order for diagnosis, it is said that rates of 25% or even 10% may be sufficient for the definition of these tumors.

Previous studies with IMPC have shown that these tumors are usually associated with several prognostic factors including higher TNM stage, lymph node metastasis and lymphovascular invasion (LVI). In our study, the prognostic parameters of breast cancer in general were compared according to the MPC ratios but no relationship was found.

Conclusion

PP-0815 [Breast Diseases and Surgery]. Tumor Characteristics and Treatment Methods in Elderly Breast Cancer Patients

Cem Karaali ¹, Can Arıcan ^1,^✉, Emre Turgut ¹, Serdar Küçükalioğlu ¹, Cengiz Aydın ¹

Objective

To determine the tumor characteristics, the surgical method, local recurrence and distant metastasis rates in women aged 70 years and older with breast cancer.

Material and Methods

The histological type, grade, size, hormone receptors, c-erbB2 receptor, axillary lymph node involvement of the tumors and the operation methods of the female patients who were operated between the dates of 30/04/200730/04/2017 in İzmir Tepecik Training and Research Hospital, General Surgery Department Unit C due to breast cancer were examined. Local recurrence and distant metastasis were also investigated.

Results

A total of 68 female patients who had undergone surgery were examined. The average age was 75.3±5.3 (min-max 70–95). When the patients were examined according to the type of operation performed, it was determined that they had been frequently performed breast conserving surgery (BCS) + axillary dissection and the most common pathological diagnosis was invasive ductal carcinoma.

When examined according to their receptors, 51 (75%) patients were found to be estrogen receptor positive (ER) and 53 (78%) patients were found to be c-erbB2 receptor negative. Only 7 of the patients (10%) had tumor grade 1 and the remaining patients had tumor grade 2 and 3. The average tumor size was 3±1,6 cm (min-max 0,1–8,5 cm) and 27 (40%) patients had axillary metastatic lymph nodes. 4 (6%) patients were found to have local recurrence and distant metastases was found in 9 (13%) patients.

Conclusion

In the literature, there is no clear treatment approach for elderly patients with breast cancer. Due to advanced age and comorbidities, anesthesia and surgical units abstain from major interventions. Although the number of our patients is not sufficient, local recurrence rates and distant metastasis rates are consistent with the literature. For this reason, we think that breast-conserving methods can be applied via patients’ participation in decision making process in elderly patients with breast cancer.

Footnotes

Note: It was accepted as a poster presentation for the 14th National Breast Disease Congress, 19–2 October 2017.

TJS. 2018;34(Suppl-1):S634–S635.

PP-0816 [Breast Diseases and Surgery]. Rare Tumor of the Breast; Can liposarcoma be treated with Oncoplasty?

Mesut Bala ^1,^✉, Güven Güvey ², Betül Bozkurt ¹

Introduction

The sarcomas of the breast constitute less than 1% of all malignant breast tumors. Liposarcomas account for about 0.3% of the sarcomas in the breast. The majority of liposarcomas in the breast are seen over the age of fifty, but they can also be seen among the young as well. In this case, we have aimed to present a 59 year-old female patient who was operated with the pre-diagnosis of liposarcoma due to a growing swelling in the right breast with her histopathological and radiological findings.

Case

A 59-year-old female patient was admitted to our general surgery department with a swelling in the right breast that was asymmetrically larger in size compared to the other breast. In the examination, the right breast was about twice the size of the other, the left breast was normal and in the the right breast, soft, painless, oval and moving mass displaying lateral localization was detected. Bilateral axillary lymph nodes were not palpable. There was no history of exogenous estrogen use and no breast cancer history in the family. In the ultrasound, similar to fat solid lesion whose AP size was measured 130 mm in size in the deepest region completely covering the upper and outer quadrants of the right breast was monitored.

In the mammography, mass lesion whose mediolateral and anteroposterior dimension measured as 20 cm in fat density, covering the entire upper middle and outer quadrant of the right breast, and that shows capsule structure with undistinguished border of the axillary was detected.

The mass was excised with firm surgical margins from the upper right quadrant of the breast by removing the skin via crescent incision, biopsy was taken from the suspected retroareolar ductal dilate region and the formed cavity was approximated by forming an intraglandular flap.

The patient did not have any problems in the postoperative period and was discharged without any problems with routine follow-up.

No postoperative recurrence was observed in 3 months, 6 months and 1 year controls.

Pathology: Well-differentiated liposarcoma, GRADE 1, ductal biopsy result was ductal epithelium mild hyperplasia.

Discussion

Mesenchymal lesions are rare in cases who were applied excisional biopsy due to mammographic mass diagnosis.

Although liposarcomas are the most common soft tissue tumors, their primary involvement in the breast tissue is rare.

The average diameter of the liposarcomas seen in the breast is 8 cm; but cases that reach much larger dimensions such as ours have also been reported.

The treatment of primary breast liposarcoma is surgery. Today, it is accepted that wide local excision of tumor-free surgical margins is also sufficient.

Breast cancer is the most common cancer in women, and it affects sexuality, psychosocial life and the quality of life of the patients. In this study, we aimed to compare postoperative psychosocial, sexual life and general quality of life of the patients who underwent breast conserving surgery (BCS) and modified radical mastectomy (MRM) in our department.

Material and Methods

The study included patients who had been operated between January 2012 and January 2014 in our department due to breast cancer diagnosis. Patients who did not want to participate in the study or who could not be reached, patients who could not give answers to questionnaire due to conditions related to intelligence or Training, patients who received neoadjuvant chemotherapy and who needed radiotherapy after radical mastectomy and ASA3 and 4 patients were excluded. The quality of life of the patients was assessed using the EORTC QLQ C30 and BR23 forms six months after the completion of patients’ treatment procedures (surgery, radiotherapy, chemotherapy).

Results

During our study, a total of 112 patients were operated in our department due to breast cancer. Of these, 16 were excluded due to exclusion criteria and a total of 96 patients were included in the evaluation. All of the patients were female and the average age was 50.5 (SD 11.4). According to the EORTC QLQ30 questionnaire, scores of the MRM group were significantly higher in terms of six functional scales (physical function, role function, cognitive function, mood, social status, general well-being). When the symptom scales are examined, no statistical significance was detected in terms of nausea, vomiting, constipation and diarrhea. However, scores of the MRM group were significantly higher in terms of dyspnoea, loss of appetite, sleep disorder, pain and fatigue. EORTC QLQ BR 23 questionnaire showed no significant difference between the two groups in terms of sexual satisfaction, whereas score of MRM group was significantly higher in in terms of body image, sexual life and future expectancy. When the symptom scales were examined, there was no difference between the groups in terms of hair loss; whereas the scores were significantly higher in patients who underwent MRM in terms of side effects, breast symptoms, and arm symptoms.

Conclusion

Due to the positive effects on the patients’ quality of life, we believe that appropriate planning of MKC will increase the quality of life of the patient.

TJS. 2018;34(Suppl-1):S637–S638.

PP-0821 [Breast Diseases and Surgery]. Can “Axillary Mucinous Adenocarcinoma Metastasis” be the Occult Breast Cancer?

İsmail Sezikli ^1,^✉, Güven Güney ², Kaan Helvacı ³, Betül Bozkurt ¹

Introduction

In occult breast cancers, main symptom is the metastasis to axillary lymph nodes or other parts of the body, and primary lesions can not be identified by breast palpation or imaging. It constitutes between 0,1% and 0,8% of breast cancer cases in women. Since 90% of metastatic axillary lymph nodes originate from breast cancer, tumors isolated from breast cancer are rare. In this case, the occult breast cancer whose left axillary lymphadenopathy (LAP) biopsy was assessed as malignant adenocarcinoma metastasis is presented.

Case

A 42-year-old female patient presented with a palpable mass under her left arm. In the left axilla, a mobile multilobule mass of 2.5x2 cm was palpated. On ultrasonography, in the left axillary region two thick cortexed lymph nodes, the larger one with the size of 24x15 mm, with echogenic hiluses pushed aside; in mammography, lymph node of 34x25 mm in size and whose fatty hilus could not be observed; in PET-CT no pathologic FDG involvement except for lymphadenopathy LAP of 2.6 cm (suv: 3.1) in the left axillary were detected. No pathological findings were found in thorax CT and breast MRI.

In the histopathology of axillary tru-cut biopsy, it was reported as a metastasis of mucinous adenocarcinoma. Upper endoscopycolonoscopy was normal. Immunohistochemical examination showed negative staining with estrogen, progesterone, TTF 1, CD X2 in tumor cells; Positive with CK 7 and CK 20; Weak staining was observed with GCDFP 15 and Mamoglobulin.

After the patient underwent 3 cycles of CA, 12 weeks of paclitaxel + herceptin chemotherapy, the breast MRI was normal. Level 1–2 lymph node dissection was performed on the patient. Pathology revealed mucinous islets, but no epithelial cells. Postoperative entire breast and axillary radiotherapy (RT) was planned for the patient.

Conclusion

Breast cancers sometimes cannot be detected by anamnesis, physical examination, laboratory findings and imaging methods, but may only appear as isolated axillary adenopathy. Immunohistochemical examination with different biomarkers for the detection of the primary is useful in differential diagnosis.

In the case whose axillary metastasis histopathology was evaluated as mucinous adenocarcinoma, the cytokeratin CK 20 with CK7 positivity provides the possibility of primary pancreatic cancer and mucinous ovarian cancer cancer; GCDFP-15 positivity which is an apocrine differentiation marker, provides the possibility of 62–77% breast cancer, salivary gland tumors, skin and adnexal tumors; 10% prostate cancer <10% lung, stomach, ovarian and genitourinary cancers. Although negative androgen receptors decrease the possibility of breast and gynecological pathologies, weak GCDFP-15 positivity suggests breast cancer. That only mucinous islet cells had remained through breast-targeted chemotherapy showed that response to the treatment was received. With all of these findings, the patient was accepted as occult breast Ca and RT was planned and monitoring was performed.

Upon the evaluation of the treatment response to imaging and histopathological data, evaluation, the patient was accepted as Occult breast Ca with clinical assessment. In cases where the available data do not fully support breast cancer, the clinical approach and response to the patient treatment is important and should be kept in mind.

TJS. 2018;34(Suppl-1):S638.

IGM can be confused clinically and radiologically with breast carcinoma. Patients can be adversely affected, especially young women, due to diagnosis difficulties, treatment failure and repetition. Histopathological examination should be the gold standard to confirm the diagnosis.

TJS. 2018;34(Suppl-1):S641.

PP-0827 [Breast Diseases and Surgery]. Giant Juvenile Fibroadenoma

Mehmet Torun ^1,^✉, Zehra Ünal Özdemir ¹

Introduction

Breast fibroadenomas are benign focal tumors usually seen in young women aged 15–25 years. Fibroadenoma is a tumor that contains both glandular and mesenchymal components.

Case

A 14-year-old female patient was admitted due to the presence of a mass in the left breast. There was a palpable and non-fixed mass of about 6 cm in the physical examination of the patient. The patient underwent USG and retroareolar solid mass in the left breast which was 54x44 mm in size with a pronounced hypervascular character that was thought as fibroadenoma in the preplan was determined. MRI showed a solid lesion with sharp contour and a lobule which grew toward the external quadrant and the posterior of the left breast aerola and 60x58 mm in diameter. Intensive contrast enhancement was present in the lesion and ductal dilation and contrast enhancement were not present. It was evaluated as BI-RADS 4. The patient was operated and excision was performed. The patient was routinely followed up since the surgical pathology was juvenile fibroadenoma.

Conclusion

Fibroadenoma is an important part of breast masses among adolescents and young women. It is usually benign, unilateral single lesion and may be occasionally multiple and bilateral. Diagnoses are made radiologically and often do not require excision and follow up is recommended.

TJS. 2018;34(Suppl-1):S641.

PP-0828 [Breast Diseases and Surgery]. Can FDG PET/MR Imaging which is a New Method Replace Sentinel Lymph Node Biopsy in Breast Cancer Surgery?

Çağrı Büyükkasap ^1,^✉, Uğuray Aydos ³, Seda Gülbahar ², Ümit Özgür Akdemir ², Osman Kurukahvecioğlu ¹, Lütfiye Özlem Atay ², Çağatay Çifter ¹

Objective

The aim of this study is to evaluate the clinical contribution of whole body and regional FDG PET/MR imaging among newly diagnosed breast cancer patients on the prediction of axillary lymph node metastases.

Material and Methods

In this retrospective study, 141 newly diagnosed breast cancer patients who had been performed sentinel lymph node biopsy (SLNB), axillary lymph node dissection (ALND), or both, and who underwent whole body and/or regional FDG PET/ MR examination before treatment were evaluated. A 5-point scoring system with values ranging from 0 to 4 was used according to the most prominent FDG uptake in the axillary lymph nodes, and that visually examined the FDG uptake in evaluating suspected axillary lymph nodes on PET/MR images. Sensitivity, specificity, positive and negative predictive values and accuracy were calculated according to this visual scoring system to accurately predict histologically confirmed axillary lymph node status.

The Ki-67 proliferation index of the primary tumor was divided into two groups, with a limit of 20%. Sensitivity, specificity, PPV, NPV and accuracy levels were calculated in both groups by accepting visual scoring system 1 and above as meaningful and 2 and above as meaningful.

Conclusion

The diagnostic performance of FDG PET/MR is similar to that of FDG PET/CT in the prediction of axillary lymph node metastasis in newly diagnosed breast cancer patients. Although high level of FDG uptake from background activity was determined to be high sensitivity and NPV, false positivity of the method was determined as high. Therefore, according to these findings, FDG PET/MR can not take place of sentinel lymph node biopsy.

TJS. 2018;34(Suppl-1):S641–S642.

PP-0829 [Breast Diseases and Surgery]. Relationship of Molecular Subgroups with Prognostic Factors in Young Breast Cancer Patients

Sertaç Ata Güler ^1,^✉, Turgay Şimşek ¹, Saffet Çınar ¹, Nuh Zafer Cantürk ¹, Nihat Zafer Utkan ¹

Breast cancer is one of the leading causes of young age cancer-related deaths, especially in developed countries. When the survival rates of breast cancer are considered, it is seen that younger age is much lower in breast cancer compared to advanced age. Young breast cancer is generally more rare but more important. Especially the results are worse. This is because of the unfavorable clinicopathologic features, more aggressive tumor biology and delayed diagnosis. When younger age breast cancer and advanced age breast cancer are compared, more advanced stage is observed with hormone receptor negativity, high grade, HER-2 positivity, triple negative molecular subgroup and high lymphovascular invasion. For this reason, the prognosis is worse, the risk of recurrence is higher and the mortality rate due to breast cancer is higher. Young breast cancer is a description of a patient group diagnosed with breast cancer, especially under 40 years of age. In addition, when the very young breast cancer group under the age of 35 is to be diagnosed, the prognosis is much worse than that of the young breast cancer group. In this study, prognostic factors of young breast cancer patients were compared with molecular subgroups according to the information given in the literature. Again, the survival results revealed a difference between the young breast cancer group and the very young breast cancer group. 624 patients who had been diagnosed with breast cancer in the General Surgery department of Kocaeli University Medical Faculty between October 2013 and February 2018 were included. In this study, molecular subgroup data and survival data of 95 young breast cancer patients, 35 of them were very young age patients, were evaluated. It was seen that of the 6 patients who died, 3 died due to breast cancer. Distant metastasis was detected in 6 patients, regional recurrence in 2 patients and local recurrence in 2 patients.

TJS. 2018;34(Suppl-1):S642.

PP-0830 [Breast Diseases and Surgery]. A Rare Variant of Metaplastic Breast Carcinoma Associated with Intraductal Breast Cancer: Case Presentation and Literature Review

Veli Vural ¹, Alim Akbarov ^1,^✉, Amil Huseynov ¹, Nurullah Bülbüller ¹

Introduction

Metaplastic breast cancer (MBC) is a rare, morphologically heterogeneous group of tumors with different immune profile. It was first described in 1973 by Huvos et al. MBC constitutes 0,25–1% of all breast cancers.

Case

On a 59-year-old female patient who was admitted due to a palpable mass in the breast, a core biopsy was planned upon the detection of a 40x37x30 mm sized hypoechoic round shaped irregularly contoured solid mass in the left breast axillary tail on USG and Mammography. In the patient who was diagnosed with metaplastic carcinoma with mesenchymal differentiation and intraductal carcinoma, no axillary pathologic lymph node was detected. After lumpectomy, neoadjuvant therapy was applied to her treatment. As a primary, MBC is usually identified as a palpable breast mass in women over 50 years of age. In the literature, the youngest reported age is 16 years. Patients with metaplastic carcinoma are admitted to the hospital with large tumor sizes with an average diameter of 3.7 cm (1.4–9.5 cm). The mammographic, sonographic and magnetic resonance imaging features of these carcinomas can be seen as irregular masses or cluster type cystic masses similar to intraductal cancers and benign lesions. Patients with MBC were found to have a lower 5-year survival (49–68%) when compared with patients with intraductal cancer. Axillary lymph node involvement varies between 8–40%. The risk of distant metastasis is higher than intraductal carcinomas and it is usually hematogenously to the lungs and bones. Hematogenous spread is more prevalent in especially those with predominantly sarcomatoid morphology. Metaplastic carcinomas are generally negative for ER, PR and HER2, but typically show positive expression of keratins with high molecular weight, including CK5/6 and 34beta E12. Estrogen and progesterone receptor positivity has been reported between 7–13%. Local recurrence rate ranges from 35–62% for 2–5 years. There are data about proven clinical and immunohistochemical factors that affect the prognosis of MBC patients. Specifically, the prognosis of the predominance of squamous cell component and skin invasion below 40 years of age is worse. Some studies have shown that adjuvant RT is beneficial to overall survival.

Conclusion

The association of metaplastic and intraductal breast cancer has been rarely reported in the literature. While there is no standard treatment approach for MBC, the presence of additional pathology in treatment should be considered. Surgery forms the basis of treatment for localized disease and can be followed by RT and/or CT, hormonal therapy and other types of targeted therapy. For more effective treatment methods, larger series of studies are needed.

TJS. 2018;34(Suppl-1):S643.

PP-0831 [Breast Diseases and Surgery]. Axillary Ultrasound in Early Stage Breast Cancer

Tugba Han Yılmaz ^1,^✉, Hasan Yerli ², Baha Arslan ¹, Varlık Erol ¹, Hüseyin Gülay ¹

Objective

Sentinel Lymph Node Biopsy is a standard procedure currently being used in the axillary evaluation of breast cancer patients. The ACOSOG Z0011 study questions the necessity of performing axillary dissection in a selected group of sentinel node positive patients and suggests to investigate the applicability of these discussions on ultrasonically positive patients. The purpose of our study is to question the reliability of ultrasound examination in evaluating axillary conditions in early stage breast cancers.

Material and Methods

Clinical T1-2, N0 patients admitted to our clinic between 2010–2016 were included in the study. When sentinel node biopsy and metastasis were detected, axillary dissection was applied to all patients. The patients’ ultrasound results were compared with their pathology.

Results

Sensitivity and specificity of axillary ultrasound for axillary disease were calculated respectively as 69.2% and 98%, negative predictive value was 86.4% and positive predictive value was 94.7%.

Conclusion

As a result of our study, high sensitivity, specificity, positive predictive and negative predictive values with axillary ultrasound may be an alternative to sentinel node biopsy in the axillary evaluation of breast cancer patients. In patients with breast cancer, axillary ultrasound will contribute to the clarification of large studies such as SOUND which operates comparatively with sentinel node biopsy.

TJS. 2018;34(Suppl-1):S643.

PP-0832 [Breast Diseases and Surgery]. Giant Apocrine Cyst

Deniz Fındık ^1,^✉, Zekeriya Pelen ¹, Ferda Nihat Köksoy ¹

Breast cysts are usually benign. Breast cysts are the most important cause of palpable breast masses. Breast cysts are thought to develop due to natural changes in hormone levels with age. Breast cysts can be seen at any age, but they are most frequently observed over 35 years of age. In a study conducted on the pathological examination of 150 breast cysts; 79 of these cysts are within the definition of ultrasonographically complicated cyst; and 18 (23%) were found to be malignant. In our case, a 36-year-old female patient was admitted to our department with complaints of asymmetry in her breasts. It was reported that there was growth without the color change on the right breast for the last six months. About a year ago a cyst in the same breast was aspirated. Physical examination revealed that the right breast was significantly larger than the other one. In the breast ultrasonography a 13x5 cm sized cystic lesion with a 1 cm diameter nodular component with internal echogenites within was observed in the right breast retroareolar area. Via breast MR, in terms malignancy a highly suspicious complicated cyst with a large number of nodular contrast involvements that showed protrusion to lumen wall was detected. Furthermore, the post-contrast examination revealed that the nodular contrast involvements were filling almost the entire peripheral wall of the right breast. No malignant lesion was detected in the left breast. The mammography revealed an increase in the parenchyma density of the right breast and a smooth contour mass filling almost the entire right breast (belonging to a complicated cyst with dense content that contained multiple contrasting papillary projections on the wall of the mass). The cyst was excised via periareolar incision. Microscopic examination of the sections revealed papillary structures with epithelial layers composed of cuboidal apocrine cells with round nucleus, large eosinophilic cytoplasm, without mitosis and atypia, branching fibrovascular cores on the wall of the cyst and stratification on these cores. With these findings, patient’s differential diagnosis was papillary neoplastic lesions and apocrine cysts. Myoepithelial layer was not detected in the papillary structures during immunohistochemically applied p63. The patient was evaluated as Giant Apocrine Cyst, Intracystic Apocrine Papillary Proliferation with these findings. Intraductal Papillom (IDP), our differential diagnosis, is benign lesions involving epithelial and myoepithelial cell layers on branching fibrovascular cores. Giant IPDs are not common, and as far as we know, only 7 cases have been reported in the literature. In our case, it was measured as 13x8x6 cm in size and it was above the standard the papillary breast lesion size.

TJS. 2018;34(Suppl-1):S644.

PP-0833 [Breast Diseases and Surgery]. Sonoelastography in the Evaluation of Solid Breast Masses

Hasan Yerli ¹, Tuğba Han Yılmaz ^2,^✉, Hüseyin Gülay ²

The aim of our study is to evaluate the effectiveness of sonoelastographic scoring system in malignant-benign differentiation of breast masses. 180 solid breast masses (147 benign, 33 malignant) in 155 patients were evaluated prospectively in a 2-year period. Each lesion was examined by B mode sonography and sonoelastography. The results of the examinations were compared with histopathological results. The diagnostic performances of sonoelastographic scoring and B-mode sonography methods were evaluated. The sonoelastography average score for benign lesions was 2.61±0.62 while for malignant lesions it was 3.73±0.69. The accuracy, sensitivity, specificity, positive and negative predictive values for B-mode sonography were 81%, 89%, 79%, 46% and 97% respectively; for sonoelastographic scoring they were 87%, 73%, 91%, 69% and 92%. In the differentiation of malignant-benign breast masses, we can say that these results and sonoelastographic evaluation after B-mode sonography examination may increase specificity.

TJS. 2018;34(Suppl-1):S644.

PP-0834 [Breast Diseases and Surgery]. The Effectiveness of Screening Applications in Breast Cancer

Ender Onur ¹, İksan Taşdelen ¹, Ali Cihan Bilgili ^1,^✉, Ahmet Yalın İşcan ¹, Mehmet Okuducu ¹

The effectiveness of screening practices in breast cancer is known. However, are these screening applications effective in our country? In order to study this issue, our hospital was selected as the screening hospital. The cases that had been operated before and after the selection were compared in our hospital.

A total of 288 patients were included. Of these 288 patients, 285 (99%) were female and 3 were male. The average age of the patients who were admitted was 56.70±13.23 (55,17–58,24). When the breast with the involvement was examined; it was seen that 153 were left breast and 135 were right breast. When the tumor size was examined, it was found that 159 (55.2%) patients had a tumor size of<2 cm, 116 (40.3%) patients had 2–5 cm, and 13 (4.5) patients had a tumor size of>5 cm. 101 patients (35.1% 4) had stage 1, 78 patients (27.1%) had stage 2A, 45 patients (15.6%) had stage 2B, 38 patients (13.2%) had stage 3A, 23 patients (8%) had stage 3C, and 1 patient (0.3%) had stage 4.

203 (70%) patients were pre-screening patient group and were referred to as Group A. 85 (30%) were post-screening group and were called Group B.

Of the 203 patients in group A, the mass in 100 patients was left-localized. When the size of the tumor in group A was examined, it was determined that 107 (52.7%) patients had tumor sizes of<2 cm, 86 (42.4%) patients 2–5 cm and 10 (4.9%) patients with a tumor size of>5 cm. It was detected that 67 patients (33%) had stage 1, 55 patients (27.1%) had stage 2A, 31 patients (15.3%) had stage 2B, 29 patients (14.3%) had stage 3A, 21 patients (10.3%) had stage 3C, and 1 patient (0.04%) had stage 4.

Of the 85 patients in group B, 53 (62.4%) patients had left breast localized mass. When tumor size was examined, it was found that 52 (61.2%) patients had a size of 2 cm, 30 (34.2%) patients had 2–5 cm and 3 (3.5%) patients had a size of>5 cm. It was found that 36 (42.4%) patients were stage 1, 23 (27.1%) were stage 2A, 14 (16.5%) patients were stage 2B, 9 (10.6%) patients were stage 3A and 3 (3.5%) patients were stage 3C.

There was no difference between the two groups in terms of all data.

TJS. 2018;34(Suppl-1):S644–S645.

PP-0835 [Breast Diseases and Surgery]. A Rare Breast Disease: Granulomatous Mastitis

Banu Karapolat ^1,^✉, Halil Afşin Taşdelen ¹, Sercan Büyükakıncak ², İzzettin Kahraman ¹, Yusuf Ziya Yamak ¹, Ömer İleli ¹

Objective

Granulomatous mastitis is a chronic inflammatory disease of breast tissue, manifested by various clinical manifestations ranging from erythema, swelling and stiffness to sinus or abscess formation. Its etiology is not fully known. Because the resulting lesions can be seen as a hard mass with irregularly circumscribed lesion, differential diagnosis with breast cancer should be performed. Determination of radiological and pathological features of granulomatous mastitis cases and examination of treatment results.

Material and Methods

Twenty-five patients who received long-term nonspecific antibiotherapy and anti-inflammatory drug treatment for 2 weeks due to mastitis and did not respond to treatment between January 2016 and January 2018 were included in the study.

Results

The ages of the cases ranged from 23 to 54 and their average age was 34 years. All cases were examined by breast ultrasonography. Mammography and breast magnetic resonance imaging were performed in cases if required. Thirteen (52%) cases had involvement in the right breast, 10 (40%) in the left breast and 2 (8%) had bilateral involvement. In terms of localization, the most common localization was right upper external quadrant by 9 (36%) cases and 4 (16%) cases had left upper external quadrant localization. Because of the malignant appearance of radiological examinations of seven (28%) patients, tru-cut biopsies were performed and the diagnosis of malignancy was excluded. The remaining cases were confirmed that they were free of tuberculosis, bacterial or fungal infections by culture or fine needle aspiration biopsy. Before treatment, abscess was detected in 6 (24%) cases and antibiotic treatment was given after drainage. All cases were treated with methylprednisolone with a dose of

0.6 mg/kg for a month. Then the dose was reduced and cut. Eighteen (72%) cases were responsive to the treatment. Three (12%) patients did not benefit from steroid treatment. Four patients (16%) had recurrence during the treatment and a surgical decision was made. In these cases, all masses were resected in order to form a negative surgical margin. Due to the histopathological examinations of the removed specimens, diagnosis of idiopathic granulomatous mastitis were made. All cases were followed for 6 months. In the only (4%) case who had been responsive to steroid therapy, 4 months later recurrence in the other breast induced by trauma was detected.

Conclusion

In cases of granulomatous mastitis, which is a rare breast disease, infection and malignancy should absolutely be ruled out among the differential diagnoses. If there is no contraindication after the diagnosis of granulomatous mastitis, steroid treatment should be started in all cases. This treatment has high success rates.

TJS. 2018;34(Suppl-1):S645–S646.

PP-0836 [Breast Diseases and Surgery]. Mastectomy Case Performed by Interfacial Body Blocks in High Risk Patient with Anesthesia

Ufuk Karabacak ^1,^✉, Cengiz Kaya ², Ayfer Kamalı Polat ¹

Case

80 years old female patient had invasive breast cancer (ER +, PR-, HER2 +) with skin involvement, 3 cm in size in the left lower middle quadrant; axillary or distant metastases were not detected. Chemotherapy was not planned by medical oncology due to high co-morbidity risk of the patient due to the presence of congestive heart failure, cardiac pacemaker, scoliosis and pectus excavatum in her history. Prenatal nerve block (PECs) and serratus anterior plane (SAP) block were planned for the surgical anesthesia of the patient with high risk score in preoperative anesthesia evaluation. The pectoralis major and minor muscles were reached with a block needle (22 G, 50–100 mm) under ultrasound (US) guidance and 0.2 ml/kg, 0.25% bupivacaine was injected. Afterwards, 0.2 ml/kg, 0.25% bupivacain was applied to the facial region between pectoralis minor and serratus anterior upon scanning anterior axillary on the 4th costa. The SAP block, on the other hand, was made in the more lateral and posterior regions and by reaching the image of the 5th costa in the midaxillary line. Here, the US probing was placed in the coronal plane and 0.4 ml/g, 0.125% bupivacaine was performed in the facial plane between serratus anterior and latissimus dorsi. Thus, left mastectomy and sentinel lymph node biopsy were performed by providing analgesia for the surgical procedures to be performed in the breast and axilla. It was observed that the need for postoperative analgesia decreased in the patient who had no complications during the perioperative period. The patient was uneventfully discharged on the third postoperative day.

PECs and SAP blocks developed by Blanko between 2011 and 2013 for thoracic anesthesia is an interfacial regional anesthesia technique applied under US guideline. PECs blocks are performed in two stages. While PECs I and the anterior branches of the medial and lateral pectoral nerves and intercostal nerves located between the pectoralis major and minor muscles are blocked, the lateral branches of the upper intercostal nerves (T3-9) are blocked by injecting a local anesthetic between the pectoralis minor and serratus anterior muscles in the PECs II block. With the SAP block, the thoracicus longus, thoracodorsal nerve and intercostobrachial nerves are blocked by the injection performed between the serratus anterior and latissimus dorsi muscles. These nerves, especially in the innervation of the axillary has important roles. These blocks were originally developed as an alternative to thoracic epidural and paravertebral blocks to provide analgesia for the surgeries performed on hemithorax; thus, hemodynamic (eg, hypotension, bradycardia) and technical side effects (pneumothorax, spinal cord injury, etc.) are prevented. In the literature, these blocks are generally combined with general anesthesia in order for postoperative analgesia in breast surgery, but they have been reported to be used alone in surgical anesthesia. In our case, PECs and SAP block were used for surgical anesthesia alone, but effective analgesia was observed in the postoperative period.

Conclusion

Although PECs and SAP block is mostly used as a component of multimodal analgesia in post-operative period of breast surgery, it can be used alone as an alternative to general anesthesia in high-risk patients.

TJS. 2018;34(Suppl-1):S646.

PP-0837 [Breast Diseases and Surgery]. Prostate Cancer and Breast Cancer Association: A Rare Case

Gizem Kılınç ^1,^✉, Hüseyin Esin ¹, Cem Karaali ¹, Kadri Murat Erdoğan ², Lütfi Mutlu ¹, Mustafa Emiroğlu ¹

Introduction

About 1% of all breast cancers are seen among males. Breast cancer is the third most common cancer type in men after prostate cancer and lung cancer. Although male breast cancer and prostate cancer are similar in etiopathogenicity, the association of these two cancer types is uncommon. This case report describes a case, with no history of breast cancer in the family, and who has been receiving medical treatment due to the diagnosis of metastatic prostate cancer and then was diagnosed with breast cancer during his follow-up.

Case

An 82-year-old male patient with a history of luteinizing hormone-releasing hormone analogue and bisphosphonates use and who had been diagnosed with prostate adenocarcinoma metastatic to the bones in 2011 with no history of operation was admitted to our department with the complaint of palpable stiffness on his right breast. Physical examination of the patient revealed a skin-invasive rigid fixed mass about 3 cm in diameter that caused shrinkage of the papilla in the retroareolar region of the right breast. It was seen on the right side of the breast ultrasound that the patient had a solid lesion with rough calcification 17x23 mm in size and with lobulated contour.

In the subsequent mammography of the patient, opacity of the mass with irregularly limited coarse calcification was observed in the right mammary retroareolar space of 24x20 mm in size. The mass was evaluated as BIRADS 4, and no malignant lymph nodes were found in axillary areas of the graphy. The patient’s tumor markers were measured as CA 15-3: 15.3 U/mL, CEA: 0.74 ng/mL, PSA: 5,138 ng/mL, and total testosterone: 1,6 ng/dL. According to the pathology result of the tru-cut biopsy performed on the right breast, the patient was reported as invasive carcinoma showing squamous differentiation ER (-), PR (-), CerbB2 (+1) (NEGATIVE), E cadherin (+) p63 rare (+), CK5/6), CD31 CD34 was reported as (+) on the vessel wall. Preoperative preparations of the patient were performed and the patient was operated on and modified mastectomy was applied to the patient. The patient was discharged on the second postoperative day without any complications.

Conclusion

About 0.2% of all cancers in males are breast cancer. The incidence of metachronous and synchronous cancers in males with breast cancer is 10.6%. Male breast cancer and prostate cancer are similar in etiopathogenicity and hormonal, genetic and environmental factors gain importance in etiology. BRCA2 mutation has been shown to increase prostate and breast cancer risk in men. Screening of the BRCA2 gene in patients with prostate cancer may be useful in the future for breast cancer risk in both the patient and family members. Although breast cancer is not common in males and since metachronous and synchronous cancers are highly prevalent, screenings and gene analysis in prostate cancer patients gain importance in early diagnosis and treatment.

TJS. 2018;34(Suppl-1):S646–S647.

PP-0838 [Breast Diseases and Surgery]. Etiological Factors in Patients Presenting with Mastalgia Complaints

Turgut Anuk ^1,^✉

Objective

Mastalgia causes approximately 2/3 of women to refer to a doctor at some point in their lives. It is defined as the feeling of pain in one or both breasts as well as pain on the nipple. It affects everyday life due to malignant suspicion in women. Many predisposing factors in the literature on mastalgia etiology have been held responsible in the literature. In particular, changes in levels of hormonal factors such as estrogen, progesterone and prolactin are discussed. Breast pain is assessed as cyclic and non-cyclic. Cyclic mastalgia is menstruation-related bilateral pain, while non-cyclic mastalgia is unilateral pain that does not follow the menstrual cycle. We aimed to reveal predisposing factors in patients with mastalgia complaints.

Material and Methods

Files and archive records of patients who were referred from the obstetrics and gynecology clinic and who were admitted to the general surgery clinic with a complaint of breast pain and without any pathology in the mammography and ultrasonography between January 2016 and December 2017 were screened. Patients’ age, occupation and educational status, complaints onset period, daily pain duration, relationship of pain and menstruation, menopausal status, family history, history of previous breast surgery, history of psychiatric admission and use of drugs, body mass indexes, FSH, LH, estrogen, progesterone and prolactin levels at the time of admission were recorded.

Analysis of the data was performed via SPSS for Windows 22 package program. Descriptive statistics for continuous variables are shown as average±standard deviation or median (minimum-maximum) and categorical variables were shown as number of cases and (%). Categorical variables among the groups were assessed with Chi-square test.

Results

The median age of the 115 patients included in our study was 37 (18–70). In seven patients, there was history of breast cancer in the family. 101 patients were housewives and 68 patients were primary school graduates. In 45.2% of patients, the pain was over 24 weeks. When the daily pain duration was examined, it was observed that the most frequent complaints were that the pain was rare and it lasted 1–2 hours per day. The mastalgia of twenty-nine patients was found to be related to the menstrual cycle. Seventeen patients were in menopausal status. Only 3 patients were found to have had breast surgery previously. Seventeen of the patients had previously referred to the psychiatric outpatient clinic and 18 were still on psychiatric drugs. It was calculated that 35.7% of the patients had body mass indexes of between 25.1–27.5. Their gynecological hormone levels are also presented.

Conclusion

Although we need patient groups with higher populations, we reached the point that the socio-cultural level of the region where our study was conducted was low, and the patients with the history of psychiatric treatment were presenting themselves to the doctors with mastalgia complaints in order to obtain secondary gain.

TJS. 2018;34(Suppl-1):S647–S648.

PP-0839 [Breast Diseases and Surgery]. Atypical Pathology Findings and Clinical Approach in Provisional Diagnosis of Fibroadenomic Excisional Breast Biopsies

Hamit Sinan Hatipoglu ^1,^✉

Objective

Excisional breast biopsies are both diagnostic and therapeutic and it is the most important and effective surgical procedure that is used in the diagnosis of masses that are thought to be clinically benign. The most common pathology of the masses in the breast was fibroadenomas. The demographic features and pathology results of the patients who were operated with clinical and radiological provisional diagnosis of fibroadenoma were evaluated retrospectively.

Material and Methods

A total of 347 consecutive excisional breast biopsies that were performed by the same general surgeon with the diagnosis of fibroadenoma, 23 under general anesthesia and 324 under local anesthesia, between May 2009 and January 2018 were included in the study. All of the patients had a a palpable mass in the breast in their pre-operative physical examination. Bilateral breast ultrasonography and mammography when required and/or breast MRI were performed in all cases. As a result of radiology; for malignancy and/or BIRADS IV and over, incisional biopsy were preferred and they were excluded from the study. All pathology results were evaluated in our hospital pathology unit and pathology results were obtained from the report result system.

Results

The average age of the patients was 27.6 (13–58) years. 298 cases (86%) had fibroadenoma, 32 cases (9%) had hamartoma, 14 cases (4%) had philloides tumor, and 3 cases (0.8%) had solid papillary carcinoma (2 cases had invasive solid papillary carcinoma with neuroendocrine and mucinous differentiation, 1 case had solid papillary carcinoma in situ carcinoma). Breast conserving surgery was performed for in situ solid papillary carcinoma while modified radical mastectomy was performed in 2 other patients. Only one of the cases with philloides tumor was diagnosed as malignancy and a modified radical mastectomy was performed as a complement treatment. There are significant differences in average pathologic mass lesion size; 2.2 cm in fibroadenomas, 2.9 cm in hamartomas, 3.8 cm in philloides tumors, 1.7 cm in solid papillary carcinomas.

Conclusion

The necessity of biopsy for each patient who were admitted to the hospital due to mass in the breast and radiologically preliminary diagnosis of fibroadenoma has once again emerged and the results of atypical pathology, which may occur in our clinical approach, and that the patient should be informed about, are remarkable. Pathologic mass lesion size should be considered clinically. In breast ultrasonography; Philloides tumors, solid papillary carcinomas and hamartomas may be confused with fibroadenomas.

TJS. 2018;34(Suppl-1):S648.

PP-0840 [Breast Diseases and Surgery]. Primary Neuroendocrine Carcinoma of the Breast

Güney Özkaya ^1,^✉, Mehmet Tolga Kırış ¹, Server Sezgin Uludağ ¹, Abdullah Kağan Zengin ¹

Introduction

The rare primary neuroendocrine carcinoma in the breast is often seen in elderly women and has similar morphological features to the neuroendocrine tumors in the gastrointestinal tract and lungs. In neuroendocrine carcinoma, more than 50% of neuroendocrine markers of tumor cells are expressed. In the case we are presenting, the tru-cut biopsy result of the patient with a mass in the right breast was invasive ductal cancer. The post-pathology result of the patient who had undergone axillary dissection due to partial mastectomy and SLNB positivity was primary neuroendocrine carcinoma. Primary neuroendocrine carcinoma is presented as a case in this article.

Case

A mass was detected in the right breast of a 68-year-old female patient with no previous complaint. A mobile, irregular contour mass of 2 centimeters in size was palpated in the lower outer quadrant of the right breast. On mammography and ultrasonography, a dense lesion accompanying with 16x27 millimeter in size irregularly limited microcalcification was observed in the right breast outer midline. In both axillary, lap in pathological dimension and configuration was not observed. It was evaluated in BIRADS-4 category. On the tru-cut biopsy examination, invasive carcinoma and ductal carcinoma focus was observed. Right partial mastectomy and axillary dissection were performed. In the pathology examination, a well differentiated neuroendocrine tumor with a diameter of 2.4 centimeters, intermediate grade, infiltrative character and showing perineural invasion was detected. There was no evidence of multicentric tumor focal, necrosis, calcification, lymphatic and blood vessel invasion in the insitu component of the tumor. The distance from the posterior surgical margin to the tumor was 0.6 centimeters and the distance to the other surgical margins was more than 1 centimeter. No tumor focus was seen on the papilla and skin breast. Carcinoma metastasis was detected in 3 of 10 lymph nodes in the right axillary and all of them were evaluated as metastatic. In immunohistochemical dye results: Estrogen receptor 90% strong positive, progesterone receptor 95% strong positive, Cerb B2 negative, Ki-67 1–5%, E-cadherin positive, chromogranin diffuse strong positive, synaptophysin diffuse strong positive, CD 56 diffuse strong positive, P63 negative, and SMA negative. In PET that was performed postoperatively, no primary focal or metastatic involvement was observed. Hormonotherapy was applied and no recurrence and metastasis were detected in 12 month follow-ups.

Conclusion

Although neuroendocrine tumors show the same features of the organ that they originate from, they all have common neuroendocrine structures. The incidence is 0.2/100.000 individuals, and constitutes 0.5% of all cancers. 65% of the cases occur in gastrointestinal system, 25% in the lung and 10% in other endocrine tissues. Breast neuroendocrine tumors are frequently found in solid form. Neuroendocrine tumors in other organs rarely metastasize to the breast as they rarely metastasize to other organs. Neuroendocrine markers such as neuron specific enolase, chromogranin A and synaptophysin are considered to be pure neuroendocrine tumors when they are found in more than 50% of malignant tumor cells. Immunohistochemistry results of our patient were: chromogranin, synaptophysin, diffuse strong positive for CD 56; 90% strong positive for estrogen receptor, 95% positive for progesterone receptor, negative for cerbB2 and no other primary foci in PET/CT after surgery support primary neuroendocrine diagnosis. Making the diagnosis of primary neuroendocrine tumor pre-operatively and our treatment approach during diagnosis is open to improvement. It is obvious that although primary neuroendocrine tumor diagnosis is possible through diligently performed histopathological examination and not detecting primary focus in other foci, improvements on diagnosis and treatment are still required.

TJS. 2018;34(Suppl-1):S648–S649.

PP-0841 [Breast Diseases and Surgery]. Do the Demographic Characteristics of Breast Cancer Vary from Region to Region?

Emel Demirel ^1,^✉, Neşe Dursun Sarıyaz ², Kayhan Özdemir ¹, Ebru Menekşe ², Havva Belma Koçer ¹

Objective

Breast cancer is the most common type of cancer among women and is among the most important causes of female deaths over 40 years of age. It is more common in developed or developing countries, but less common in undeveloped countries. The incidence of breast cancer also shows regional differences in our country. Differences in regional risk factors may change this incidence. Breast cancer risk factors include; female gender, 50 years of age and above, the age of menarche and menopause, giving birth in advanced age, not breastfeeding, family history of breast cancer, oral contraceptive use, obesity, lack of physical activity and environmental factors. Our aim in this study is to determine the demographic characteristics of patients who have been admitted due to breast cancer in Sakarya and Ankara and to show the difference if they exist.

Material and Methods

The demographic characteristics of 174 breast cancer patients treated in Sakarya Training and Research Hospital, Department of General Surgery between 2015 and 2017 were compared with the parameters of 242 breast cancer patients in Ankara Numune Training and Research Hospital, Breast Endocrine Unit between 2004–2009. In this retrospective study, the age of the patient, age at menarche, age at first birth, age at last birth, age of menopause, height, weight, body mass index, education status, hormone replacement therapy and oral contraceptive use, smoking and alcohol use, family history were evaluated.

Results

The average age of patients with breast cancer who were operated on in Sakarya was 54.14 years, whereas the average age of patients in Ankara was 51.15 years. It was found that breast cancer patients over 50 years of age in Sakarya were more than those in Ankara over 50 years of age (p<0.05). The menarche age of patients with breast cancer in Sakarya is higher than the menarche age of patients in Ankara (p<0.05). The rate of oral contraceptive use is higher in Sakarya. The proportion of patients who did not give birth in both cities is the same. There is no significant difference in terms of education status, age at last birth, HT, alcohol and tobacco use, and family history. The BMI of the patients in both cities was 30–35%.

Conclusion

Environmental and genetic factors play a role in breast cancer etiology. Environmental and cultural differences can show regional change. Breast cancer risk factors show regional differences in our country.

TJS. 2018;34(Suppl-1):S649–S650.

PP-0842 [Breast Diseases and Surgery]. Clinical Presence of Axillary Metastases in Node-Negative Breast Cancer

Orhan Üreyen ^1,^✉, Demet Kocatepe Çavdar ², Zehra Hilal Adıbelli ³, Enver İlhan ¹

Objective

The most important prognostic factor of breast cancer is axillary involvement. For this reason, axillary staging in terms of treatment planning and survival is very important. Axillary dissection is quite morbid. For this reason, sentinel lymph node biopsy is routinely performed in most centers with no clinical manifestations of axillary involvement. Axillary metastasis can be detected in a significant number of these cases. We aimed to investigate the factors associated with the detection of metastases in the sentinel lymph node biopsy without clinical axillary involvement in our study.

Material and Methods

Cases who had been performed on sentinel lymph node biopsy due to breast cancer between January 2012 and January 2018 were evaluated retrospectively through electronic data records. Cases were performed sentinel lymph node biopsy with combined (blue dye + lymphoscintigraphy), blue dye or lymphoscintigraphy. The status of axillary was determined according to the histopathological result of the sentinel lymph node. The patients were divided into two groups: cases with axillary metastases (Group I) and cases without axillary metastases (Group II). Groups were compared in terms of age, hormone receptor status, menopausal status, tumor location, histopathologic type of tumor, Ki 67, C-erb B2, tumor size and other prognostic factors. Ki-67 was determined as negative below 14% and positive in 14% and over.

Results

A total of 64 cases were included in the study; twenty-nine (45%) cases in Group I and 35 (55%) cases in Group II. The average age of group I was 53,48±13,37 years and the average age of group II was 51,29±11,58 years. There was no significant relationship in terms of age (p: 0,681). Group I average tumor size was 25,71±13,56, for group II the average was 21.37±14.46 (p: 0.069). While there was no significant difference between the groups in terms of tumor invasion type, histological grade, vascular invasion, nerve invasion, tumor T stage, multifocality and bilaterality (p>0,05), Lymphovascular invasion was significantly higher in group I compared to group II (57% versus 13%) (p:0.003).

There was no significant correlation in terms of estrogen receptor and C erb b2 (p>0,05), while there was a significant difference in terms of progesterone and Ki67 between the groups (p values were 0.036 and 0.045, respectively). There was no significant difference in terms of menopausal status, tumor’s being palpable or not, combined or single sentinel node biopsy, total number of examined lymph nodes, the presence/absence of paracentinal lymph nodes and presence of one or more sentinel lymph nodes (p>0,05).

Conclusion

Axillary involvement can be detected in a significant number of cases with no clinical axillary involvement. Our study also found that lymphovascular invasion was associated with sentinel lymph node biopsy positivity. In addition, although the Ki 67 value’s being less than 14% and the positive progesterone receptor is known to be a good prognostic factor, we also found that these two parameters correlate with axillary involvement. These results showed that in cases with axillary involvement, the classical prognostic factors we know in breast cancer are open to different interpretations in clinically undetected cases.

TJS. 2018;34(Suppl-1):S650.

PP-0843 [Breast Diseases and Surgery]. Incorrect Negativity in Sentinel Lymph Node Assessment during Intraoperative Consultation in Breast Cancer

Arzu Erdemir ¹, Kürşat Dikmen ², Güldal Esendağlı ¹, Osman Kurukahvecioğlu ^2,^✉

Objective

Lymphadenectomy is a standard procedure in the staging of breast cancer and in the selection of treatment options as in many malignant tumors. It has been reported that axillary lymph nodes for intraoperative consultation in breast cancer have successfully demonstrated the status of axillary with the percentage of 90–98% and false negativity in less than 5%. In this clinicopathologic study, it was aimed to determine the false negativity rate determined in the histopathological examination of the sentinel lymph node materials sent to the pathology laboratory for intraoperative consultation and the reasons for this.

Material and Methods

A total of 2012 axillary sentinel lymph nodes of 760 cases sent to the pathology laboratory for the intraoperative consultation between 2008–2017 at Gazi University Faculty of Medicine and were retrospectively screened from the hospital information management system and report registry books and reevaluated by a breast pathology and the results were presented as percentages.

Results

Of the 760 patients who had been operated due to invasive breast carcinoma, 755 (99.3%) were female and 5 (0.7%) were male. The average age ranged from 28 to 72 years. 1535 (76.3%) of a total of 2012 sentinel lymph nodes sent for intraoperative consultation were studied with “frozen” section and “imprint” method and the remaining 487 (23.7%) lymph nodes were evaluated in permanent sections following tissue follow-up. Metastasis was detected in 169 (11.0%) of 1535 lymph nodes examined in intraoperative consultation and the metastatic lymph node was confirmed in the permanent sections. No false positivities were found. However, it was understood that the micrometastasis focus of one lymph not that had not been detected in permanent sections but was observed in the “frozen” section was due to the depletion of the tumor focus in the tissue in the process of shaving. A total of 234 (11.6%) lymph node metastases were detected after the examination of all sentinel lymph nodes with permanent sections, including the lymph nodes sent to the intraoperative consultation but not with the “frozen” section. The number of lymph nodes evaluated as false negative was 65 (3.2%).

Conclusion

In the literature, the incidence of false negativity in the intraoperative consultation of sentinel lymph node evaluation is<5% and the result we obtained in our study about this issue is consistent with the literature. Among the causes of false negativity, histological subtype and size of the tumor, section-folding and spillage, frozen artifact of the tissue-very common problems that are commonly experienced during frozen section procedure-were determined. Sentinel lymph node biopsy has proved to be a successful indicator for lymphadenectomy in breast cancer staging. However, it should be known by both the surgeon and the pathologist that there might be natural sampling and macroscopic-microscopic examination errors in intraoperative consultation. For this reason, the sentinel lymph nodes sent for intraoperative consultation should be optimally examined by the pathologist in accordance with the expected intraoperative consultation protocol, which is determined at each center.

TJS. 2018;34(Suppl-1):S650–S651.

PP-0844 [Breast Diseases and Surgery]. The Efficacy of Tropical Steroid Use in the Treatment of Idiopathic Granulomatous Mastitis

Mustafa Ümit Uğurlu ^1,^✉, Züleyha Özgen ², Samet Kurnaz ³, Ahmet Koçak ³, Burak Bilir ³, Furkan Yılmaz ³, Enes Gök ³, Bahadır Mahmut Güllüoğlu ¹

Objective

Idiopathic granulomatous mastitis (IGM) is a chronic inflammatory breast disease that can be confused with breast cancer clinically and radiologically, with no known etiology. The treatment of the disease is still controversial. It is aimed to determine the effectiveness of topical steroid use in IGM treatment.

Material and Methods

The 3 month-clinical follow-ups of the patients who had been admitted to Marmara University, Faculty of Medicine (MUFM) Department of General Surgery, Breast-Endocrine Unit and who were already diagnosed with IGM and treated with topical steroids were performed. The criteria to be included in the study were: being 18 years old and above, clinically and pathologically diagnosed with IGM, unresponsive to oral steroids. Pregnants, cases with malignant diagnosis and who did not give consent were not included in the study. In addition to the demographic features of the cases, radiological responses (presence of abscess, number of lesions, localization of lesions), changes in physical examination findings (fistula, presence of erythema), pain conditions [Visual Analogue Scale (VAS) (0–10 points)] were evaluated. Clinical and radiological healing/recurrence presence was noted.

Results

Eighteen women with IGM diagnosis were included in the study. The average age of the patients was 35.6±6.4 years and the average duration of the illness was 11.2±9.0 months. While the pain VAS score at the onset of the disease was 5.3±3.2, it was 1.9±1.7 in the first month and 0.6±0.3 in the third month [Onset vs 1st month (p=0.002) and 1st month vs 3rd month (p=0.003), onset VAS vs 3rd month VAS (p=0.004)]. While at the beginning of the disease, erythema was detected in 88.9% of the patients (n=16), in the 3rd month examination 46.6% (n=7) of the patients had erythema (p=0.005). While the sensitivity rate at the first month was 44.4% (n=8), the sensitivity rate in the 3rd month was 46.7% (n=7) (p=0.067). While the presence of fistula was found as 27.8% (n=5), in the third month the rate was determined as 20.0% (n=3) (p=0.02).

Conclusion

The use of topical steroids in IGM patients has been shown to reduce pain in a statistically significant manner. In addition, a decrease in the number of fistula and breast erythema has been detected. Findings regarding sensitivity, malformation, and mass were not significantly altered.

TJS. 2018;34(Suppl-1):S651.

PP-0845 [Breast Diseases and Surgery]. The Effectiveness of the BREAST-Q Breast Conserving Surgery Module in Measuring the Quality of Life and Patient Satisfaction in Cases on whom were Performed Oncoplasty Breast Surgery

Mustafa Ümit Uğurlu ^1,^✉, Bülent Saçak ², Yasemin Nazlı ¹, Bahadır Mahmut Güllüoğlu ¹

Objective

PP-0848 [Breast Diseases and Surgery]. A Case of Isolated Hydatid Cyst of Breast

İskan Çallı ¹, İsmail Zihni ^1,^✉, Serap Taş ², Serap Koç ²

Hydatid cyst is a parasitic disease that is mostly seen in endemic areas. It is an important health problem in our country especially in Eastern and Southeastern Anatolia Region. Hydatid cyst of the breast is very rare even in endemic areas and it constitutes only 0.27% of all hydatid cyst cases. It can be part of a common hydatid disease or it can be primary. Surgical treatment is the best treatment option. There are not many publications in the literature about hydatid cyst of the breast. Most of the reported cases were diagnosed postoperatively. It is not always possible to make a definitive diagnosis only by clinical examination and radiological tests. In this case we discussed the case of isolated hydatid cyst of breast in a 43-year-old woman.

TJS. 2018;34(Suppl-1):S653.

PP-0849 [Breast Diseases and Surgery]. Breast Conserving Oncoplasty Surgery Experience in a Young Breast Cancer Patient

Hasan Turgut Aydın ^1,^✉, Zafer Şahlı ¹, Sacit Altuğ Kesikli ¹, Hilmi Erencan Polat ¹, Mete Keskin ¹, Atila Korkmaz ¹

Introduction

The most common malignant tumor in women is breast cancer, accounting for about 30% of all cancers. Breast conserving surgery, which is a current approach in the treatment of breast cancer, involves a variety of aesthetic and oncologic problems. The oncoplastic surgical approaches that were first introduced in 1994 have the advantages: correction of cosmetic problems, reduction of mastectomy rates, sampling of the other breast, high quality of life and application of single session. Below is a discussion of our experience with oncoplastic surgery according to Wise’s pattern in a 40-year-old patient.

Case

A 40-year-old woman was admitted to our department with a complaint of stiffness and pain in the right breast under areola for approximately 1 week. On physical examination, a hard mass of approximately 1 cm was detected at 2 o’clock position in the right breast under areola and excisional biopsy was performed on the patient. Upon the detection of malignancy in the biopsy, oncoplastic surgery was planned for the patient with Wise’s pattern. No metastasis was detected in the preoperative staging of the patient. The patient’s breast was marked with Wise’s pattern by including the areola and mastectomy margins were determined. In the sentinel lymph node study pathology lymph node was not detected. After the mastectomy, the patient’s breast was repaired with oncoplasty. Pathologic examination of the mastectomy specimen, including the areola, revealed infiltrative ductal carcinoma with grade 2, multifocal, peritumoral lymphatic invasion with negative surgical margins. The patient was discharged with healing without any additional problems during the follow-ups.

Conclusion

Oncoplastic surgery has several disadvantages in spite of its various advantages. In addition to the disadvantages such as the presence of aesthetic expectancy more than breast conserving surgery, the necessity of mastectomy due to the surgical margin positivity between 7–12%, longer operation time, delay of adjuvant chemotherapy onset periods in complicated cases, controversial algorithms and indications, the important obstacles of the development and implementation of these methods are the lack of publications with high value of evidence. The requirement of MRG in long-term survival data and follow-up is another important problem. Drawing with Grosmann and Roudber Disc is the most commonly used method in our country. The skin marking using Wise’s pattern is the most common method used in patients with macromastasis and it includes an incision of the areola circumference, a vertical incision to the lower breast line, and a horizontal incision below the breast. Its results with the Wise’s pattern used as a traditional approach in reduction mammoplasty with suitable mastopexy are promising. There are publications reporting that it may also be performed after neoadjuvant chemotherapy in locally advanced cancers. However, it should be remembered that the knowledge and experience of the surgeon is very important because of the complex structure of the procedure and the possible complications.

TJS. 2018;34(Suppl-1):S653–S654.

PP-0850 [Breast Diseases and Surgery]. Clinical Experience in Male Breast Cancer Patients

Kazım Çağlar Özçelik ¹, İsmail Zihni ^2,^✉, Oktay Karaköse ³, Hüseyin Pülat ⁴, İskan Çallı ², Hasan Erol Eroğlu ⁵

Objective

Breast cancer is rarely found in men. However, the incidence of breast cancer is increasing in men as well as in women in recent years. We retrospectively reviewed the data of male breast cancer patients undergoing surgery in our study and evaluated the clinical and pathological features of the disease under the light of the literature.

Material and Methods

The files of 6 male patients with breast cancer were retrospectively studied. The patients were diagnosed and treated between January 2012 and January 2016 in Süleyman Demirel Faculty of Medicine Hospital Department of Surgical Oncology Clinic.

Results

The average age of the patients was 60.3 (min: 50-max: 69). The lesion was detected as 33.3% in lower external quadrant and 66.7% in subareolar region. In four patients, palpable lymph nodes were detected in the axillary and axillary was clinically negative in 2 patients. The 66.6% of the patients received the diagnosis of invasive ductal carcinoma, and 16.7% had the histopathological diagnosis of mucinous and micropapillary carcinoma. Modified radical mastectomy (MRM) was applied to all of the patients. The average tumor size was 2.3 cm (min: 1.5-max: 3), while approximately 30.5 lymph nodes were dissected in axillary dissection (min: 17-max: 40): 30) about 18.5 lymph nodes (min: 7-max: 30) were found to be metastatic. HER2 was positive in only one patient when all estrogen and progestron receptors were positive in all patients.

Conclusion

Male breast cancer (MBC) constitutes a small proportion of all breast cancers and cancers found in men. However, due to the detection in advanced stage at the time of diagnosis, morbidity and mortality rates are high. Treatment is performed through modified radical mastectomy but breast conserving surgery and sentinel lymph node sampling might also be performed in early stage patients. However, 5-year survival is 40–65%.

TJS. 2018;34(Suppl-1):S654–S655.

PP-0851 [Breast Diseases and Surgery]. Reverse Mapping with Fluorescent Method in Secondary Axillary Surgery

Hakan Yiğitbaş ^1,^✉, Merve Tokoçin ¹, Osman Bilgin Gülçiçek ¹, Atilla Çelik ¹

Introduction

Lymphedema is a chronic and progressive process that its treatment is more difficult than prophylaxis. Since it is vitally important in terms of breast cancer prognosis, it is a sad complication that is encountered after the axillary sampling or dissection. Especially in secondary surgeries there is more risk. We aimed to demonstrate the protection of arm lymphatics by Indocyanine green (ICG) fluorescence reverse mapping in our secondary axillary intervention.

Case

A 28-year-old woman presented herself to the department of chest diseases with the complaint of swelling under the arm which had been there for 2 years but enlarged in the last month. While there was no palpable mass present in both breasts, from the upper external quadrant of the left breast to the axillary, a solid, mobile and partially painful lesion was palpated. On the USI control, a 4x4 cm solitary lesion extending from the upper external quadrant of the breast to the axillary was detected and a thick needle biopsy was performed accompanied with the imaging. Upon receiving the result as Schwannom, excision of the mass was performed by the neurosurgical clinic. Since the pathology result was adenosquamous carcinoma with surgical marginal positive low-grade, the patient was reevaluated by the tumor counselor and the decision of quadrantectomy and axillary dissection was taken. Under general anesthesia, 0.2 cc ICG was injected under the skin in 3 different places on the back of the left hand and lymph node dissection was performed by monitoring and maintaining the the arm lymphatics with the Novodaq Spy Elite Fluoroscopic Imaging System and upper external quadrantectomy was performed covering the old incision. The pathology a surgical margins were compatible with invasive adenosquamous carcinoma at a single focus with of at least 1 mm and 23/0 positive lymph node.

Axillary lymph node assessment has a critical role in breast cancer. In patients who were performed axillary dissection, lymph-edema can be seen in different clinical series by 5–28%. The axillary dissection was not performed in the first attempt due to Schwannom thick needle pathology, but axillary dissection was caused by adenosquamous carcinoma of the final pathology. The dissection was performed by reverse mapping method due to the deterioration of the lymphatic channels extending from the papilla to the axillary. With this method, lymphedema that could develop in our patient was prevented.

Conclusion

We believe that the risk of other methods will be avoided by reverse mapping, which is performed with ICG and Fluorescent Imaging to prevent the development of lymphedema in secondary interventions to Axillary.

TJS. 2018;34(Suppl-1):S655.

PP-0852 [Breast Diseases and Surgery]. Comparison of Pathology Results of Breast Cancer Cases via Preoperative Magnetic Resonance Imaging

Selman Emirikçi ^1,^✉, Leman Damla Ercan ¹, Ravza Yılmaz ², Mahmut Müslümanoğlu ¹

Objective

In breast cancer, Imaging methods provide the surgeons the opportunity to plan in order to obtain negative surgical margin prior to the operation in breast cancer. Thus, it is aimed to reduce additional surgeries and recurrences. Today, MR imaging is significant in terms of local staging of breast cancer. It provides important data on the tumor size, displacement of the surrounding breast tissue, insitu dimension, multifocality and multicentricity.

Material and Methods

The data of 282 patients who had been operated between January 2017-December 2017 at Istanbul University Faculty of Medicine, Breast Surgery Unit was evaluated retrospectively. The pathology results of the patients with multifocal, multicentric or insitu foci in MR reports and patients whose preoperative evaluation had been performed via MR were evaluated in detail.

Results

It was determined that 173 of 282 patients went through preoperative MR and 46 of these patients’ MR were found to be suspicious in terms of multifocal, multicentric and/or insitu displacement. Of the 46 patients, 20 (53.5%) were performed breast conserving surgery (BCS), 26 (56.5%) had mastectomy. In the comparative evaluation of pathology and MR results, it was determined that MRI and pathology results were different 18 (39.1%) patients. While the findings in the MRI of 11 (23.9%) patients were suspected of multifocal disease, in the pathology specimen it was seen that the malignancy had single focal. When secondary USG was performed in 6 of these 11 patients, no pathology was observed in the additional foci in the MR. While 5 (10.8%) patients’ MR showed single focal insitu displacement, pathology specimen showed multifocal tumor. In the comparison that was performed in terms of insitu focal assessment, it was observed that the MR of 5 (10.8%) patients had false negativity and 2 (4.3%) had false positivity. In the pathology evaluation of patients, it was determined that 25 had IDC, 4 had mucinous carcinoma, 2 had DCIS, 7 had combined type (IDC+ILC), 3 had ILC and 1 had metaplastic carcinoma. When the biological subgroups of the tumors were analyzed, 17 patients were in luminal A, 15 were in luminal B, 5 patients were in triple negative group.

Conclusion

PP-0858 [Breast Diseases and Surgery]. Early Stage Oncoplastic Breast Conserving Surgery Experience

TJS. 2018;34(Suppl-1):S659–S660.

PP-0862 [Obesity]. Short-Term Results of Bariatric Surgery in Type 2 Diabetes Mellitus Patients

Ozan Akinci ^1,^✉, Müge Yurdacan ¹, Yasin Tosun ¹, Başar Can Turgut ¹, Abdullah Kağan Zengin ¹

Objective

Type 2 diabetes mellitus (DM) is a health problem that has become pandemic all over the world and has serious complications with psychosocial and economic dimensions if uncontrolled. Recently, bariatric surgery has been widely accepted because of its positive results in Type-2 DM treatment. In addition to short-term (reduced calorie intake) and long-term results (reduced fat mass and body weight) of bariatric surgery, it is thought to contribute to Type 2 diabetes remission, resulting in changes in glucose metabolism, insulin resistance and adipocytokine release. In this study, we aimed to present the results of 6 month follow-up of 20 patients undergoing laparoscopic mini-gastric bypass surgery due to Type 2 DM in our department.

Material and Methods

We included 20 cases who underwent laparoscopic mini-gastric bypass surgery due to type 2 DM. Preoperative and postoperative 6th month body mass index (BMI), body weight, fasting blood glucose (BMI), HbA1c level, and insulin use of the cases were compared. Vitamin B 12, folic acid levels were measured postoperatively. Categorical data were evaluated in the SPSS 21.0 program. The significance test of the difference between the two pairs was used to compare the data. p<0.05 was considered significant.

Results

10 of the cases were female, 10 were male and the average age was 51. 12 patients were on insulin preoperatively and 8 were on oral antidiabetic treatment. The average postoperative hospital stay was 5.2 days. In one case, anastomosis leakage developed and the patient was performed drainage and conservative treatment with antibiotherapy. When the averages of preoperative/postoperative values are compared; body weight decreased from 104 to 71; BMI from

37.5 to 25; HbA1c decreased from 7.1% to 6%; and Fasting blood glucose decreased from 195 to 108 and it was seen that the difference between these values was statistically significant (p<0.05). Only one of the preoperatively insulin-using patients continued to the insulin treatment and 2 of them moved on with the oral antidiabetic treatment. The indication of antidiabetic medical treatment has been eliminated in all cases who used to be on preoperative oral antidiabetic use. In the postoperative period, 5 of the cases developed vitamin B-12, 7 of them developed folic acid deficiency and the replacement for their deficiency was performed.

Conclusion

Laparoscopic mini-gastric bypass surgery, one of the modification techniques of bariatric surgery that is increasingly widespread in the world is a reliable method with positive metabolic effects even in the short term with cases diagnosed with Type 2 DM.

TJS. 2018;34(Suppl-1):S660.

When the literature is examined, liver retractors may lead to liver ischemia and disseminated intravascular coagulation. The risk factors for ischemia are prolonged surgery time (as it happened in our case), increased liver size and the reverse trendelenburg position, which is used in upper abdominal surgery. We think that it is important to intermittently release and displace the retractor in patients with these risk factors.

TJS. 2018;34(Suppl-1):S662.

PP-0866 [Obesity]. Neuroendocrine Tumor in Sleeve Gastrectomy Specimen: A Case Report

Ahmet Mücteba Öztürk ^1,^✉, Savaş Yakan ¹, Yasemin Şahin ², Murat Bayram ¹, Mehmet Yıldırım ¹

Introduction

Obesity is one of the biggest health problems in our country and in the world, and the number of obese individuals increases day by day, resulting in accompanying diseases, mortality and morbidity. Studies have shown that the only option in obesity treatment is surgical treatment, and after surgery all the samples were sent to the pathology unit and examined. We aimed to present our case in whom neuroendocrine tumor was detected in his pathology specimen after sleeve the gastrectomy performed in our department.

Case

A 37-year-old male patient referred to our outpatient clinic for morbid obesity. The patient with a body mass index of

50.7 kg/m2 and no additional disease was included in the program of obesity surgery. The patient who had no pathology on his preoperative examinations was subjected to standard sleeve gastrectomy. The patient who did not develop any problems postoperatively was discharged without any problems on the 3rd postoperative day. In the pathological examination of the sleeve gastrectomy material; Two neuroendocrine tumors were observed in the dimensions of 6x4 mm and 4,5x3 mm. The tumor has passed the lamina propria and infiltrated the submucosa. Tumor cells were Keratin (+), Chromogranin-A (+), Synaptophysin (focal +) and CD56 (+) and Ki-67 proliferation index was around 12%. In the tumoral areas, eight mitoses were observed in 10 Large Growth Areas. In other areas, common intestinal metaplasia, chronic atrophic gastritis as well as neuroendocrine cell hyperplasia findings of linear and micronodular species were present and reported. The patient was consulted by with oncology clinic and was scheduled for a follow-up.

Conclusion

The importance of the surgery in the treatment of obesity is unquestionable and samples taken after the surgery should definitely be sent to the pathology umit. Additional pathologies that are missed during routinely examined specimens can be detected.

TJS. 2018;34(Suppl-1):S663.

PP-0867 [Obesity]. Concurrently Performed Cholecystectomy with Sleeve Gastrectomy? Evaluation of 294 Cases

Ahmet Mücteba Öztürk ^1,^✉, Savaş Yakan ¹, Burak Dede ¹, Ozan Barış Namdaroğlu ¹, Mehmet Yıldırım ¹

Objective

Obesity is increasingly observed in the world and in our country, resulting in increased obesity related complications, morbidity and mortality. Laparoscopic sleeve gastrectomy (LSG) is the most frequently encountered surgical procedure in the surgical treatment of obesity. The association of obesity with colelitaisis is known and the incidence of colitisasis increases with weight loss after obesity surgery.

Material and Methods

Between 2014 and 2018, 294 obesity surgeries were performed in our department, of which 292 were sleeve gastrectomy and 2 were gastric bypass operations. The findings of the patients were retrospectively reviewed and preoperative abdominal ultrasonography records were recorded.

Results

Of the patients, 58 were male (19.7%) and 236 were female (79.3%). Between 18 and 64 years of age, body mass index (BMI) was 40–67 kg/m². Forty-one patients (13.9%) were found to have cholecystectomy in the preoperative period. Colelithiasis was detected in 50 patients (16.8%). Of the 50 patients who had undergone sleeve gastrectomy, cholecystectomy was performed on 5 patients (10%) since it became symptomatic in the later period. Patients without any complications were uneventfully discharged on the 2nd postoperative day.

Conclusion

Although cholecystectomy is one of the most frequently performed operations in general surgery and complication rates are low, cholecystectomy with sleeve gastrectomy may lead to a greater destruction in terms of complication. We think that sleeve gastrectomy and cholecystectomy should not be performed at the same time in order to avoid the situation mentioned above and to give additional surgical burden to patients.

TJS. 2018;34(Suppl-1):S663.

PP-0868 [Obesity]. Should Obesity Surgery be in The Curriculum of Resident Training? Evaluation of 294 Cases

Ahmet Mücteba Öztürk ^1,^✉, Savaş Yakan ¹, Ozan Namdaroğlu ¹, Burak Dede ¹, Mehmet Yıldırım ¹

Objective

Obesity is one of the greatest public health problems in our country and in the world, and the number of obese individuals increases day by day and thus obesity associated concomitant diseases, mortality and morbidity increase. According to the TURDEP-II study conducted in 2014 in our country, 48% of women and more than 30% of men are overweight. In the same study, patients with type 2 diabetes mellitus constitute almost 10% of the population and the number of morbid obese individuals are millions. Studies show that surgery is the most effective treatment option in obesity treatment. Patients with severe comorbidities constitute the group of patients most benefiting from surgery.

Material and Methods

Between 2014 and 2018, 296 obesity surgeries were performed in our department, 2 patients underwent gastric bypass, and the remaining patients underwent sleeve gastrectomy. 58 of the patients were male (19.5%) and 236 were female (79.5%). Their age ranged between 18 and 64 years and body mass index (BMI) was 40–67 kg/m². Two of our patients died on the first and third days postoperatively, and two of our patients had leakage. The leakage on two patients were taken under control through nitinol coated stent. 68 of our patients’ procedures were primarily completed by our residents.

Conclusion

Obesity is increasing in our country and in the world and has almost reached a pandemic size. The number of obesity surgeries worldwide is around 350000 while in our country this number is around 15000–20000. Our residents have completed our cases under our supervision as primary. There was no surgical pathology in the postoperative period and the patients were healed and discharged. Therefore, we think that the obesity surgery should take part in the residency training program.

TJS. 2018;34(Suppl-1):S664.

PP-0869 [Obesity]. The Histopathological Findings of Duodeno-Ileal Bypass + Sleeve Gastrectomy with Single Anastomosis in Obese Rats and its Effect on Metabolic Hormones

Osman Bilgin Gülçiçek ¹, Merve Tokoçin ¹, Ali Solmaz ^1,^✉, Talar Vartanoğlu ¹, Nihat Buğdayci ¹, Fatih Çelebi ¹, Atilla Çelik ¹, Ayşegül Güneş ², Tuğçe Çay ³, Onur Tokoçin ⁴

Objective

Objective

Laparoscopic sleeve gastrectomy (LSG) for surgical treatment of morbid obesity has become an increasingly common method in recent years. In this method, a stomach part of about 1000–1100 ml volume is resected. Some of the studies evaluating this part of the resected stomach were reported to reveal incidental malignant lesions. The purpose of this study was to evaluate the histopathologic results of patients undergoing laparoscopic sleeve gastrectomy and to discuss the factors, if present, affecting the development of malignant lesions.

Material and Methods

Prospectively recorded medical data of 246 patients who underwent LSG surgery in a single academic center between January 2013 and October 2017 in accordance with the World Health Organization criteria were retrospectively reviewed.

Results

72.4% of the patients were female. The mean BMI was 45,41 kg/m2. The most common pathological finding was gastritis. Incidental malignancy was detected in 3 patients and atrophic gastritis and diffuse intestinal metaplasia were detected in two patients (Graph 1). These findings were not found in the preoperative evaluations of malignant patients.

Conclusion

TJS. 2018;34(Suppl-1):S669.

PP-0879 [Obesity]. First in the Literature; Impact of Intraabdominal Abscess After Sleeve Gastrectomy: Rothia Mucilaginosa

Yaşar Çöpelci ^1,^✉, Ümit Koç ², İsmail Gömceli ², Serkan Güler ¹

Introduction

One of the complications encountered after laparoscopic sleeve gastrectomy (LSG) is intraabdominal abscess. In this case presentation; management of a case of intraabdominal abscess developing due to a microorganism relationship of which has not been previously defined with LSG in the literature was reported.

Case

A-40-year old male patient 177 cm in height, weighing 155 kg (BKI: 49,4) and having no characteristics in his medical and family history was taken for LSG operation after appropriate preparation. With prophylactic 2 g cefazolin administration, he was followed-up postoperatively without developing any preoperative. His postoperative vital signs were stable and laboratory values were normal. The content of the serous drain was 100 cc on the postoperative first day, and 50 cc on the second day. On the third day, oral contrast-enhanced CT showed a hematoma with a perigastric depth of 2 cm and no leakage was observed at the anastomosis line. Following oral intake, he was dischrged with LMWH prescription without developing any complication. On the postoperative 9th day there was an isolated tenderness in the epigastric region in the physical examination of the patient who was admitted to the emergency service with abdominal pain and fever and defense and rebound were negative. He had an ability to defecate. Laboratory values were Hb: 13,4 WBC: 18,1 CRP: 169. In the tomography taken; it was seen that the hematoma grew and there was free air flowing from between the stomach and hematoma to the epigastric region. He was hospitalized with diagnoses of leakage and abscess and empirical ciprofloxacin and metronidazole were initiated. Laparoscopic exploration decision was taken. The hematoma was aspirated, the sample was taken for culture from the fluid, the drain was placed and no gastric leakage was found. Postoperative vital signs of the patient had a stable course and there was no significant amount of content in the drains of the patient. Hb values were stable between 11.1 and 10.6. Daily post-operative infection parameters were; WBC: 13.2-11.8-9.7-8.7 CRP: 377-334-199-122 respectively. On reproduction of Rothia mucilaginosa in the preoperative culture taken, ertapenem and linezolid treatment were applied to the patient in view of the department of infectious diseases. Oral intake started on the postoperative fifth day. He tolerated it. Following the completion of the antibiotherapy on day 14, the patient was discharged.

Conclusion

Anastomosis line leakage and bleeding are the most common complications in LSG. Intraabdominal abscess development can be seen after anastomosis leakage. In this case, resource control, culture intake and initiation of appropriate treatment at the end of the antibiogram reduce morbidity and mortality. In general practice, E. faecalis and faecium, Staphylococcus epidermidis, C. albicans and P. aureginosa are generally identified in the postoperative intraabdominal abscesses. Rothia mucilaginosa is a rare gram positive coccus isolated intraabdominally and has been shown in only abscesses related with peritoneal dialysis in the literature and it is located in the normal flora of the oropharynx and respiratory system. This patient was able to be discharged healthily by reducing the comorbidities with efficacious treatment after the appropriate algorithm was followed. Since we could not find a study in the literature showing the relationship of R. mucilaginosa and LSG,we think that this is the first case presentation examining this issue.

TJS. 2018;34(Suppl-1):S669.

PP-0880 [Obesity]. Case: Rare Location of Appendix After Bariatric Surgery

İhsan Burak Karakaya ^1,^✉, Tuna Bilecik ¹, Sefa Özyazıcı ¹, Faruk Karateke ¹, Süleyman Çetinkünar ¹

Introduction

The development of incisional hernia in the trocar entry site is a complication of laparoscopic and robotic surgery and its incidence is reported to be 1% to 22%. Although incisional hernias developed from these defects can be asymptomatic, we encounter with severe clinical pictures up to strangulation.

Case

A 51-year-old female patient had a sleeve gastrectomy a year and a half ago. The patient who lost 105 kg was reoperated for abdominoplasty. Herniation of the Appendix vermiformis was observed in the subumbilical median trocar entry. Appendectomy was performed. No problems were encountered in the postoperative period.

Conclusion

When the trocar defects are not closed, patients may come with the pictures such as herniation of intestinal loop and rarely appendix vermiformis herniation. It is also envisaged that if the patient develops acute appendicitis, the patient may have serious changes in his clinical and physical examination findings. The closure of trocar defects in the light of this information is thought to reduce the incidence of incisional hernia in the later period.

TJS. 2018;34(Suppl-1):S670.

PP-0881 [Obesity]. Difficulties That May be Encountered in Bariatric Surgery in Morbid Obese Patients With Liver Cirrhosis

Erkan Yardımcı ^1,^✉, Halil Coşkun ¹

Introduction

The prevalence of obesity in the liver transplant population is increasing rapidly. It was aimed to demonstrate the difficulties that may be encountered in bariatric surgeries performed before transplantation in morbid obese patients with liver cirrhosis.

Case

Laparoscopic sleeve gastrectomy surgery was planned for a-52-year-old male patient with liver cirrhosis developed on hepatitis B background having body mass index of 41 kg/m2 and Child-Pugh stage A, MELD score 10, and grade II esophageal varices at upper gastrointestinal endoscopy. There was enlargement of liver nodules and short gastric vessels in cirrhosis base in the operation we performed routinely with 5 ports. The stomach was released after liver exartation. During the posterior release of the stomach fundus, bleeding occurred when clipping the enlarged vein structures. After laparoscopic hemostasis, the operation was completed without any problems.

Conclusion

The limited number of studies in the literature suggest that optimal management of transplant candidates with morbid obesity and liver cirrhosis is controversial. In cases with BMI>40 kg/m2, transplantation is not possible in most centers. Bariatric surgeries can be performed with low complication rates in cases where calorie restriction and dietary changes do not provide sufficient weight loss in comprehensive centers where transplantation is performed by experienced surgeons.

TJS. 2018;34(Suppl-1):S670–S671.

PP-0882 [Obesity]. “Gastro (Remnant)-Cutaneous Fistula Case and Management” After Sleeve Gastrectomy

İlker Sücüllü ^1,^✉, Ahmet Ziya Balta ¹, Tuba Gülçelik ¹, Sümeyra Emine Bölük ¹, Süleyman Atalay ¹, Adem Aslan ¹, Yavuz Kurt ¹

Introduction

Gastrocutaneous fistula case one of the rare complications after sleeve gastrectomy, and its management will be presented.

Case

A-34-year-old male patient with BMI 45 who admitted for exogenous obesity, underwent sleeve gastrectomy following preoperative preparations. Surgery was performed again immediately after stomach content came out from the drain of the patient whose abdominal and shoulder pain complaints started on the postoperative 2nd day and leakage was detected as a result of the test performed with methylene blue. At surgery, it was observed that there was decomposition at incisura angularis level in the sleeve line, and the defect was repaired by laparoscopy primarily. Four days after the second operation, the diffuse abdominal pain and septic findings occurred agin and the patient was re-operated and laparotomy was performed. The reattachment of the suture line was seen again, and the pylorus was divided almost 5–6 cm proximal to the stomach staples and a single anastomotic mini gastric bypass was performed between the remnant stomach in the proximal and jejunum. After the third postoperative complaints rapidly regressed and the general condition improved, after discharge the patient complained of bilious discharge from the median incision line over the abdomen. As the expected fistula closure was expected to decrease as a controlled fistula but the continuous drainage continued, the patient was admitted to our clinic one year after his first admission for fistula treatment. On the MR examination, which was performed by giving opaque material from the fistula tract, it was seen that the fistula was between the remnant stomach and the skin. During the operation, the tract was exposed by giving methylene blue to the external mouth of the fistula, and skin and remnant stomach tissue was resected from the pylorus level and the fistula tract was removed. At the same time, the incisional herniorrhaphy was added to the patient who had an incisional hernia. The patient was discharged without any problems on the fifth postoperative day.

TJS. 2018;34(Suppl-1):S671.

PP-0883 [Obesity]. Micronutrient Levels in Patients Undergoing Bariatric Surgery

Nihal Çınar Özcan ^1,^✉, Aydemir Ölmez ¹, Mehmet Özgür Türkmenoğlu ¹

Objective

In our retrospective study we aimed to investigate the presence of micronutrient deficiency in patients undergoing bariatric surgery.

Material and Methods

Eighteen patients who underwent bariatric surgery by the same surgeon in Mersin University General Surgery Department between January 2016 and January 2017 and reached the target weight loss were included in the study. The mean age of the group consisting of 11 female and 7 male was 39,33±11,68 (minimum: 21, maximum: 55). Three patients underwent gastric bypass and 15 patients underwent sleeve gastrectomy. All the patients in the group were given nutritional solutions and vitamin preparations in the postoperative 1 month period. Their follow-ups were made with blood values in postoperative 1st, 3rd, and 6th months and 1st year. Micronutrients that were missing during the controls were replaced. The levels of micronutrient (hemoglobin, hematocrit, ferritin, albumin, vitamin D, folic acid, and vitamin B12) were compared in preoperative and postoperative 1 year follow-up. There was a statistically significant increase in vitamin D levels (p=0.037). However, there was no statistical difference in terms of other variables (p>0,05).

Conclusion

There was no decrease in nutritional parameters despite expectations after bariatric surgery. Possible micronutrient deficiencies can be prevented by the use of short term follow-ups and supplementary products.

TJS. 2018;34(Suppl-1):S671–S672.

PP-0884 [Obesity]. Complication Analysis After Bariatric Surgery: Single Center, 309 Patients

Hakan Çakıt ^1,^✉, Abdullah Şişik ¹, Fatih Başak ¹, Yahya Özel ², Fikret Ezberci ¹

Objective

Bariatric surgical applications with effective results in the treatment of obesity are accompanied by some complications. When these complications can not be managed, serious morbidities and mortalities can occur. Many surgeons remain distant from this practice because of the complications that may arise postoperatively. Surgeons who practice bariatric surgery need to have sufficient knowledge about complication management as well as surgical technique. We aimed to present complications after our bariatric surgery applications and treatment methods in our clinic.

Material and Methods

Bariatric surgery applications in our clinic between March 2015 and December 2017 were retrospectively reviewed. The demographic characteristics (age, sex) of the patients, the type of surgery applied, the number of days of hospitalization, the complications after surgery and the treatment methods of these complications were recorded. The obtained data were also grouped by years.

Results

309 patients underwent bariatric surgery between March 2015 and December 2017 due to obesity. 258 of the patients were female (83.5%) and 51 were male (16.5%). 299 patients had sleeve gastrectomy and 10 patients had transit bipartition operation. Complications were not observed in 292 patients (95%) and complications occurred in 16 patients (5.2%). Three patients (0.9%) were found to have postoperative leakage. Leakage was taken under control by endoscopic stent and percutaneous drainage methods. Postoperative stenosis was detected in 3 patients (0.9%). In 2 of these patients, stenosis was seen to appear due to technical reasons and it was treated with endoscopic dilatation methods. In 1 patient, functional stenosis due to postoperative akalasis was observed. Firstly, endoscopic methods were used for treatment, and heller myotomy was applied because of not being successful. There was postoperative bleeding in six patients (1.9%). Infected hematoma was determined in 5 of them, and treated with percutaneous drainage. One patient (0.3%) developed portal venous thrombosis postoperatively and was treated conservatively with anticoagulant medication. Enterocutaneous fistula due to evisceration developed in one patient who underwent open surgery due to previous laparotomies, and local nutrition of the fistula was provided and nutrition of the patient was regulated. The patient was treated with partial resection of the small intestine at 6th months. Two patients (0.6%) developed postoperative early period atelectasis and respiratory exercises were sufficient. One patient (0.3%) developed mortality due to non-surgical comorbid causes. 1 stenosis in 37 patients in 2015, 3 leakages, 1 stenosis, 5 major bleedings, 2 atelectasis in 116 patients in 2016 and 1 stenosis, 1 major bleeding, 1 portal vein thrombosis and 1 enterocutaneous fistula occurred in 156 patients in 2017. One patient had a mortal course due to comorbid reasons.

Conclusion

Various complications arise after bariatric surgery. Leakage, stenosis and bleeding are the most known complications. It is also possible to encounter rare complications such as portal vein thrombosis and enterocutaneous fistula. It is possible to obtain effective and safe results when management of complications after bariatric surgery is done as required.

TJS. 2018;34(Suppl-1):S672.

PP-0885 [Obesity]. Laparoscopic Sleeve Gastrectomy Application in Patients with Laparotomy History

Burhan Mayir ¹, Ayşe Arduçoğlu Merter ^1,^✉, Serkan Ceylan ¹, Osman Zekai Öner ¹, Mehmet Tahir Oruç ¹

Objective

Bariatric surgical interventions are among the most common surgical interventions in recent years.

While there are different types of procedures, sleeve gastrectomy is the most common intervention performed in Turkey and in the world. Although previous abdominal surgery is not a contraindication to laparoscopic sleeve gastrectomy, due to the thickened abdominal wall with obesity and adhesions that may be due to past surgery, these patients may experience difficulties in performing the planned surgery due to the entry of the initial trocar and intraabdominal adhesions. In this report, we present the results of patients with previous laparotomy history in our clinic and who underwent sleeve gastrectomy.

Material and Methods

Patients undergoing sleeve gastrectomy and previously undergoing laparotomy into the supraumbilical region for any reason were included. Patients with a history of laparoscopic surgery and who underwent laparotomy with pfannenstiel or subumbilical midline incision were excluded. Medical histories, operation findings and follow-up data were taken from the patient files and recorded. Firs trocar was applied with open technique as surgical technique.

Results

Twenty-one patients were included in the study. Of these patients who underwent complete sleeve gastrectomy, the rate of these patients was 6%. 19 (90.5%) of the patients were female and 2 (9.5%) were male. The ages of the patients were 2560 (mean47.2) and the duration of the operation was 42–98 (mean: 64.8) minutes. The most common causes of laparotomy were cholecystectomy (right subcostal or supraumbilical midline incision), hysterectomy with supra-and sub-umbilical midline incision and appendectomy. In addition, 4 patients were treated with graft repair due to incisional hernia. There was no pathology developed due to adherence during entry to trocar and surgeries in any patient. When we compare the duration of operation for 100 patients who did not have laparotomy history and for whom we applied sleeve gastrectomy it was determined that the duration of operation was longer than the patients with no laparotomy history.

Conclusion

Laparoscopic sleeve gastrectomy is a common surgical procedure. It was observed in our study that laparotomy was performed mostly due to cholecystectomy. In many patients undergoing bariatric surgery, the vast majority of these patients are female patients. Being female and obesity are risk factors for cholelithiasis. For this reason, the most common cause of laparotomy is cholecystectomy. Previous laparotomy is not an obstacle to laparoscopic sleeve gastrectomy. Open entry of the first trocar and intra-abdominal adhesions can lead to a long operation duration. We believe that laparoscopic sleeve gastrectomy can be performed safely with a careful surgical approach in these patients.

TJS. 2018;34(Suppl-1):S672–S673.

PP-0886 [Obesity]. The Efficacy of Tisseel Application on the Stapler Line in Laparoscopic Sleeve Gastrectomy

Burhan Mayir ¹, Serkan Ceylan ^1,^✉, Ayşe Arduçoğlu Merter ¹, Osman Zekai Öner ¹, Mehmet Tahir Oruç ¹

Objective

Bariatric surgical interventions are among the most common surgical interventions in recent years. While there are different kinds of procedures, the most common intervention performed in Turkey and in the world is sleeve gastrectomy. Sleeve gastrectomy has been performed worldwide for over 15 years, and standards in many issues have not yet been established. One of these is the application of a stapler line reinforcement to the stapler line to reduce the risk of bleeding or leakage. In our clinic, there is no other application besides tisseel on the stapler line. In this study, the results of the patients for whom Tisseel fibrin sealant on the stapler line was applied and not applied were compared and the benefit of tisseel use was questioned.

Material and Methods

The patients who were operated in the department of general surgery in Antalya Training and Research Hospital due to morbid obesity were included. Patient and surgical information, postoperative follow-up and complication information were recorded retrospectively from the patient files. All operations were performed by the same general surgeon. Two groups were treated with sleeve gastrectomy using the same surgical technique. Tisseel application was done to include all stapler lines in patients for whom Tisseel was applied. No application was made to the stapler line in the patients without Tisseel. Patients were divided into two groups: patients who received Tisseel (group 1) and those who did not (group 2).

Results

Forty seven patients for whom tisseel was applied and 47 patients for whom not applied were included in the study.

The age and gender status of the patients were similar. The mean duration of operation was 57.4 (31–95) in group 1 and 53.7 (35–88) min in group 2. No leakage was observed in the two groups after the operation, whereas bleeding necessitating blood transfusion developed in 2 patients in the group not applied tisseel. No additional morbidity and mortality was observed in any patient except bleeding

Conclusion

Many studies on sleeve gastrectomy have reported that a number of treatments have been performed to strengthen the stapler line, but none of them are clearly beneficial. In our study bleeding was observed in 2 patients in whom tisseel was not applied on the stapler line. There was no difference in terms of other complications. We conclude that tisseel application on stapler line can be effective to prevent bleeding but we think that the number of patients included in the study should be increased to observe its effect on leakage.

TJS. 2018;34(Suppl-1):S673–S674.

PP-0887 [Obesity]. Do We Perform Sleeve Gastrectomy Correctly? A Case Presentation With Resleeve Gastrectomy

Burhan Mayir ¹, Onur Özener ^1,^✉, Yaşar Çöpelci ¹, Barış Özkara ¹, Hülya Evrim Özak ¹

Introduction

Sleeve gastrectomy is the most commonly performed bariatric surgical procedure worldwide. It is performed more commonly in our country since it can be performed in a shorter time and with less experience than other bariatric surgical procedures. In this case report, we present surgical findings of a patient who had previously undergone sleeve gastrectomy but was operated by us because of the lack of weight loss.

Case

A 67-year-old female patient admitted us with a complain of not being able to lose weight despite having undergone sleeve gastrectomy 7 years ago. The patient stated that she had lost 13 kg in the first month after the first operation, but did not lose any weight in the following months, and gained the weight she had given. When the patient was questioned, she stated that she could eat the amount starting from the month after the operation. She did not have any comorbid disease but it was learned that she had diffuse knee pain. When the patient admitted, her height was 153, weight was 98 and body mass index was 41.9. It was seen in the endoscopic examination of the upper gastrointestinal system that the stomach was in normal size and there was fundus. The patient was scheduled for laparoscopic surgery. It was observed that the antrum was healthy in the surgery performed with 4 trocars. It was seen in the dissection towards fundus starting from here that resection was started from 10–12 cm proximal of the pylorus with first stapler and the stomach was resected for 10 cm along fundus. Not much adhesion was observed in fundus and antrum. There was adhesions only in corpus. After dissections performed, it was observed that fundus and antrum were never released and no resection was done in these regions. The patient was scheduled for sleeve gastrectomy again. Stomach large curvature was completely released from the fundus to pylorus. Sleeve gastrectomy was performed starting from 2 cm proximal of pylorus through the orogastric tube. The macroscopic view of the removed stomach specimen revealed that only a resection was made from the corpus region, no resection was performed from the fundus, and the first surgical procedure was thought to be performed inadequately. Oral fluid intake was initiated on the first day after the operation and the patient was discharged without any problems on the third postoperative day.

Conclusion

Sleeve gastrectomy is a very popular surgical procedure in our country as well as in the world. Corpus and antrum, and especially the fundus should be included in to the resection in sleeve gastrectomy. This requires complete release of the large curvature of the stomach. Here, dissection and complete release of the fundus are important because of technical difficulties. Insufficient dissection and post-resection may result in the failure of the intervention.

TJS. 2018;34(Suppl-1):S674.

PP-0888 [Obesity]. The Effect of Laparoscopic Sleeve Gasrectomy on the Quality of Life: Before and After

Erdinç Kamer ^1,^✉, Coşkun Onak ¹, Fevzi Cengiz ¹, Mustafa Agah Tekindal ², Mustafa Peşkersoy ¹

Objective

Obesity means that the body mass index is over 30kg/m2. Obesity is increasing in Turkish society, as it is in many countries. Studies have shown that obesity decreases the quality of life of individuals significantly. When decrease in physical capacity, pain, deterioration in interpersonal relations, decrease in self respect, loss of self confidence, depression, social labelling, difficulty of finding job and rejection from the school and work environment are taken into consideration, it is understood that the health-related quality of life of obese individuals is so low. Laparoscopic sleeve gastrectomy (LSG) is a popular, safe, frequently used and effective bariatric surgical method for patients and surgeons. There are few studies in the literature, showing the negative effect of obesity on quality of life and improvement in bariatric surgery. The aim of our study is to assess the effect of LSG on the quality of life of patients.

Material and Methods

50 patients who underwent LSG due to morbid obesity (BMI 40 kg/m 2) in the General Surgery (Group D) of İzmir Katip Çelebi University Ataturk Training and Research Hospital were included in the study. WHOQOL-BRIEF which is short form of World Health Organization life quality scale was applied before and after LSG for the patients included in the study. WHOQOL-BRIEF included a total of 26 questions, including two questions, one of which is the general perceived quality of life and the other perceived health status. LSG was applied to all of the patients by the same surgeons.

Results

Of the 50 patients included, 38 (76%) were female and 12 (24%) were male, and the mean age was 43.67±8.34 years (range: 20–65 years) and mean BMI was 47.4±10.65 kg/m2 (range: 40.0–61.6kg/m2). There was a statistically significant relationship between BMI and physical health status, psychological state and social communication status before LSG with one increasing and the other decreasing at the rates of 72.9%, 49.2% and 29.7%. Thus, as BMI increases health status, psychological status and social communication status decrease. There was a statistically significant relationship between age and pre-LSG physical health status and pre-LSG psychological status at the rates of 30.3% and 28.4%. There was a statistically significant relationship between age of female and only pre-LSG psychological state at the rate of 53.4%. When we look at BMI, there was a statistically significant difference in pre-LSG physical health status and pre-LSG psychological status in women at the rates of 69.6% and 49.7%. While there was no statistical significance between age and groups in males, statistically significant difference was detected between physical health status before and after LSG with BMI at the rates of 82.4% and 68.5%. While there was no relationship between age and any group in single patients, there was statistical significance between physical health status, psychological status and environmental status before LSG with BMI at the rates of 75.4%, 85.2% and 73.3%respectively. While there was no relationship between age and any group in the married patients, there was statistically significance between physical health status, psychological status and general health status before LSG in terms of BMI at the rates of 72.3%, 33.9% and 34.4%, respectively.

Conclusion

As a result, laparoscopic sleeve gastrectomy severely helped them to lose excess weight in morbid obese patients and dramatically improved their post-operative quality of life, and a significant improvement in all post-LSG correlations was achieved.

TJS. 2018;34(Suppl-1):S674–S675.

Laparoscopic sleeve gastrectomy is a bariatric surgical method that can be used in revision surgery if there is not enough weight loss in patients who have previously had gastric band.

TJS. 2018;34(Suppl-1):S676.

PP-0893 [Obesity]. Splenic Vein Thrombosis with Superior Mesenteric Vein after Laparoscopic Sleeve Gastrectomy

Cengiz Eriş ^1,^✉, Yasin Duran ², Nertila Hysenaj Cevheroğlu ³, Nijet Alishev ⁴, Roya Alp ⁵

Introduction

We aimed to emphasize that portal venous system thrombosis, which is a complication of bariatric surgery, is a rare but serious complication.

Case

TJS. 2018;34(Suppl-1):S681.

PP-0901 [Obesity]. Leakage Associated with Post-Sleeve gastrectomy Intraabdominal Hemorrhage

Elşad Rzayev ^1,^✉, Haydar Öcal ¹, Nurhan Haluk Belen ¹, Veysel Karahan ¹, Yüksel Beyaz ¹, Cüneyt Kırkıl ¹, Erhan Aygen ¹

Objective

To investigate hemorrhage complications of laparoscopic sleeve gastrectomy (LSG) patients.

Material and Methods

1892 primary LSG cases were retrospectively evaluated in our department. The data of 27 (1.4%) patients who developed hemorrhage were reviewed.

Results

Patients’ median hospital stay was 7 days (range 4–102 days). Patients were divided into two groups according to the median day of hospitalization (group 1: 7 days or less n=16, group 2: longer than 7 days n=11). The demographic characteristics of the groups, the amount of hemorrhage and hematomas, abscesses or leakage complications were compared using the Mann-Whitney U test and chi-square test at a 95% confidence interval. There was no difference among the groups in terms of age, sex, amount of hemoglobin decrease, amount of drainage, history of anticoagulant usage, hypertension, and OSAS. The mean values of BMI, platelet count and hospital stay in Group 1 and Group 2 were significantly different (respectively 41.8±3.6 vs. 46.7±6.9, p=0.020, 257.1±80.0 vs. 320.9±63.0, p=0.008, 5.3±1.7 vs. 30.1±30.8, p<0.001). While hematoma was developed in only 2 patients (12.5%) in group 1, 7 patients developed hematoma (63.6%) in group 2 (p=0.011). In Group 1, no abscess developed in any of the patients, whereas in Group 2, 6 patients developed abscess (54.5%) (p=0.002). Similarly, group 1 did not develop any leakage, but in group 2, 4 patients developed leakage (36.4%) (p=0.019). Laparoscopic exploration was performed in 3 patients in Group 1 (18.8%). None of the patients in this group required radiological or endoscopic interventional procedures. In Group 2, 6 patients (54.5%) underwent radiological intervention (p=0.002), 3 patients (27.3%) had endoscopic stenting (p=0.056) and one patient (9.1%) underwent surgical treatment (p=0.624). In patients who did not develop hematoma no leakage was observed (0/18) but four (9.4%) out of 9 hematoma patients leakage developed (p=0.007).

Conclusion

Intraabdominal hemorrhage that is observed postoperative LSG usually limits itself and increases the leakage rate in the presence of hematoma, and thus this leads to an increase in the number of additional intervention and duration of hospitalization.

TJS. 2018;34(Suppl-1):S681–S682.

PP-0902 [Obesity]. The Effect of Laparoscopic Sleeve Gastrectomy on Liver Function Tests and Cholestasis Enzymes in Obese Patients

Uğur Doğan ¹, Yaşar Çöpelci ^1,^✉, Osman Zekai Öner ¹, Mehmet Tahir Oruç ¹

Objective

Investigation of the effect of laparoscopic sleeve gastrectomy on liver function tests and cholestasis enzyme levels in morbidly obese patients.

Material and Methods

170 patients who had been diagnosed with morbid obesity and who had undergone laparoscopic sleeve gastrectomy (LSG) were included in the study. 5cc blood samples were taken from the patients before the LSG operation and in the postoperative 3^rd and 6^th months. After resolving the serums AST, ALT, total bilirubin, direct bilirubin, GGT, LDH, ALP, Amylase and Lipase enzyme levels were analyzed. Body mass indexes (BMI) were calculated preoperatively and in the 3^rd and 6^th postoperative months. Statistical analyzes were performed using Friedman Test, Wilcoxon-Signed Rank Test, Paired Samples t Test, and Bonferroni-Dunn Test.

Results

The average age of 170 morbidly obese patients that were included in the study was 37.24±13.39. Their preoperative BMI (kg/m2) was calculated as 44,67±4,28, BMI in the 3^rd postoperative was 35,86±8,38, the 6^th postoperative BMI was calculated as 30,34±6,27 (P<0,001). Their preoperative AST (U/L) level was measured as 33,11±14,73, postoperative 3^rd month level was 30,95±13,41, postoperative 6^th month level was 26,93±14,33 (P<0,001). Preoperative ALT (U/L) level was 34.51±21.42, postoperative 3^rd month level was 33.01±23.59, postoperative 6th month level was 27.79±22.35 (P<0.001). Preoperative direct bilirubin (mg/dL) level was 0,14±0,09, postoperative 3rd month level was 0,14±0,06 and postoperative 6th month level was 0,16±0,08 (P=0,005). Postoperative 6^th month AST and ALT values were significantly lower than preoperative and postoperative 3^rd month values. Direct bilirubin value was found to increase in the postoperative 6^th month according to preoperative values. No significant differences were determined in the preoperative and postoperative total bilirubin, amylase, lipase, GGT, LDH and ALP values

Conclusion

Case

A 28-year-old female patient. In the examination of the patient who had been admitted to the emergency department with acute abdomen symptoms, acute pancreatitis and a cystic mass about 6 cm in diameter were found in the pancreatic body-tip junction. In the patient who had been admitted to the hospital for examination and treatment; in the endoluminal ultrasonography (EUS) elevated amylase and carcinoembryogenic antigen levels were detected in the cyst content. The patient was diagnosed with pancreatic cystic malignant tumor and underwent distal pancreatectomy plus splenectomy. The patient was discharged with recovery after the postoperative period. Histopathological examination of the surgical material was reported as “cystic endometriosis of the pancreas”.

Conclusion

Pancreatic endometriosis is extremely rare and frequently confused with other cystic lesions of the pancreas. Preoperative diagnosis is extremely difficult.

TJS. 2018;34(Suppl-1):S692.

PP-0921 [Pancreas Surgery]. Pancreatic Neuroendocrine Tumors: Analysis of 9 Patients

Metin Yalaza ¹, Sadettin Er ^1,^✉, İbrahim Doğan ¹, Birkan Birben ¹, Özgür Akgül ¹, Betül Keskinkılıç Yağız ¹, Sabri Özden ¹, İsa Sözen ¹, Mehmet Keşkek ¹, Arif Zeki Akat ¹

Objective

Neuroendocrine tumors are a heterogeneous group of neoplasms exhibiting variable clinical and histological features and emerging from neuroendocrine cells that are scattered throughout the body. Pancreatic neuroendocrine tumors (PNET) are rare and they constitute only 12.1% of all gastroenteropancreatic neuroendocrine tumors. In this study, 9 PNET cases operated between June 2015 and April 2017 in Ankara Numune Training and Research Hospital, General Surgery Department are presented.

Material and Methods

Nine patients who had undergone pancreatectomy or enucleation due to PNET for 22 months were included in the study. Neuroendocrine tumors are classified as pathological according to the World Health Organization (WHO) 2010 endocrine tumor classification. Patients were evaluated according to their age, sex, comorbidities, type of surgery, tumor size, duration of operation, length of hospital stay and follow-up. Pancreatectomy or enucleation was performed in 9 patients with PNET at Ankara Numune Training and Research Hospital, Department of General Surgery within the subject duration of time. The diagnosis of PNET was made by histopathological examination and immunohistochemical staining of surgical specimens with chromogranin A and synaptophysin. The tumor was classified as “dysfunctional,” regardless of plasma hormone levels or tissue immunological activity, unless the patient typically had clinical symptoms resulting from the exhibition of functionality according to excessive hormone secretion and preoperative symptoms, clinical signs, and hormone levels. The data were collected retrospectively. Immunohistochemical staining was performed in 8 patients for Ki67. Tumor size was defined by the largest diameter of the tumor.

Results

Of the 9 patients, 5 (55.6%) were male, 4 (44.4%) were female and the average age was 48.4 (18–69) years. Functional tumors were detected in 3 patients and the preoperative diagnosis was confirmed as insulinoma. The average tumor size was 4.1 cm (between 1.2–7.5 cm). The tumor was located in the head of the pancreas in 3 (33.3%) patients, 2 (22.2%) in the body of the pancreas, and 4 (44.5%) in the tail. The surgical margin was positive in one patient. The average duration of surgery was 175.83 (75–300) minutes. Average hospital stay was 10.33 (4–23) days. The average disease-free survival was determined as 19.3 months (0–31 months). Although PNET is a rare and slow growing tumor, it can be malignant and its survival rate might be low. Major studies evaluating the surgical and conservative treatment of PNET are required.

TJS. 2018;34(Suppl-1):S692–S693.

PP-0922 [Pancreas Surgery]. Histopathological Evaluation of Pancreatic Specimens: Analysis of 41 cases

Ceren Canbey Göret ^1,^✉

Objective

Pancreaticoduodenectomy (Whipple) and distal pancreatectomy (DP) operations are the preferred methods for indications ranging from benign inflammatory cases to malignant neoplasia. Pathological examination of both whipple and distal pancreatectomy specimens requires special attention in order to correctly evaluate many prognostically important factors. In this study, we aimed to present the pathological results of a total of 41 whipple and distal pancreatectomy cases that we evaluated retrospectively in a 6 year time period.

Material and Methods

A total of 41 whipple procedures and distal pancreatectomy specimens that were evaluated as benign and malignant in Istanbul Ekin Private Pathology Laboratory between January 2010 and January 2016 were included in the study.

Results

Of 41 cases; 10 (24.4%) were of distal pancreatectomy and 31 (75.6%) were of pancreaticoduodenectomy (Whipple) operations. 22 (53.6%) of the cases were male and 19 (46.4%) were female and the average age was 59.8. Six of the cases (14.6%) were benign and 35 (85.4%) were malignant. Of the 35 malignant cases; 15 were female, 20 were male and the average age was

60.44. In terms of localization, 6 of the tumors (17.1%) were ampulla, 7 (20%) were distal, 2 (5.7%) were duodenum and 20 (57.2%) were head of the pancreas localized.

Conclusion

In both whipple and pancreatic carcinoma cases on whom distal pancreatectomy procedure is applied, comprehensive knowledge of pathologic macroscopy is required, and all the specimens should be carefully sampled. Thus, the parameters that fundamentally affect the survey such as tumor type and lymph node status will be evaluated more accurately. Furthermore, we can reduce the rate of resection in benign lesions to some extent by performing FNAB via ERCP or EUS on the masses detected by preoperative imaging.

TJS. 2018;34(Suppl-1):S693.

PP-0923 [Pancreas Surgery]. The Effect of Log Odds of Positive Lymph Nodes (LODDS) on Prognosis After Curative Resection in Patients with Ampullary Adenocarcinoma

Coşkun Onak ^1,^✉, Tuğba Balkaya ¹, Turan Acar ¹, Emine Özlem Gür ¹, Gülden Ballı ¹, Ahmet Er ¹, Fatma Hüsniye Dilek ², Osman Nuri Dilek ¹

Objective

The prevalence of ampulla vater adenocarcinomas has increased in the last years with the extensive technological developments on diagnosis and treatment. It is known that compared to other periampullary cancers, its 5-year overall survival rate after radical resection is 30–70% with a relatively better prognosis. It has been emphasized that presence of lymph node metastasis is an important factor affecting the prognosis. For this reason, the proportion of metastatic lymph node number and metastatic/total dissected lymph node number has been examined in various studies. In recent years, Log Odds of Positive Lymph Nodes (LODDS) has been used in order to evaluate the prognostic significance of lymph node metastasis, but there are very few studies examining the prognostic significance of LODDS in ampullary adenocarcinomas. Our aim is to investigate the prognostic significance of LODDS in ampullary adenocarcinomas.

Material and Methods

The study was formed by the retrospective examination of hospital database. Patients who were operated in our department between 2010 and 2014 with complete follow-up were included in our study. Patients who had died in the early postoperative period (0–90 days) and with positive surgical margin were not included in the study. The LODDS calculation was performed as log (number of metastatic lymph nodes + 0.5)/(total number of lymph nodes + number of metastatic lymph nodes + 0.5). LODDS was divided into 3 subgroups and these were LODDS1 (LODDS<-1), LODDS2 (-1≤LODDS≤-0.5), and LODDS3 (LODDS>-0.5).

Results

33 male and 14 female patients were included in the study. The average age of the patients was 57.8 (±1.6) and the average survival was 37.8 (±4.3) months. 1, 3 and 5 year survival rates were respectively 73%, 47% and 39%. The average number of extracted lymph nodes was 15.4 (±1.2) and the average tumor size was 2.33 (±0.9) cm. The average LODDS value was calculated as-0,9178 (±0,06). When the patients were divided according to their LODDS values; 22 patients were in the LODDS1 group, 17 patients were in the LODDS2 group, and 7 patients were in the LODDS3 group. Average survival time of LODDS 1, 2 and 3 subgroups were calculated respectively as 52.3, 24 and 25.9 months and it was found that the survival effect of LODDS1 was statistically significant compared to LODDS2 and LODDS3 (p<0,05). It was determined that LODDS values displayed strong correlation with perineural invasion (p<0.05). Microvascular invasion was found to be significantly less in the LODDS1 group (p<0.05), but there was no significant difference between the LODDS2 and LODDS3 groups as in survival time.

Conclusion

We think that LODDS, which is calculated as a result of the detection of metastatic lymph nodes and resected lymph nodes in ampulla tumors, may be an important prognostic factor in predicting survival.

TJS. 2018;34(Suppl-1):S694.

PP-0924 [Pancreas Surgery]. Isolated Pancreatic Transection due to Blunt Trauma; Case Report and Review of Literature

Aybala Koptur ¹, Amil Huseynov ^1,^✉, Demet Sarıdemir ¹, İsmail Demiryılmaz ¹

Introduction

Blunt traumas of the pancreas are serious lesions. An isolated injury to the pancreas is rare. Physical findings and laboratory parameters are often misleading and missing clinical findings may cause serious problems.

Case

A 39-year-old female patient was reported with blunt pancreatic trauma following a kick of a cow and the computerized tomographic scan showed severance along the tail of the pancreas. Favorable results were obtained after the distal pancreatectomy of the patient. Studies have shown that amylase elevation in both serum and peritoneal lavage fluid is neither sensitive nor specific for the diagnosis of pancreatic damage. In a study of blunt pancreatic injury literature, Bradley showed that serum amylase levels were elevated in 82% of more than 400 reported cases with documented pancreatic injury. Since more than 75% of patients with blunt abdominal trauma and proven pancreatic injury have elevated amylase in blood, a sign of possible pancreatic injury should be considered in the case of blunt abdominal trauma and further examination should be performed.

Conclusion

This case reminds that pancreatic injuries should be considered in differential diagnosis of blunt abdominal trauma cases. Contrast-enhanced computerized tomography confirms the diagnosis, but if the diagnosis is still unclear, immediate endoscopic retrograde cholangiopancreatography is recommended. In addition, the clinician should be aware of the fact that when pancreatic injuries are managed conservatively, clinical, radiological, and laboratory parameters must be monitored until they are resolved.

TJS. 2018;34(Suppl-1):S694–S695.

PP-0925 [Pancreas Surgery]. Pancreatic Tuberculosis Patient Surgically Treated with Pancreatic Serous Cystic Mass Presence

Veysel Karahan ¹, Nurhan Haluk Belen ^1,^✉

Introduction

Tuberculosis is still a common disease in the world and one of the extrapulmonary spreading areas in the gastrointestinal system. Isolated pancreatic tuberculosis is rare. Solitary mass due to pancreatic tuberculosis may be diagnosed as pancreatic cystic neoplasm. With imaging techniques, we presented a pancreatic tuberculosis case that might be defined as pancreatic serous cystadenoma or serous cystadenocarcinoma.

Case

A 37-year-old female patient was admitted to the epicenter with the complaint of pain in the epigastric region that had been lasting for 2 weeks. Due to the mass detected via abdominal ultrasonography at the head of the pancreas, the patient was referred to us. Physical examination revealed no signs other than tenderness in the epigastric region. There was no hepatitis, jaundice, tuberculosis, malignancy in her history. The patient did not have any complaints of fever, jaundice, and coughing. In the laboratory evaluation of the patient, the results were as wbc: 5.4 (3.8–8.6), hgb 11.2 (11.1–17.1), plt: 122 (140–360), ast: 71 (540) (0–1.5), alt:68 (5–40), alp:1466 (30–120), ggt:689 (0–55), amylase: 78 (28–100), d.bil: 0.5 (0–0.35), total bil: 0.8 (0–1.1), cea: 0.01 (1–5), ca 19–9: 13.01 (0–33). Serological tests performed for Hiv, hepatitis B, and hepatitis C were negative.

The abdominal ultrasonography showed 37x31x55 mm in size millimetric cysts showing no doppler flow in the uncinate process of the pancreatic head and hypoechoic mass lesion with a soft tissue component (Serous cystadenoma-cystadenocarcinoma?). Hepatic artery and portal vein were reported to be present in the mass lesion with no significant stenosis or invasion. In the Triphasic abdominal CT, A hypodense lesion with a macrocystic component of 44x50 mm in size was seen in the axial that displaced portal vein to the arterior with the pancreatic head extending to the portal hilum in the superior section (Serous cyst adenoma-Cystadenocarcinoma?). Thorax CT was evaluated as normal. The endoscopic ultrasound showed an approximately 4 cm sized lobule multicystic lesion. The classic whipple surgery was performed with prediagnosis of serous cystadenoma and cystadenocarcinoma. In the pathologic evaluation of the specimen, chronic granulomatous inflammation was widely observed. There was no evidence of malignancy and the patient was diagnosed with pancreatic tuberculosis. The patient received antituberculosis treatment in the postoperative period and no pathology was detected in the follow-up period.

Conclusion

In tuberculosis disease, extrapulmonary spread is the most common abdominal tuberculosis. Pancreatic tuberculosis is very rare and most common involvement is seen in the pancreatic head and the uncinate process of pancreas. The most common symptoms are abdominal pain, nausea, vomiting and weight loss. They may display a wide variety of images radiologically and may mimic pancreatic cystic neoplasms. They are microcystic, usually smaller than 2 cm but may reach larger sizes. In CT, cystic lesions form multilocular, thin septa, central scar and star-shaped calcification. In our patient, the whipple procedure was performed because of the radiologic diagnosis of serous cystadenomas or serous cystadenocarcinomas. After the evaluation of the tissue, anti-tuberculosis treatment was applied to the patient who was diagnosed with pancreatic tuberculosis and the patient’s complaints were found to be regressed. Pancreatic tuberculosis may be confused with pancreatic cystic masses and should be kept in mind when there is a pancreatic serous cystic mass since it can not be diagnosed without laparotomy.

TJS. 2018;34(Suppl-1):S695.

PP-0927 [Pancreas Surgery]. Clinicopathological Approach in Pancreatic Neuroendocrine Neoplasms: A Single Center Experience

Hızır Taner Coşkun ^1,^✉, Coşkun Onak ¹, Umur Özkerim ², Şebnem Karasu ³, Turan Acar ¹, Fatma Hüsniye Dilek ⁴, Mehmet Hacıyanlı ¹, Osman Nuri Dilek ¹

Pancreatic neuroendocrine neoplasms (NEN) have begun to be detected in clinics increasingly. Despite the fact that the majority of NENs are non-functional, resection is still the most important approach in their treatment. Here, we aimed to address our patients diagnosed with NEN between 2013–2017 and our clinicopathological approaches performed in our department. In our hospital, 58 patients were diagnosed with NEN between the years of 2013–2017. 35 of the patients are male and 23 are females. The average age was determined as 59 years. 1 patient was incidentally diagnosed with abdominal ultrasonography, 27 patients with (EUS + Bx), 16 patients with CT, 8 patients with MRI and 6 patients with PET CT. 54 patients were evaluated as non-functional and 4 were functional NEN. The most common functional NENs are insulinoma and gastrinomas. Of the functional NENs in our series, 3 were assessed as insulinoma and 1 as somatocytatinoma. 23 patients underwent follow-up and 34 had surgery. One patient did not agree with the operation and quit the follow up procedure. 2 cases had enucleation, 1 case had local resection, 5 cases had distal pancreatectomy, and 26 cases had pancreaticoduodenectomy (Whipple procedure). As a result, we have begun to encounter an increasing number of NEN cases today with the contribution of new diagnostic methods. Although surgical methods are often preferred in treatment, alternative methods such as ethanol injection etc. have recently been reported to be used.

TJS. 2018;34(Suppl-1):S695.

PP-0928 [Pancreas Surgery]. Progrostic Factors of Our Patients Who Underwent Whipple Procedure due to Pancreatic Tumor?

Yusuf Emre Altundal ^1,^✉, Ekrem Ferlengez ¹, Fazilet Erözgen ¹, Gamze Çıtlak ¹, Muzaffer Akıncı ¹

Objective

Pancreatic Cancer is a cancer type with still a very high mortality in the whole World. Many patients are still not suitable for surgery today. Factors affecting the survival of patients who underwent whipple procedure due to pancreatic tumors in our hospital.

Material and Methods

40 patients were included in our study who underwent Whipple procedure between January 2013 and January 2013 in our hospital. The demographic data of the patients was evaluated and also tumor localizations, tumor markers, hematocrit, albumin values were examined. Postoperatively, the patients’ length of hospital stay, survival time, and pathology results were examined.

Results

Age, albumin levels, tumor markers, lymph node positivity and TNM stage of the patients who underwent operation were significantly effective on survival. Bilirubin level and gender were unable to be found effective on survival.

Discussion

Today, the whipple procedure performed due to pancreatic tumor is considered as the gold standard for treatment, but its effect on survival has not still reached satisfying levels.

TJS. 2018;34(Suppl-1):S696.

PP-0929 [Pancreas Surgery]. A Rare Pancreatic Tumor: Anaplastic Carcinoma

Orhan Üreyen ^1,^✉, Olçun Ümit Ünal ², Demet Alay ¹, Ayşe Yağcı ³, Enver İlhan ¹

Introduction

Anaplastic carcinoma of the pancreas is rarely encountered and is usually a case report in the literature. Anaplastic carcinoma has poorer progronosis than ductal adenocarcinomas of the pancreas. This tumor is usually cystic, closely related to the surrounding tissues and diagnosed at an advanced stage. The efficacy of chemotherapy and radiotherapy in treatment is controversial. We aimed to present the management of a pancreatic anaplastic carcinoma case on whom we had performed “Whipple” procedure due to a mass in the pancreatic head.

Case

In the examination of a 78-year-old case with complaints of jaundice, icterus was detected on his whole body. The examination of his abdomen showed that his gall bladder was palpable. According to his laboratory tests, total bilirubin: 22.11mg/dl, direct bilirubin: 11mg/dl, Gamma Glutamyl Transferase 458 U/L, Alkaline Phosphatase: 582 U/L, CA 19.9:433 U/mL, carcinoembryonic antigen: 2.7 ng/mL, Aspartate Transaminase: 180 U/L, Alanin Aminotransferase: 152 U/L. Other laboratory findings were normal. In radiological imaging; the choledoch was approximately 2 cm wide and all intrahepatic and extrahepatic bile ducts were larger than normal. It was also narrowed in the shape of a penpoint in the distal section. There was also a mass of approximately 15 mm in the pancreatic head. Metastasis was not detected in the distant organ scan. With these results, the case was planned for ERCP. However, in both ERCP attempts, choledoch could not be cannulated. Since the patient also could not be performed percutaneous transhepatic cholangiography and due to his excessive bilirubin elevation and his deteriorating general condition, “Whipple” procedure was performed. In the patient’s histopathology, anaplastic carcinoma of the pancreas (undifferentiated) was detected and carcinoma metastasis was detected in two of the 8 dissected lymph nodes. Tumor size was 2.4x2, 1x1.5 cm. While lymphovascular invasion was not detected, perineural and neural invasion was observed. It was detected that CK (+), CK19 (+), CK20 (-), e-cadherin (-), sinoptinin (-), chromagranin (-), p53% 90 (+), and Ki 67% 20 (+). The case was started oral treatment on the 3rd postoperative day. On the postoperative 12th day, nausea and vomitting started. The gas gaita discharge decreased. Abdominal distension developed. The case was began to be followed via nasogastric probe. On the postoperative 22nd day, relaparatomy was performed on the patient who had been followed for about 10 days and whose ileus condition had not shown any improvement. The follow-up did not reveal any pathology in the previous surgical site and anastomoses. A small intestine segment was obstructed at approximately 7–8 cm proximal of the ileocecal valve, it was severely narrowed, and adhered to retroperitoneum. Bowel loops were deteriorated in some places but necrosis was not observed. In all the proximal region of this site, small intestines were severely dilated. ‘’ Loop ileostomy ‘’ was administered. After the second surgical procedure, the patient was discharged on the 11th day without any problems.

The patient was in stage IIB (T3N1M0). Chemotherapy was planned by the oncology council for the patient. During his 6th month controls, two metastatic lesions were detected in the liver. All his postoperative laboratory values are normal and the patient is still having an ongoing chemotherapy.

Conclusion

Radical surgical resection with safe surgical margin is the most effective treatment for pancreatic anastomotic carcinoma. It should be kept in mind that unexpected problems may occur in the postoperative period of pancreatic surgery.

TJS. 2018;34(Suppl-1):S696–S697.

PP-0930 [Pancreas Surgery]. Detection of Primer Localization in Periampullary Regional Tumors by KRAS Mutations

Seçil Ak Aksoy ^1,^✉, Fuat Aksoy ², Berrin Tunca ¹, Halit Ziya Dündar ², Pınar Taşar ², Ömer Yerci ³, Nesrin Uğraş ³, Yılmaz Özen ², Ünal Egeli ¹, Gülşah Çeçener ¹, Ekrem Kaya ²

Objective

The clinopathologic parameters that can be used to determine the behavior of the tumor and the primary localization in the periampullary region tumors (PRT) are limited. In this study, it was aimed to investigate the genetic and epigenetic changes that might clarify the molecular characteristics of PRT and the localization of the primary tumor.

Material and Methods

In this study, genes and miRNAs targeting RAS and EGFR signaling pathways were analyzed in a total of 126 patients, including 48 pancreatic heads, 41 ampulla of vater, 25 distal choledoch, 12 duodenum.

Results

Of the patients evaluated in the study, 54 were male and 72 were female. The average age was determined as 63.34 years. It was also determined that the KRAS codon 13 mutation was effective in the formation of pancreatic head tumors (82%; p<0.001). The low expression of miR-143 was statistically significant in ampulla of vater tumors.

Conclusion

In the case of PRT carrying the KRAS codon 13 mutation in consideration of the present results, the primary tumor localization is determined as the pancreatic head and treatment options can be formed in this direction.

TJS. 2018;34(Suppl-1):S697.

Before donor liver transplantation, the models obtained from 3D printers can be used to evaluate the anatomic structure of the donor liver candidate. Similarly, prior to complicated liver resections, this model may provide a different perspective to surgeons for safer surgeries in terms of more effective preoperative planning and evaluation.

TJS. 2018;34(Suppl-1):S699.

PP-0934 [Transplantation]. A Rare Complication in a Liver Transplant Patient: Biliary Stenting Related Perfusion of Meckel’s Diverticulum

Uğur Topal ^1,^✉, Abdulalh Ülkü ¹, Ahmet Gökhan Sarıtaş ¹, Cihan Atar ¹, Atılgan Tolga Akçam ¹

Introduction

Liver transplantation is the only definitive treatment option for end-stage liver disease that develops due to infectious, toxic, metabolic, biliary and vascular reasons as well as acute liver failure and some liver neoplasms. Meckel’s diverticulum is the most common congenital anomaly of the small intestine. It originates from the failure of the omphalomesenteric duct to obliterate completely. The incidence is between 0.5% and 2% and it is usually asymptomatic. It becomes symptomatic when the complications such as obstruction, hemorrhage, diverticulitis, perforation, umbilical fistula are seen. The most common complications after liver transplantations are biliary complications. Balloon dilation and stent placement that are performed via percutaneous and endoscopic methods may resolve the problem by 60–70% in the cases of biliary obstruction. Gastrointestinal problems in transplant patients may be fatal. Previous abdominal surgery, long length of surgical time, relaparotomy, portal vein thrombosis, high-dose steroids use and the presence of CMV infection increases the risk. Perforation due to biliary stenting after liver transplantation is much less common.

Case

3 years ago, a 20 years old male patient was performed right lobe liver transplantation from a live donor on the development of acute hepatic failure during Acute Lymphoblastic Leukemia (ALL) continuation treatment. He was admitted to our department with abdominal pain, nausea and vomiting. In his physical examination, there was sensitivity in the lower and upper right quadrant of the abdomen and his rebound present fever was 38. The patient’s other system examinations were normal. Lab results were as follows: Wbc 10.210, Hgb/Htc 12.8/39, Plt 144.000, Alt/Ast 71/76, Alp/Ggt 108/228, Tbil/Dbil 2,9/0,9, Bun/Cr 10/0,53, and Albumin was 3.1. In the patient’s abdominal CT, tx secondary changes in the liver, revealed intrahepatic bile ducts and air densities, suspected thickening on the wall of the cecum and smear-like fluid in the vicinity of cecum, and a foreign body? in the small intestines were observed. Upon these findings, the patient was operated on emergency conditions. The exploration revealed purulent fluid in the pericecal region, meckel diverticulum in the 40 cm proximal of the ileocaecal valve and biliary drainage catheter perforating the diverticulum. The abdomen was bathed and the Meckel diverticulum was excised. Appropriate antibiotherapy was given during his postoperative follow-ups. Medical regimen was initiated and since he had had no additional problems in his follow-ups and he was discharged with an adjusted medical therapy plan.

Discussion

In adults, the most common complication in Meckel’s diverticulum is obstruction. Its incidence is between 26.2% and 53.4%. The most common complication after liver transplantation is biliary occlusion, usually occurring 9–11 months after the transplant. In patients with biliary occlusion, diagnosis is made by cholestasis tests, CTMRCP and cholangiography. Balloon dilation and stenting with PTK or ERCP are often successful in these patients. The most feared biliary stent related complication is stent migration. When we look at the literature, we see migrations and perforations due to biliary stents. Gastrointestinal perforation after liver transplantation among children is 2.7%. In recent studies, the incidence of bowel perforations among adults is between 1% and 5.3%. In the literature, there is no perforation of the meckel diverticulum case although there are cases with small intestinal perforation and rectum perforation due to biliary stenting. For this reason, our case is the first in this regard.

TJS. 2018;34(Suppl-1):S699–S700.

PP-0935 [Transplantation]. Cases with Double Ureters in Kidney Transplantation

Yücel Yüksel ^1,^✉, Deniz Yüksel ², İbrahim Duman ⁴, Mehmet Sarıer ⁴, Levent Yücetin ³, Sabri Tekin ¹, Asuman Yavuz ⁵, Alper Demirbaş ¹

Objective

Ureter duplication (UD) is a rare anomaly. As it may be asymptomatic throughout life, recurrent urinary tract infections may cause urinary tract stones. There is no consensus on ureteroneocystosomy (UNS) to be performed in patients with UD when transplanting kidneys. In this study, we aimed to share our experiences about the UNSs performed on patients with UD in our department.

Material and Methods

Between January 2014 and December 2017, 2309 kidney transplants (KT) were performed in Antalya Medicalpark Organ Transplantation Department. Patient records were reviewed retrospectively. Age, sex, duration of dialysis, duration of follow-up after KT, renal donor type (live-cadaver), demographic characteristics, chronic renal failure (CRF) etiology, donor gender and donor age were examined. Urinary complications after KT, creatinine levels in follow-up, graft survival and patient survival were evaluated.

Results

A total of 28 cases with UD were detected in our center, 22 were live and 6 were cadaver donors. Four of the live donors received open donor nephrectomy and 18 received laparoscopic donor nephrectomy. 15 of the kidney recipients were male and 13 were female, their average age was 38.07±14.7 (8–60), tissue compatibility was 2.6±1.2 (0–4), the average follow-up duration was 37.1±15.4 months (9–59) months (the first case was in January 2013, the last case was in April2014), average duration of surgery was 80.6±13.4 minutes (65–109), 13 patients were having preemptive, 14 patients were having hemodialysis and 1 patient was having peritoneal dialysis. Four patients had KT for the second time. Seven of the donors were male 21 were female. Average donor age was 48.6±15.5 (14–81) (14 year old donor was a cadaver donor). Graft loss occurred in 2 patients 3 weeks after KT (BN due to Focal segmental glomerulosclerosis-FSGS) and 2 months after KT (renal tx from cadaver donor). Four patients died of opportunistic infections and cardiac causes in the KT postoperative 3rd, 7th, 12th, and 14th months. The final creatinine control values of the 22 follow-up patients were 1.4±0.8 mg/dL (0.5–4.2). In one patient, urinary incontinence was seen in the second month, the patient was operated, no urinary incontinence was observed during follow-ups. Furthermore, presence of anastomotic stricture or vesicoureteral reflux were not observed among in follow-up patients. Demographic characteristics of renal transplant recipients and donors are shown in Table 1.

Conclusion

The best treatment for chronic renal failure is KT, but patients’ cadaver waiting list is long [11]. As a result, in cadaver or live kidneys that are extremely important for patients with CRF, UD for KT should not be considered as an obstacle. However, our experiences and the experiences of other authorities suggest that in single ostium LG UNS method in graft kidneys with UD, use of 2 DJS are more secure compared to other methods. Studies should continue although there are sufficient studies in this regard.

TJS. 2018;34(Suppl-1):S700–S701.

PP-0936 [Transplantation]. Kidney Transplantation Experiences in Patients with Vascular Problems

Yücel Yüksel ^1,^✉, Deniz Yüksel ², Levent Yücetin ³, Mehmet Sarıer ⁴, İbrahim Duman ⁴, Meltem Demir ⁵, İlker Tekin ⁶, Sabri Tekin ¹, Asuman Yavuz ⁷, Alper Demirbaş ¹

Objective

Chronic renal failure (CRF) is a systemic disease that affects the vascular system negatively. Diabetes mellitus (DM) patients constitute 40% of CRF patients. Hypertension (HT) and smoking increase atherosclerosis in DM.

Material and Methods

Between January 1, 2014 and January 31, 2018, 1782 kidney transplants were performed in the Antalya Medicalpark Organ Transplantation Department. Of these cases, 193 were DM, 232 were HT and 110 were DM + HT. We retrospectively evaluated patients’ average age, duration of hemodialysis, concomitant disease, smoking habits, duration of operation, donor type, follow-up period, operation time, discharge and postoperative KT average creatinine levels, grafts and patient survivals. In 3 patients, aortobifemoral bypass (ABB) was performed prior to KT by cardiovascular surgery (CVS) department (1 of these cases had coronary bypass followed by ABB in the same session). Renal artery anastomosis was then performed on the vascular graft by the organ transplantation surgery (OTS) team. Of the patients, 9 were heparinized after the renal perfusion due to the absence of flow in the distal anastomosis, their renal anastomoses were disrupted, the graft kidney was removed and reperfused again on the back table. An iliaco-iliac vascular graft was anastomosed by OTS. Renal artery anastomosis was performed on the graft artery again. In 5 of the cases, vascular grafts were placed on the iliac arteries by OTS before the kidney anastomoses, and the lower extremity circulation was provided, then live donor was operated and transplantation was performed. Four patients were reoperated on the basis of the presence of circulation problems while standing (postop 120th, 150th, 150th, 180th minutes) determined during their service follow-ups after KT. A dissection was detected in the distal anastomosis of the renal artery. The vascular graft repair in the dissected segment was performed by the OTS team. The transplanted kidney was evaluated as macroscopically normal. One patient who underwent radiotherapy for seminoma treatment before KT and had fibrosis in the vena cava, in both iliac veins, aortic and iliac arteries was performed KT by OTS team after additional bilateral ileocaval and ABB vascular graft repair.

Results

19 of the patients were male, 3 were female. 19 were live donors and 3 were cadaver donors. Average age was 51.9 years, average follow-up period was 33.7 months, average duration of dialysis was 37.7 months. 9 patients had hypertension (HT), 6 patients had DM + HT, 3 patients had HT, 18 patients were consuming 18.7 packets of cigarette/year, Average duration of operation was 237 minutes, average discharge time was 9.1 days, average creatine levels for the 1st, 2nd, 3rd, 4th years were 1.9-1.32.1-1.7-1.5 mg/dL. 4 cases died on the 3rd, 10th, 21st and 31st months due to myocard infections and opportunistic infections. One of cases from cadaver donor had graft loss.17 patients’ kidney functions are normally followed. The cases were discharged with antiagregin aspirin and clopidogrel (plavix).

TJS. 2018;34(Suppl-1):S701.

PP-0937 [Transplantation]. Variations of Liver Vascular Structures and Biliary Tracts

Conclusion

PH-1, which accounts for approximately 1% of pediatric end-stage renal failure, is a genetic disorder with high morbidity and mortality due to oxalosis and its final treatment is liver/kidney transplantation. Although early diagnosis and short duration of dialysis of the patient increase the chance of combined transplantation, a strategy to be followed with a multidisciplinary approach keeps the success rate of SLKT high.

TJS. 2018;34(Suppl-1):S704.

PP-0942 [Transplantation]. Kidney Transplantation Experience of Medicana International Hospital, Ankara

Ulaş Sözener ^1,^✉, Tevfik Eker ², Sadık Ersöz ³

In this study, the demographic data (age, sex, transplant donor-recipient degree), postoperative complications, graft and patient survival of 417 renal transplantation cases performed between September 2009 and February 2015 at Ankara Medicana International Hospital Organ Transplantation Center are retrospectively evaluated and we aim to present our five year cadaveric and living donor renal transplantation experience.

TJS. 2018;34(Suppl-1):S704–S705.

PP-0943 [Transplantation]. Determination of Posttransplant Recurrence Mechanisms in HCC by Gene Expression Profiles

Halit Ziya Dündar ^1,^✉, Fuat Aksoy ¹, Seçil Ak Aksoy ², Berrin Tunca ², Nesrin Uğraş ³, Ömer Yerci ³, Ekrem Kaya ¹, Ünal Egeli ², Gülşah Çeçener ²

Objective

Hepatocellular carcinoma (HCC) is an important health problem as it is one of the most frequently observed neoplasms in the world. Nowadays, liver transplantation is performed especially in the treatment of cirrhotic HCC patients with local or distant metastases. However, recurrence after transplantation is an important risk factor in the treatment of these patients and it reduces the success in treatment. In this study, it is aimed to explain the differences between the primary tumors of HCC patients with recurrence and the primary tumors of HCC patients without recurrence after liver transplantation. We would like to identify the mechanisms that are effective in recurrence and to determine the markers that can be used in routine practice.

Material and Methods

Thirty-four patients with HBV-associated HCC who were treated at our department and who had at least one year of follow-up were evaluated. Eighteen different genes were analyzed by PCR Array method in 4 patients with recurrence and in 30 other patients.

Results

In our study, 16 normal liver tissues were evaluated as control group. Among the 18 genes, p53, MET, TNFbeta, MAPK and SMAD4 genes were statistically significant when compared to 34 tumor control tissues. High E2F and AKT gene expressions were determined in 4 recurrent cases (p<0.005).

Conclusion

In the literature, pre-transplantation clinical data such as tumor diameter, number of nodules, vascular invasion and pre-transplant serum alpha-fetoprotein levels are associated with tumor recurrence. However, when these parameters are observed in normal values, markers in order for the prediction of recurrence are needed. Our work will be expanded by increasing the number of cases and including their clinical data. However, our findings suggest that E2F and AKT gene regulations can be used as predictive markers in predicting recurrence after transplantation.

TJS. 2018;34(Suppl-1):S705.

PP-0944 [Transplantation]. Liver Transplantation After Downstaging with TARE in Patients with Beyond-Milan Hepatocellular Carcinoma

Ömer Cennet ^1,^✉, Ahmet Bülent Doğrul ¹, Gonca Eldem ², Bora Peynircioğlu ², Osman Abbasoğlu ¹

Liver transplant is one of the curative treatment options in Hepatocellular carcinoma (HCC). Liver transplantation provides significant long-term survival advantage in these patients because it treats both HCC and underlying liver disease. Only a small percentage of HCC patients meet the criteria for Milan. For this reason, for selected patients, in order for the tumor to meet the criteria of Milan downstaging might be a solution. Options include transarterial chemoembolization (TACE) and transarterial radioembolization (TARE). In this case, TARE was applied to the patient who had HCC with chronic liver disease background due to Hepatitis B and did not meet the criteria of Milan. We aimed to present the analysis of the patient who had cadaveric liver transplantation upon meeting the criteria of Milan after TARE. Downstaging in Beyond-Milan patients provides success in about half of the patients. However, extensive studies are needed to optimize success by setting appropriate standard protocols for this topic.

TJS. 2018;34(Suppl-1):S705–S706.

PP-0945 [Transplantation]. Liver Transplantation in the Treatment of Crigler-Najjar Syndrome

Adil Başkıran ^1,^✉, Sezai Yılmaz ¹

Objective

Crigler-Najjar Syndrome (CNS) is a rare disorder of bilirubin metabolism caused by the absence or scarcity of uridine diphosphoglucronosyl transferase (UGT) enzyme. This hereditary disease shows a high serum concentration of unconjugated bilirubin. In Crigler-Najjar syndrome, bilirubin’s conjugation does not have a function in the liver despite normal parenchyma. The accumulation of unconjugated bilirubin in the basal ganglia and cerebellum leads to neuronal cell death. CNS patients are at risk of irreversible brain damage. Hyperbilirubinemia is reduced by phototherapy, but this treatment is less effective as the patient grows. Children usually do not show compliance to treatment. The purpose of orthotopic liver transplantation (OLT) is to reduce serum bilirubin concentration to safe limits.

Material and Methods

2130 patients were examined retrospectively at İnönü University liver transplantation institute between the years of 2002 and 2018 and 4 patients were seen to have liver transplantation with living donor with crigler najjar diagnosis. These patients were evaluated in terms of height, weight, sex and duration of follow-up period.

Conclusion

Four patients underwent live-donor liver transplantation due to Crigler-Najjar syndrome type 1. Three pediatric patients were male, aged 24, 23 and 15 months, with weight and height measurements 85 cm/13 kg, 85 cm/10 kg and 61 cm/5 kg respectively. The pretransplantation non-conjugated bilirubin concentration was 22 to 30 mg/dL despite 12 to 14 hours of phototherapy per day. Neurological examination results were normal. After the plasmapheresis, the liver transplantation with live donors were performed. The patients were had liver transplantations respectively in 2015, 2016 and 2017 with live donors. Our 4th patient, a 20-year-old female, had been followed for years with a high unconjugated bilirubin level and referred to our department for liver transplantation. The female patient with height and weight measurements of 160cm/60 kilograms was performed liver transplantation with living donor in 2013. Three patients had left lateral liver segment transplantation and one patient had right lobe living-donor liver transplantation. In all patients, the nonconjugated bilirubin concentration was normal on day 1 after transplantation and no phototherapy was needed. 1 month after the transplantation, the 23-month-old infant died due to bacterial growth in blood culture and sepsis despite the antibiotherapy. Other 3 patients are living with normal neurological findings. In Type 1 Crigler-Najjar syndrome, irreversible brain damage may occur. Urgent treatment methods such as plasmapheresis, blood transfusion, phototherapy and liver transplantation may not be able to reverse brain damage. CNS-diagnosed infants should be carefully assessed for signs and symptoms of bilirubin encephalopathy. Liver transplantation heals if it is applied before the development of neurological dysfunction.

TJS. 2018;34(Suppl-1):S706.

PP-0946 [Thromboembolism, Anticoagulants]. Acute Arterial Occlusion due to Vascular Closure Device: A Report of Two Cases

Süleyman Utku Çelik ^1,^✉, Ömer Arda Çetinkaya ¹, Can Konca ¹, Mehmet Ali Koç ¹, Akın Fırat Kocaay ¹, İskender Alaçayır ¹

Introduction

Vascular closure devices (VCD) are frequently used after endovascular procedures and have emerged as an alternative to manual compression. In addition to providing rapid hemostasis at the puncture site, VCD allows early mobilization of the patient and reduces workload in the department. However, although rarely, complications related to the procedure have been reported. In this study, two acute arterial occlusion cases that occurred right after VCD use and required surgical intervention are reported.

Case

A fifty-five-year-old female patient underwent a selective vertebral angiography of the right femoral artery and was admitted to our department with severe pain, paleness and coldness. In detailed evaluation, it was learned that arterial puncture was closed with VCD due to antiplatelet therapy. The right leg was colder and paler compared to the left leg. Distal pulses could not be palpated. Doppler ultrasound showed monophasic flow in the popliteal artery and its distal portion. Aorto-ilio-femoral angiography revealed a filling defect in the right main femoral artery. Then the patient underwent thrombectomy and the vascular closure device seen in the femoral artery puncture site, the collagen plug, an anchor (out of absorbable material) and the suture were removed together. A 60-year-old male patient underwent angiography to evaluate the superior mesenteric artery occlusion following aorto-bifemoral bypass grafting and was admitted to our department with complaints of severe pain, pulseness and coldness on his left arm. Because of the anticoagulant treatment and bypass history, it was learned that the patient had been performed arterial puncture from the left axillary artery and hemostasis was achieved with VCD. On his physical examination the left arm was cold and pale. Radial and ulnar pulses were not palpable. Doppler ultrasonography showed that the left axillary artery was occluded and thrombectomy was performed urgently. During the procedure, VCD was removed with the thrombus material. Both patients were discharged without complication after 2 days of follow-up after the procedure.

Conclusion

VCD is designed to provide rapid hemostasis after arteriotomy. The device, which consists of an absorbable polymer anchor, a small collagen sponge and suture holding them, is absorbed within 60–90 days. Despite several advantages, due to possible complications, VCD use is not recommended in every patient: Especially patients with collagen allergies, pediatric patients or patients with a femoral diameter less than 4 mm, patients with previous history of autoimmune diseases, patients who were performed arterial access through the arterial graft, with bleeding disorders and with number of platelets<100,000. In the studies performed, symptomatic lower extremity ischemia associated with the device was reported in 0.2% of the patients. The causes of this condition include malformation of the device, intimal dissection and significant atherosclerosis at the puncture site. In addition, diabetes, obesity, peripheral vascular disease and ischemic heart disease may also contribute this situation. Acute arterial ischemia due to VCD is an uncommon complication and immediate surgical treatment is unavoidable in this case. Therefore, VCD should be used in appropriate patients and with caution.

TJS. 2018;34(Suppl-1):S707.

PP-0947 [Thromboembolism, Anticoagulants]. Surgical Complications and Clinical Course in Patients Using Oral Anticoagulant and Antithrombotic Drugs

Mustafa Buğra Kardaşlar ^1,^✉, Hasan Kaplan ²

Objective

The aim of this study is to evaluate the complications arising from the widespread use of oral anticoagulant and anti-thrombotic drugs and to clarify the factors that may cause these complications.

Material and Methods

Forty-seven patients who had been hospitalized in our department due to complications arising from oral anticoagulation and antithrombotic drugs were included in this retrospective clinical trial. These complications and the factors that might be affecting these complications were investigated.

PP-0951 [Thromboembolism, Anticoagulants]. Acute Mesenteric Ischemia with Superior Mesenteric Artery and Thrombosis in Superior Mesenteric Vein: A Rare Case Report

Çağrı Akalın ^1,^✉

Introduction

Acute mesenteric ischemia (AMI) whose prognosis is quite a bad pathology leads to acute abdomen. AMI may occur due to arterial or venous blood flow occlusion, or non-occlusive obstruction and it indicates that intestinal hypoperfusion has a sudden onset. While occlusive arterial occlusion is usually caused by embolism and thrombus in the mesenteric arteries, venous occlusive obstruction is commonly caused by thrombosis or segmental strangulation. We aimed to present acute mesenteric ischemia due to both superior mesenteric artery (SMA) and superior mesenteric venous (SMV) thrombosis in our case.

Case

An 87-year-old female patient was admitted to the emergency department with a 1-day of ongoing abdominal pain complaint. Abdominal pain was persistent and in the periumbilical region. She had chronic hypertension. Physical examination revealed tenderness in the periumbilical region. Laboratory findings showed that the white blood cell count was 7.4 10³ U/L, C-reactive protein was 2.54 mg/dl. Complete abdomen computed tomography (CT) revealed an increase in nonspecific density of the mesentery. The patient was hospitalized since her symptoms did not regress during her follow-ups despite medical treatment. On the second day of hospitalization, on the physical examination of the patient, the complete abdominal CT was reperformed at the level of angiography upon having a defensive development in abdominal periumbilical, right middle quadrant, and in the left middle quadrant with 17.8 10 3 U/L of white blood cell count. According to the CT, there was thrombus in the superior mesenteric artery and the superior mesenteric venous distal and it was interpreted as there was an increase in contrast in the walls of the small intestinal loops in the lower left quadrant. Due to the patient’s acute abdomen and acute mesenteric ischemia revealed in the CT, the patient underwent laparotomy. In laparotomy, there was minimal purplish color change in the wall of all small intestinal segments from treitz to terminal ileum, and bowel mobility was also present. Superior mesenteric artery and superior mesenteric vein were canalized selectively. With transverse incisions, embolectomy was performed with the help of 3F and 4F Fogarty catheters and the operation was terminated to allow for second look operation. Patient was hospitalized in the intensive care unit and was initiated on wide spectrum antibiotic, nasogastric decompression, and intravenous heparin treatment. At the second look operation performed on the postoperative 48th hour, transmural ischemic and occasional gangrenous intestinal segments were present in all segments from the treitz ligament to the terminal ileum. These segments were resected and gastroileostomy was performed. The patient was announced exitus on the first day of the second operation.

Conclusion

Acute mesenteric ischemia (AMI) is a life-threatening vascular urgency that requires early diagnosis and treatment. The four main reasons of acute mesenteric ischemia are; superior mesenteric artery embolism (50%), superior mesenteric artery thrombosis (15–25%), mesenteric vein thrombosis (5%), non-occlusive ischemia (20–30%) and the likelihood of thrombosis in both SMA and SMV is very rare. We believe that, in spite of early diagnosis of AMI and early medical and surgical treatment, thrombosis in both SMA and SMV might have contributed poor prognosis and increased morbidity and mortality.

TJS. 2018;34(Suppl-1):S709–S710.

PP-0952 [Thromboembolism, Anticoagulants]. Treatment of Central Venous Catheters that Are Occluded in Dialysis Patients Using Alteplase

Tuğba Han Yılmaz ^1,^✉, Baha Arslan ¹, Varlık Erol ¹, Hüseyin Gülay ¹

Objective

Alteplase is a thrombolytic drug that is used for treatment in cases where acute myocardial infarction or embolism is present. Tissue is the plasminogen activator. This study discusses the efficacy and side effects of the drug used to open occluded hemodialysis catheters.

Material and Methods

Dialysis patients who had experienced hemodialysis catheter occlusion and alteplase administration in the last 2 years were included in the study. Patients with known mechanical obstruction, heavy bleeding and risk of embolization were excluded from the study. A total of 10 ml alteplase vials were added into 100 ml of two physiological saline solution (5 ml of alteplase each) and they were administered in either of the tunnels separately within 30 minutes. The catheter was checked 60 minutes after the operation and the patients were discharged after at least 6 hours of monitoring. Patients were monitored for side effects that could develop within 30 days after the procedure. Side effects and efficacy of the drug were questioned.

Results

The medication was used on a total of 18 patients (12 males, 6 females, average age 46 years) and 17 patients used the catheter effectively after the procedure. One patient was referred to neurology department due to involuntary movements that developed 2 days after the procedure. The patient’s brain MR was taken, no evidence of intracerebral hemorrhage was seen. It was determined that their complaints gradually decreased in the following days.

Conclusion

Alteplase is an effective agent that can be used to open an occluded hemodialysis catheter. Side effects and efficacy will become clearer with increasing number of patients.

TJS. 2018;34(Suppl-1):S710.

PP-0953 [Thromboembolism, Anticoagulants]. Pharmaco-Mechanical Treatment of Acute Iliac Vein Thrombosis in a Patient with Chronic Deep Venous Thrombosis: A Case Report

Zafer Cengiz Er ¹, Ertan Demirtaş ¹, Kıvanç Atılgan ¹, Hasan Börekçi ^2,^✉

Introduction

Deep vein thrombosis (DVT) is a pathology that may cause significant mortality and morbidity if untreated. It occurs with symptoms of pain, swelling, tenderness and redness developed due to the obstruction of one or more venous thrombus in the deep venous system. Treatment options include oral anticoagulants, low molecular weight heparin, and recent oral anticoagulants and pharmacomechanical thrombectomy procedures. While interventional therapies are applied in cases of acute thrombus, their efficacy in chronic cases is unfortunately limited. For this reason, medical treatment is still the most important option in chronic cases. Today, the number of cases of acute and chronic lesions as a result of increased life expectancy and recurrence rates has increased. To what extent pharmacomechanical treatment will find its place in the treatment of combined cases?

Case

The patient who presented himself to the emergency service of our hospital with complaints of fulminant pain, cyanosis and swelling on the fingers was performed lower extremity venous color doppler ultrasonography (CDUS) and then was diagnosed with acute iliac vein thrombosis on the basis of chronic popliteal vein thrombosis. When it was observed coldness and cyanotic changes on the toes of the patient, he was taken to the angiography unit for emergency pharmacomechanic treatment due to the risk of critical lower limb ischemia. In order to reduce the risk of pulmonary embolism during the procedure, a vena cava filter was inserted through the intervention from right femoral vein. Pharmaomechanical thrombectomy was then performed by cannulating the left femoral vein guided with CDUS. After the procedure, the iliac vein was opened. 24 hours after the procedure, improvement was observed in the patient’s clinical and physical examination findings and compared to the patient’s preoperative condition, a 3 cm decrease in diameter was measured on the left lower extremity thigh. In the 1st postoperative follow-up, the iliac vein lumen was found to be open.

Conclusion

We believe that pharmacomechanical treatment of acute venous thrombosis is a new treatment option with rapid, effective and satisfactory results.

TJS. 2018;34(Suppl-1):S710–S711.

PP-0954 [Thromboembolism, Anticoagulants]. Massive Rectus Hematoma Associated with Subcutaneous Enoxaparin Use

Rahman Şenocak ^1,^✉, Oğuz Hançerlioğullari ¹, Şahin Kaymak ¹, Aytekin Ünlü ¹

Introduction

Low molecular weight heparin (LMWH) has been increasingly used by doctors in many clinical situations such as deep vein thrombosis, atrial fibrillation and pulmonary embolism. LMWH is generally safe due to improved bioavailability and pharmacodynamics. Therefore, its subcutaneous use is performed by nurses, patients and even those with appropriate training. In this article, it is aimed to present a case that is complicated with type 3 massive rectus hematoma after subcutaneous enoxaparin injection due to pulmonary embolism.

Case

Eighty-four-year-old female patient was referred to the emergency service from the external center with the complaint of abdominal pain with sudden onset which was not associated with trauma and that had been going on for two days. It was learned that the patient had been treated for massive pulmonary embolism 3 weeks before and then admitted to the chest diseases hospital when the complaint of shortness of breath had continued and been initiated on anticoagulant treatment via low molecular weight heparin with 0.6 IU 2x1 dose (enoxaparin). At the time of admission, ECG revealed the presence of atrial fibrillation, that the number of respiration was tachypneic and the oxygen saturation was 89%. The examination showed tenderness in the right lower quadrant and hypogastric region, a palpable mass and ecchymosis on the right abdominal wall. Laboratory tests revealed that urea: 150 mg/dl, creatinine 2.5, hemoglobin 8.2 g/dL (12.0–16.0), active partial thromboplastin time 30 sec (22.6–35), and prothrombin time 12 sec (11.4–15.5). The patient was monitored in the surgical intensive care unit. Unenhanced abdominopelvic tomography revealed a 10x15 cm of high-density locular fluid area on the right quadrant, in the anterior of urinary bladder and a hematoma of 73x42 mm in the right rectus region associated with this area. Type III rectus sheath hematoma diagnosis was made. Anticoagulant therapy was discontinued in the patient. Upon the decrease in hemoglobin values, a total of 5 units of erythrocytes and 3 units of TDP were administered. Due to concomitant embolism and renal failure, prophylactic interventional and surgical treatments were considered unsuitable and a standard IV heparin 5000 IU 2x1 infusion was initiated. The patient’s hemoglobin level elevated to 10.4 gr/dL and aptt values were 1.5 times than the normal. Her oral intake started. Subsequently, on the 14th day of her admission, due to sudden decrease of O₂ saturation and respiratory distress which required mechanical ventilation, the patient became exitus.

Conclusion

Hemorrhage in type III hematoma occurs between the muscle and the transverse facia, in the peritoneum and prevesical regions. Blood transfusion and blood products may be required. Surgical intervention might be required for hematomas that can not be controlled and that progress in size. Morbidity and mortality rates are higher in patients who are on anticoagulant treatment, with large hematomas, advanced age, and severe co-morbidities. Rectus sheath hematoma has been reported to have a mortality rate of 1.6–25%. The possible underlying mechanism is believed to be the combination of accidental intravenous injection of enoxaparin or damage of epigastric vessels with rich anastomotic nerves at the injection sites and a significant anticoagulant effect in the elderly.

TJS. 2018;34(Suppl-1):S711.

PP-0955 [Wound, Wound Care, and Burn]. The Relationship of Bonzai Use with Burns

Talar Vartanoğlu Aktokmakyan ^1,^✉, Osman Bilgin Gülçiçek ¹, Erkan Yavuz ¹, Önder Önen ¹, Mustafa Turan ¹, Atilla Çelik ¹

Objective

We aimed to determine the incidence of substance dependence in patients who were followed up on the burn unit. We investigated the relationship between burns and especially recently increased use of bonzai which is type of a synthetic cannabinoid, in Turkey and we examined its effects on morbidity and mortality.

Material and Methods

During the year 2017, 11 patients hospitalized in University of Health Sciences, İstanbul Bağcılar Training and Research Hospital Burn Unit were examined retrospectively in terms of age, gender, length of stay, causes of burn, morbidity and mortality.

Results

In 2017, 11 of the 112 patients hospitalized in the intensive care unit of the burn unit had the history of substance use, and 8 were known to use bonzai. The average age was 30.6 years and all of them were male. While the average length of stay in the unit was 14 days, it was 20.6 among cases with the history of bonzai use. Eight patients were followed up at the ICU. It was observed that the average length of stay in the whole unit increased to 20.6 days in patients with a mean duration of hospitalization of 14 days and those with a history of bones. Eight of these burn cases were caused by flame and mortality was not observed. Of the 112 patients, 6 were found to undergo amputations, while 3 of them were found to be bonzai users.

Conclusion

Burn clinicians should be aware of the increased use of addictive substances such as bonzai, should know that the course of burns associated with substance use and the duration of hospitalization differ according to other burn patients.

TJS. 2018;34(Suppl-1):S712.

PP-0956 [Wound, Wound Care, and Burn]. Application of Vacuum Wound Closure System on Necrotizing Fasciitis After Abdominopelvic Resection+Os Cocygys Resection

Perihan Büyükaslan ^1,^✉

Introduction

Necrotizing Fasciitis (NF) is a life-threatening soft tissue infection caused by the progressive necrosis of skin and subcutaneous tissue fascia. Various types of bacteria cause necrotizing fasciitis. The most common and known species is the Streptococcus group A. Treatment begins with strong antibiotics. Necrosis means that it is not possible for antibiotics to reach all of the infected areas. As a result, the necrotic tissue should be aggressively debrided. The prognosis of a 62 year old male patient with Rectum Ca diagnosis.

Case

A 62-year-old male patient admitted to our polyclinic with a complaint of abdominal pain. 28 day neoadjuvant radiotherapy was given to the patient who were diagnosed with Rectum Ca after the examinations. Abdominopelvic resection + os cocygys resection was performed as a secondary treatment. On the postoperative 4th day, after the culture taken from the gleet coming from sacral region, it was observed that E. coli and Klebsiella tigecycline-sensitive carbapenem resistant Enterobacteriaceae had reproduced. No improvement was observed in the wound site of the patient after the treatment with vancomycin and Meronepem. On the postoperative 18th day wound site debridement and vacuum wound closure system were administered. On postoperative 37 day, a muscle-skin flap was applied in a 25x20 cm deep pouched defect area of the patient’s sacral area. After the suturation, 8x1 cm area in the donor area was left for secondary healing. On the postoperative 75th day, lateral ends of the flabs performed in the sacral region were refreshed and the area of approximately 6x8 cm which had been left open was skin grafted using the skin taken from the femur. The problem was exterminated on the postoperative 117th day.

Conclusion

Vacuum wound closure application is a good treatment option that accelerates wound healing through an increase in local blood flow, acceleration of granulation tissue development, control of edema and exudates.

TJS. 2018;34(Suppl-1):S712–S713.

PP-0958 [Wound, Wound Care, and Burn]. Burn in Geriatric Patients

Talar Vartanoğlu Aktokmakyan ^1,^✉, Erkan Yavuz ¹, Osman Bilgin Gülçiçek ¹, Onur Olgaç Karagülle ¹, Hakan Yiğitbaş ¹, Önder Önen ¹, Atilla Çelik ¹

Objective

According to the data provided by Turkey Statistical Institute, while the elderly population in our country (65 and over) in 2012 was 5 million 682 thousand and 3, this number has increased in the last 5 years by 17.1% and reached 6 million 651 thousand 503 in 2016. As it is known, with aging neurological functions, musculoskeletal system weakness, patients’ consciousness, awareness, motor and sensory functions decrease. In addition, the blood circulation system and the nutritional system are distorted. Wound healing process becomes more difficult with the inclusion of comorbidities. This prone-to-trauma group is expected to suffer more damage and the healing-treatment process is more difficult. Geriatric burns are a special group of all burn patients and should be handled specially. In this retrospectively planned study, our aim is to evaluate geriatric burn patients in terms of etiology, treatment approach and prognosis.

Material and Methods

65 years and older patients, who were hospitalized in the Burn Center of Republic of Turkey Ministry of Health, University of Health Sciences, Istanbul Bağcılar Health Practice and Research Center (UHS BAĞCILAR HPRC), were examined in terms of etiology, percentage of burn, co-morbidities, length of stay, and mortality-morbidity.

Results

Between 2016 and 2017, we treated and monitored 156 patients aged 65 and above in our burn unit and in the ICU. Of these patients, 69 were male and 87 were female with an average age of 75 years. While the average stay in the service was 2.1 days, in the intensive care unit it was 12.3 days. While there was no mortality in the patients who had been followed up in the service; 8 of the 17 patients that had been followed in the burn intensive care unit became exitus. The cause of the burns of the patients is mainly due to the flames or hot matter from the house accidents.

Conclusion

Geriatric patients comprise a small but significant percentage of the population. While there was no mortality in the patients who were followed in the service, the duration of hospitalization was observed to be prolonged due to the presence of co-morbid diseases. It is noteworthy that intensive care follow-ups had especially mortal course. In terms of etiology, home accidents constituted the majority. At the same time, their long duration of the ICU stay was noteworthy since they needed monitoring provided by ICU unit. In this context, we recommend that burn clinicians be more careful in the follow-up and treatment of geriatric patients.

TJS. 2018;34(Suppl-1):S713.

PP-0959 [Wound, Wound Care, and Burn]. It is Important to be Careful in the Follow-Up and Treatment of Decubitus Ulcers: Decubitus Ulcers May Cause Fournier Gangrene

Mehmet Eren Yüksel ^1,^✉, Mehmet Akif Diri ², Mustafa Sami Bostan ¹, Namık Özkan ¹

Introduction

Fournier gangrenous is infectious necrotizing fasciitis of perinenin and genital area. The mortality rate in Fournier gangrene is up to 67%. Care must be exercised in the follow-up and treatment of patients with decubitus ulcers. Fournier may cause gangrene. Early identification of Fournier’s gangrene and extensive surgical debridement immediately after diagnosis are life-saving.

Case

The patient who presented himself to the emergency service with the complaints of discharge and pain due to decubitus ulcer and whose left leg was amputated from the knee down had been followed up by infectious diseases and plastic surgery departments. Despite the oral antibiotic treatment (Moxifloxacin 1x1 tb), the patient complained of pain and purulent discharge, and the patient was evaluated for abscess or fistula. Patient’s contrast-enhanced pelvic magnetic resonance imaging (MR) that had been performed at the external center was interpreted by the radiology department. Extensive soft tissue inflammation extending from the sacrococcygeal region in the pelvic region to the gluteal region and the perineum in the right side, a deeply located abseiform collection in the right side of the perineum and enlarged lymph nodes in both iliac obturator chains were detected. The laboratory results of the patient were: serum creatinine: 5.8 mg/dL, ALT: 49 U/L, AST: 96 U/L, Ca: 6.56 mg/dL, CRP: 358 mg/L and white blood cell: 15,510x109/L. Intravenous (iv) antibiotic therapy with piperacillin + tazobactam was initiated by the Department of Infectious Diseases for the treatment of sepsis. The patient was operated under local anesthesia and sedation in the lithotomy position. The right pararectal area was enlarged with finger dissection and the abscess/collection at the end of the existing decubitus ulcer was removed. It was seen that the collection had been placed at the end of the pouch of decubitus ulcer. In addition, right perianal and scrotal areas were exposed and debrided. The wound was washed with oxygenated water and povidone iodide solution. Colostomy was also performed to the patient so that the wound would not be smeared with gaita. The wound was debrided twice more every three days after the surgery. Improvement in creatinine values was observed with iv hydration in the direction of the nephrology department’s recommendation. With the help of intravenous antibiotic therapy and vacuum assisted closure (V.A.C.) complete recovery was provided on the patient’s wound.

Conclusion

Decubitus ulcers in patients with spinal cord injuries increase the risk of Fournier’s gangrene development. Vacuum-assisted closure (V.A.C.) in Fournier gangrenous paraplegic patients who develop secondary decubitus ulcers due to ischialgia pressure facilitates the closure of the wound. Treatment of Fournier’s gangrene due to decubitus ulcer requires interdisciplinary collaboration. It is essential that urology, radiology, infectious diseases, internal diseases, nephrology, general surgery and plastic surgery departments work in cooperation in the treatment of patients with Fournier gangrenous. Decubitus ulcer may cause Fournier gangrene. Early identification of Fournier’s gangrene and extensive surgical debridement immediately after diagnosis are life-saving. Vacuum assisted closure (V.A.C.) helps to close the defect at the wound site in patients who have been operated on due to Fournier’s gangrene.

TJS. 2018;34(Suppl-1):S713–S714.

PP-0960 [Wound, Wound Care, and Burn]. Skin Staples that Are Not as Innocent as They Seem: A Small Bowel Injury due to Skin Staples after Evisceration

Hüseyin Kılavuz ¹, Enver Reyhan ¹, Abit Yaman ^1,^✉, Mehmet Kemal Yener ¹, Murat Aygün ¹

The word “stapler” was first used in 1901 by American Munsey Magazine to describe a machine holding a thin metal wire with paper. In the following years, the skin staples from the automated stapler devices produced by the developing technology were started to be used to close the surgical incisions. The fact that the skin stapler can be used with little experience, that they shorten the operation and duration of the anesthesia have made it be frequently preferred to close surgical incisions. In our patient who had been operated under immediate circumstances with septic symptoms due to delayed referral of peptic ulcer perforation, abdominal median incision was closed with skin staples. On the fourth postoperative day, evisceration of the small intestine from the incision line due to severe coughing developed. We aimed to draw attention to patient selection for the use of skin staples due to damage caused by skin staples in the small intestine meso and serosa.

TJS. 2018;34(Suppl-1):S714.

PP-0961 [Wound, Wound Care and Burn]. Evaluation of the Effect of Topical Coenzyme Q10 in Experimental Burn Model in Rats

Ceren Canbey Göret ¹, Aslı Kiraz ², Nuri Emrah Göret ³, Sevilay Oğuz Kılıç ⁴, Ömer Faruk Özkan ^5,^✉, Muammer Karaayvaz ⁶

Objective

Effective and successful treatments of burned patients are still an important medical problem and there is limited data on the efficacy of coenzyme Q10 (CoQ10) in burn wounds. In this study; we aimed to investigate the effect of topically applied CoQ10 on wound healing in burned rats.

Material and Methods

Twenty-seven Wistar Albino rats weighing 200–240 g were divided into 3 equal groubs (n=9) and all rats were under general anesthesia. The backs of Group 1 were shaved and no further intervention was done. The back part of Group 2 and Group 3 was shaved and the shaved area was contacted with water at 95 C for 10 seconds. The rats were wrapped in cold towels after the burn application and 8 ml of intraperitoneal ringer lactate solution was given to prevent burn shock. Group 2 received silver sulphadiazine and Group 3 received sterile derivative of 10 mg/kg CoQ10 which was prepared with normal saline topically everyday. Biopsies were taken for histopathological examinations under general anesthesia from burned tissues on days 3 and 10 and the rats were sacrificed. Histopathologic parameters were assessed by Hematoxylin & Eosin and immunohistochemical free oxygen radicals were assessed by Glutathione S-transferase, Glutathione Reductase, Superoxide dismutase, and Catalase.

Results

In CoQ10 applied group; there was no statistically significant difference in inflammation, epidermal, vascular, collagen damage in samples taken at both 3rd and 10th days. In terms of edema parameters; a statistically significant difference was detected between the 10th day samples of the group for which CoQ10 was applied and the 3rd day samples of the group for which silver sulfadiazine was applied and it was determined that these parameters increased. In terms of free oxygen radicals immunohistochemically, a statistically significant difference was detected between the 10th day samples of CoQ10 and silver sulfadiazine applied groups and it was determined that these parameters increased.

Discussion

No positive result has been obtained that CoQ10 reduces the incidence of burn injury, but this substance has been found to increase free oxygen radicals in tissues in immunohistochemical analysis to detect tissue edema and oxidative stress.

TJS. 2018;34(Suppl-1):S714–S715.

PP-0962 [Wound, Wound Care and Burn]. Fast and Fatal Necrotizing Fasciitis

Gülten Çiçek Okuyan ^1,^✉, Mehmet Talu ¹, Metin Tilki ¹, Ali Sürmelioğlu ¹

Introduction

We wanted to present a rapid and fatal case brought to the emergency service with an abdominal pain and without inflammation and crepitation was taken in deep palpation and radiology was helpful in diagnosis.

Case

A 78-year-old female patient with abdominal pain and mental state change for 3 days was brought to our emergency outpatient clinic. She had a history of diabetes and 20 days of NSAID use. She had mental fog and Tension: 90/50 heart rate, pulse: 140/min, fever: 38.5 degrees, BMI: 45. She had no distension in abdominal examination and tenderness in all quadrants and crepitus was found in deep palpation. There was no temperature, redness, edema, or open wound on the skin. Laboratory findings were as follows: leukocyte: 20.000, Hb: 10.2 gr/dl, hct: 30.8%, albumin: 1.5 gr/dl, glucose: 304 mg/dl, creatinine: 0.6, CK: 442U/l, INR: 1,58, CRP: 24 mg/dL. serum Na: 135 meq/l. Wide air images progressing along the fascia extending to the inguinal and genital area below and lumber region in the entire abdominal wall was observed. No pathology was detected in the internal abdomen. She was urgently taken to the operation with the prediagnosis of NF. Grey-brown color change was observed in the subcutaneous fat tissue and on fascia at exploration. The vessels were thrombosed and diffuse necrosis were observed. Aggressive debridement was applied. Postoperative. She was referred to postoperative reanimation clinic. Debridements were repeated on day 1 and 2. But the patient is was exitus on the 2nd day.

Conclusion

NF is a rare but lethal soft tissue infectious disease with rapid tissue destruction and systemic toxicity. Early diagnosis and aggressive surgical debridement reduce mortality and morbidity but it is difficult to diagnose. It is usually seen in perineum and the body. Etiologically, they are isolated from S. aureus, S. pyogenes enterococci, as gr(+) organisms and from E. coli, types of Pseudomonas as gr (−) organisms and from bacteroides and Clostridium types as anaerobes. Acinetobacter spp. reproduced in the tissue culture. Additionally they were consistent with changes associated with necrotizing fasciitis in the histopathology. Risk factors for NF were; Diabetes, CRI, immunosuppressive drug use, malnutrition and the underlying malignancy and obesity. NSAID and NF relationship have been shown. Our patient had a history of diabetes and NSAID use history. NF usually has inflammation in skin. In our case there was no skin findings but she had severe pain and deep crepitation was observed with palpation. Crepitation is seen at 18% and is a poor prognostic indicator. Abdominal CT performed to help in diagnosis is 80% sensitive in detecting NF.

It is important to detect the depth and breadth of the infection. It helped to diagnose quickly and to begin treatment without delay. However, the patient showed a very rapid progression and she was exitus. As a result, NF is a rare condition with high morbidity and mortality. Clinicians should consider NF in patients with skin erythema, fever and pain, especially immunodeficiency and chronic disease. The guidance of radiology should also be remembered.

TJS. 2018;34(Suppl-1):S715.

PP-0963 [Wound, Wound Care and Burn]. Recurrent Burn due to Bonzai Use: Case Report

Talar Vartanoğlu Aktokmakyan ^1,^✉, Serhat Meriç ¹, Önder Önen ¹, Mustafa Turan ¹

Introduction

We aimed to present our patient who admitted to University of Health Sciences Istanbul Bağcilar HARC Burn Unit by burning twice in the same year and in line with this patient we aimed to share the treatment differences and the necessary precautions to be taken in recurrently burned patients.

Case

A 22-year-old male patient who admitted to the external center due to burn during bonzai use was interned with a total of 30%, 2, and 3 degree flame burns in the bilateral lower extremity and was discharged after 2 months of treatment with autologous skin graft following repetitive debridements. The patient continued to use drugs and after 4 months of his discharge he admitted to our center again with similar burns in the same regions. The patient was followed in intensive care unit with the diagnosis of 3rd degree having a total of 30% flame burn in bilateral lower extremity. At the time of hospitalization, no circulation could be provided in the right leg of the patient despite fasciotomies and below knee amputation was performed. Despite continuing hyperbaric oxygen therapy with 47-day multi-disciplinary intensive care and service follow-up, a similar situation was experienced for the left leg of the patient and amputation decision was taken. After bilateral lower extremity amputation, the patient was discharged with recovery.

Conclusion

We see in this example that we should be more cautious in situations that cause recurrent burns such as increased drug use, psychopathological problems, diabetic neuropathy and mental retardation. In this patient with Bonzai use history, the first treatment remained ineffective due to the continued use of the substance and resulted in extremity loss. Raising awareness of patients and their relatives, providing the necessary rehabilitation, and regulating the living area appropriately increases the success rate in the patients in the risk group.

TJS. 2018;34(Suppl-1):S715–S716.

PP-0964 [Wound, Wound Care and Burn]. The Effects of Carbon Dioxide-induced Pneumoperitone on Peritoneal Structure

Bekir Sarıcık ^1,^✉, Ömer Rıdvan Tarhan ¹

Objective

As laparoscopic surgeries have begun to be performed many gases have been tried to form pneumoperitoneum. Among these, carbon dioxide gas has still the most common use. Pneumoperitoneum formed with carbon dioxide causes some undesirable changes on the peritoneal structure even though it creates a suitable area for surgeons during laparoscopic operations. Although some of these side effects are inevitable, some side effects may change depending on the application.

Material and Methods

This article was prepared considering the experimental and clinical studies in the literature on the effects of carbon dioxide induced pneumoperitoneum on the peritoneal structure.

Results

Pneumoperitoneum formation affects the peritoneal environment and therefore the organism. This effect is due to intraabdominal pressure increase, local peritoneal destructive effects of carbon dioxide, carbon dioxide absorption and chemical metabolic changes. The rate of insufflation and its pressure usually make hemodynamic changes. Hypoxic and toxic effects of carbon dioxide, its dryness and coldness cause structural deterioration of peritoneal environment.

Conclusion

Laparoscopic surgery is becoming widespread every day. For this reason, it is important to have awareness of the effects of pneumoperitoneum, especially in patients with comorbid diseases or obese patients. We are of the opinion that this awareness will reduce the impact of unwanted changes in the pneumoperitoneum of patients.

TJS. 2018;34(Suppl-1):S716–S717.

PP-0965 [Wound, Wound Care and Burn]. Comparison of the Effects of Ozone and N-Acetylcysteine on Burn Stasis Zone

Meriç Emre Bostancı ^1,^✉, Murat Can Mollaoğlu ², Mustafa Atabey ³, Muhammed Aykota ⁴, Ali Kaan Gökakın ⁴

Objective

In this study, it was aimed to save stasis zone by intraperitoneal application of N-acetylcysteine and ozone in the rats by forming an experimental burn model and to compare the biochemical and pathological findings after the treatment.

Material and Methods

24 female rats were included in the study. The rats were divided into three equal groups. Tissue specimens were taken from the rats at the end of the 10th day.

Group 1; Intraperitoneal control group
Group 2; Ozone was administered intraperitoneally at a dose of 10 μg/mL daily for 10 days.
Group 3; N-acetylcysteine was administered intraperitoneally at a dose of 100 mg/kg daily for 10 days.

The rats were subjected to the burn model defined by Regas and Ehrlich. To form this burn model, a comb-shaped tool with four rectangular contact areas of 1x2 cm in size was used and in the back of the rats 4 burn regions of 2nd degree having rectangular shapes with the size of 1x2 cm in the middle line bilaterally in such a way that there would be 3 stable zones between them with the size of 0.5×2 cm were formed. The burned areas formed were considered as coagulation zones and the solid tissue areas of 0.5×2 cm between them were considered to be ischaemia (stasis) zone. For the study, 5 cc blood was taken from the tail vein of the rats and malondialdehyde, superoxide dismutase, catalase and glutathione peroxidase values were measured for comparison between groups.

Results

In our study; pathologically edema, hyperemia, epithelial degeneration, necrosis, inflammatory infiltration, fibrosis measurements were performed. When compared with the control group, the tissue damage score was lower in the group given intraperitoneal NAC. MDA level was found lower in the intraperitoneal NAC group than in the control group. SOD, catalase and GSH-Px levels were higher in the intraperitoneal NAC group than in the control group. MDA levels in intraperitoneal ozone group were lower than intraperitoneal NAC group. SOD, catalase, GSH-Px levels were higher in intraperitoneal ozone group compared to intraperitoneal NAC. We are of the opinion that prospective randomized, large-scale clinical trials are necessary to recommend the use of ozone as a standard wound care product. When ozone and N-acetylcysteine groups are compared, histopathological improvement findings in the ozone group are better and when ozone and N-acetylcysteine groups are compared; the positive effects of reducing the oxidative stress level of ozone and enhancing wound healing are more apparent than those of N-acetylcysteine.

Conclusion

In this study; it was determined that intraperitoneal ozone application on wound healing was superior to intraperitoneal N-acetylcysteine administration in the experimental wound model created in rats. We believe that prospective randomized clinical trials should be performed to use intraperitoneal ozone as a wound care product. The effects of ozone on the stasis zone, the most effective treatment dosage, the side effects, and the duration of treatment should be investigated in new studies and it should be considered as a molecule to enter into active clinical use.

TJS. 2018;34(Suppl-1):S717.

PP-0967 [Wound, Wound Care and Burn]. The Effect of Topical Epidermal Growth Factor on Wound Healing

Yiğithan Yasin Keskin ^1,^✉, Hemşire Cemile Sazak ¹, Ömer Arda Çetinkaya ¹, Hakan Uncu ¹

Objective

There are studies reporting that the topical epidermal growth factor contributes to the process by effecting cell proliferation and collagen increase on burns and diabetic foot injuries. The aim of this study is to investigate the effectiveness of the product as one of the first centers to use this newly licensed product in our country and to report its initial results.

Material and Methods

A total of 17 patients aged between 35 and 81 (mean age 60.7) were included in this study, 6 of whom were women and 11 were men. Patients had a history of diabetes ranging from 2 to 40 years (mean 22 years), 10 patients had arterial insufficiency and 7 had venous insufficiency. Diabetic ulcer sites are most frequently found in finger (33,3%) and secondly in the sole region (23,8%). The patients’ debridement was performed surgically. Topical epidermal growth factor was applied to the wound surfaces of patients day after day. The duration of treatment varies between 11 and 180 days (mean 59.4 days). Chlorhexidine acetate or Ag alginate covers were used to cover the wound dressings of the patients. The injuries were assessed according to the Wagner criteria.

Results

According to the Wagner staging, 10 patients were evaluated as stage II, 2 patients were stage III, 4 patients were stage IV, and 1 patient was stage V. After treatment it was observed that two patients’ wounds were completely closed (11,8%), ulcer areas decreased from 11,0 cmx4,5 cm to 8,4 cmx4,0 cm by providing adequate granulation at the wound site in 13 of the patients (76,4%) and wound healing could not be provided in 2 patients in stage IV and V (11,8%).

Conclusion

According to this study, the topical epidermal growth factor is effective in diabetic wounds ranging from Wagner’s staging I–III. This product promises to protect patients from the major amputation in chronic wounds that do not have infection or osteomyelitis, can not be treated by vascular intervention, and result can be obtained by classical dressing. In order to confirm this interpretation in this treatment method which we report the first results, studies including more patients and more data are needed.

TJS. 2018;34(Suppl-1):S717–S718.

PP-0968 [Wound, Wound Care and Burn]. Use of Dermal Collagen Implant in Electricity Shock Burns

Nadire Dinç ^1,^✉

Dermal collagen skeleton is a wound care product used in the treatment of wounds that can not be covered with partial skin grafts or fleps used in burns and wound healing. In this case, we describe the results of closure of the deep tissue defect covering the wrist and sole of a 23-year-old patient having electricity shock associated 3^rd degree burn complaint with a dermal collagen skeleton and a postoperative follow-up of 3 months. A 23-year-old male patient was admitted to the burn unit with a 5% third degree burn in both wrists and right foot due to electrical shock. On the first day, escarotomy and fasciotomy were performed due to the compartment syndrome developing in the left forearm and wrist. On the 10th day right toe amputation and debridement and on the 24th day, debridement and grafting were performed to the right hand and left hand finger. On the 38th day, dermal collagen skeleton was applied to the left wrist and foot sole. On the 58th day, the wounds were completely closed with grafting to the collagen skeleton applied regions. The patient had left ulnar nerve damage during the hospitalization and he developed claw hand deformity. In the outpatient clinic follow-up following discharge, it was seen that the patient walked comfortably without any complaints, he was able to move his left wrist comfortably without contracture, could hold the equipment and the

claw hand deformity disappeared. Joint burns that can not be covered with surgical methods such as grafting or flap, or disrupt the function of the patient are very common in electrical shock cases, but the morbidity contracture rate is high in these cases. The use of dermal collagen skeleton in such cases is thought to reduce morbidity.

TJS. 2018;34(Suppl-1):S718.

PP-0969 [Wound, Wound Care and Burn]. Use of Postpartum Radiotherapy in the Treatment of Hypertrophic Scar and Keloid, Developing in Pregnancy after Milk Burn

Nadire Dinç ^1,^✉, Azamat Dauletkazin ²

It is wound healing that causes severe itching, pain and cosmetic problems seen very commonly in hypertrophic scar and keloid burn patients. From time to time they can cause morbidity that can prevent the patient from maintaining his daily life. Hypertrophic scar is usually a fluffy healing that does not exceed the pink or red wound borders. Keloid is the fluffy healing that usually goes out of the wound borders and is in the skin color. We will try to explain the efficacy of radiotherapy in postpartum patients with hypertrophic scars and keloids that do not respond to cream, pomade and compression garment treatment. A 32-year-old female patient was admitted to our outpatient clinic due to swelling associated with a previous burn on the extensor side of the left arm, pain and itching. At the time of admission, the patient, who was 7 months pregnant, stated that her arm was burned 1 year ago with milk and her arm healed without blistering, she became pregnant 5 months after the burn, burn area began to blister from 2nd trimester, could not use her arm and sleep because of pain. On physical examination, there was a hypertrophic scar and partial keloid areas in the entire burn area of the left arm extensor. Postpartum compression garment was recommended to the patient who was taken into follow-up. However, there was no decline in her complaints. She said that she could not hold her baby because of pain and it was very difficult to breastfeed the baby. Steroid injection could not be performed because she was in lactation and it may cause systemic side effect. The patient was treated with 12 MeV of energy and 8 Gy of electron radiotherapy in a single fraction. In her follow-up 2 weeks later, she said that her pain stopped, itchiness significantly decreased and she could easily use her arm. Although there are not enough studies in the pediatric age group, there are many studies showing that hypertrophic scar and radiotherapy are effective in keloid treatment in adult patients. Because of the dramatic improvement in our patient, we think that radiotherapy is an effective treatment method for selected patients.

TJS. 2018;34(Suppl-1):S718–S719.

PP-0970 [Wound, Wound Care and Burn]. Use of the Sural Nerve Graft in Conjunction with the Inguinal Flap in Managing the Tissue Defect in the Hand and Ulnar Nerve Damage Developing due to Electrical Burn

Mete Demir ^1,^✉, Melih Bağır ², Koray Daş ¹, Kayhan Gürbüz ¹, Abdulkadir Başaran ¹, Orhan Eroğlu ¹, Ali Yarçe ¹, Özer Özlü ¹, Uğur Topal ³

Introduction

Electrical injuries seen most commonly after boil-burning and flame burns are important causes of morbidity and mortality. Different physiopathological explanations and different treatment approaches are being applied in high voltage electrical injuries occurring with very different mechanisms from the thermal burns. The most important factor in determining the prognosis of electric injury is the amount of voltage in the clinic divided into low and high voltage according to the 1000 volt limit. Hands are affected in 80% of the burned cases, despite being a small portion of the surface of the body. Hand burns require a therapist approach trained in edema control, wound/graft care, splinting, scar control and pain. Pedicle groin flap is an axial patterned flap originating from superficial circumflex iliac arterial. It is important as a good alternative providing an adequate coverage in defects of various sizes located in different regions of the upper extremity having low donor area morbidity. Interfacial nerve graft is a useful method for repairing nerve defects. Sensory return to a certain degree is possible for a good motor function.

Case

A 20-year-old male patient was admitted to our clinic because of electrical burn. Physical examination revealed a 3-degree burn area in the right hand hypothenar region, extending into the lateral region of the wrist. The right hand and the forearm had ulnar nerve motor and sensory deficits. He had TA: 110/70 mmHg, pulse: 72/minute, fever: 37.2 C. No systemic pathology was detected in systemic examination. His biochemical values were normal. Wound was prepared for flap after serious dressing and debridements. The sural nerve taken from the left leg for the ulnar nerve defect was interfascicular grafted. The right superficial circumflex iliac artery pedicle was preserved and the fasciocutaneous inguinal flap was elevated. This flap was then sutured over the open wound to the hypothenar region of the right hand. After 3 weeks, he left the flap pedicle. The donor area was closed primarily.

Conclusion

Electrical burn is a common trauma in our country and in our region, which has a serious morbidity rate and causes the patient to stay in the hospital for a long time and to undergo numerous operations. Tendons, veins, nerves, bones and joints may be damaged in electrical injuries. Such injuries should be debrided with appropriate flaps in the a-early stage. Pedicled inguinal flap is a safe treatment alternative in the patient group in defects that can not be covered with local flaps and the structures such as bones, nerves and tendons are exposed due to high-voltage electrical burns of the upper extremity and the use of free tissue transfer is risky. Peripheral nerve injuries are pathologies that have extremely severe functional and aesthetic troubles Nerve grafts are preferred for the management of these injuries in order to gain motor power and restrain holding functions of the hand.

TJS. 2018;34(Suppl-1):S719–S720.

PP-0971 [Wound, Wound Care and Burn]. Examination of the Role of Burn Center in Toxic Epidermal Necrolysis Over A Case

Mete Demir ^1,^✉, Kayhan Gürbüz ¹, Abdulkadir Başaran ¹, Orhan Eroğlu ¹, Ali Yarçe ¹, Özer Özlü ¹, Uğur Topal ², Koray Daş ¹

Introduction

Toxic Epidermal Necrolysis (TEN) is an immunocytotoxic destruction of keratinocytes that the body develops against various antigens. It is most often seen after the administration of drugs [antibiotics, allopurinol, nonsteroidal antiinflammatory drugs (NSAIDs), anticonvulsants] but also after infection, cancer and vaccination. Its incidence is 0.4–1.2/million people in the world. It is mostly seen in the adult age group but rarely seen in children. TEN has a mortality rate of 10–30%. In the lesions seen, there is a separation in the dermo-epidermis junction, including intact areas. Mortality frequently occurs due to infections secondary to skin lesions. As a 20% burn case requires immediate intervention, toxic epidermal necrolysis, which can hold up to 20% of the body surface area, requires immediate intervention. In these cases, topical wound care is an integral part of the overall treatment. Areas with epidermal loss can be mixed with partial thickness burns. In this presentation, we aimed to investigate the role of burn center following a case of TEN developing associated with gemifloxacin in epidermal lesions.

Case

A 61-year-old female patient with known heart failure, hypertension, COPD and chronic atrial fibrillation had used gemifloxacin 320 mg for the first time 10 days ago due to gastroenteritis. The patient who had clinical improvement had used gemifloxacin once again 3 days before he was re-diarrhea. The patient already used diltizem, aldactone, beloc, digoxin and xarelto and the patient admitted to our hospital because of erythematous bullous lesions in the whole body. On physical examination, the patient was conscious, cooperative and had arterial blood pressure 160/90 mmHg, pulse 110/min, body temperature 37.4 °C. Erythematous lesions in the oral mucosa were present on the skin examination, and there were diffuse painful hyperemic rashes, and bullous lesions, especially in the hip region in all the body except the head and neck region. Erythematous lesions and epidermolysis affected an area larger than 40% of the body surface. In the laboratory examination, CRP was high and there was leukocytosis and the other parameters were in the normal range. Dermatology performed frozen examination to the patient. Full-thickness necrosis was seen in the patient and the patient was diagnosed with TEN and hospitalized in the internal intensive care unit. Skin lesions were sterile and they were cleaned daily with isotonic NaCl solution. Distorted skin areas were debrided and followed by waxy sterile closed dressing.

Conclusion

TEN is a very severe drug reaction. A history of medication can be detected in almost 90% of patients. Major antibiotics such as sulfonamides, aminopenicillins, cephalosporins and quinolones pose a risk There is no specific laboratory finding specific to the disease. The suspected drug withdrawal and supportive treatment is the first step in TEN treatment. It has been demonstrated that withdrawal of the suspected drug reduces mortality significantly.

Supportive treatment is similar to treatment applied in severe thermal burns and includes fluid replacement, adequate nutritional support, wound care, and protection from infections. Daily wound care, hydration and nutritional support are essential, and follow-up of serious cases in the intensive care unit is recommended. We believe that the experience we have in burn centers in wound care of patients is beneficial.

TJS. 2018;34(Suppl-1):S720.

PP-0972 [Wound, Wound Care and Burn]. Assessment of Pressure Ulcers in Patients in the Palliative Care Unit and Treatment Options

Hasan Calış ¹, Yılmaz Güler ^1,^✉, Serkan Şengül ¹, Mani Habibi ¹, Zülfikar Karabulut ¹

Objective

Pressure ulcers occur as a result of damage to the skin and subcutaneous tissue by pressure, friction or shear force. Blood circulation decreases with the pressure to the tissue between the surface and the bone and pressure ulcers develop in patients who remain in the same position for a long time. Apart from this, immobility, mental status change, malnutrition also have an important place in ulcer development. Most pressure ulcers are preventable wounds. The study was conducted to evaluate pressure ulcers and treatment options in patients treated in palliative care unit.

Material and Methods

The data of patients treated for pressure ulcer in the palliative care unit of Ahi Evran University Education and Research Hospital between October 2016 and November 2017 were evaluated retrospectively. data were collected from specially filled forms for every patient. The stage of pressure was determined according to National Pressure Ulcer Advisory Panel classification.

Results

Forty eight patients were treated for pressure ulcer during the period of treatment in the palliative care unit according to the results of the retrospective evaluation. Pressure ulcers were most common in the sacral region (18 patients, 37.5%), ischial tuberosity (12 patients, 25%), trochanters (9 patients, 18.7%), malleolars (3 patients, 6.2%) and soles (6 patients, 12.5%). 12,5% of the patients were stage I, 62.5% of stage II, 14.5% of stage III, 6.2% of stage IV and 3.7% of suspected deep tissue damage. Stage I disease was treated only with dressing and wound care. All other patients underwent surgical debridement. While epidermal growth factor (EGF) was applied in 2 patients in stage III and type-I collagen including particles was applied in 4 patients, negative pressure vacuum system was applied to all other patients, depending on the formation of granulation tissue.

Conclusion

The most common sites of pressure ulcers are the sacrococcygeal region, trochanters and heel regions. Treatment of pressure ulcers should be done by a team that can prevent ulcer development and treat developed ulcers. The most effective and easiest way of treating pressure ulcers is protection. Apart from these, many medical and surgical treatment options are available. These treatments may have advantages over each other at the cost and benefit point. The main purpose of the treatment is to increase infection management and wound healing.

TJS. 2018;34(Suppl-1):S720–S721.

PP-0973 [Wound, Wound Care and Burn]. Hypertrichosis Forming as a Result of Intralesional Steroid Injection in Burn Induced Hypertrophic Scar Tissue

Nadire Dinç ^1,^✉, Adulkadir Calavul ²

Hypertrophic scar is a fluffy wound healing causing severe itchiness, pain and cosmetic problems in burn patients. Steroidal pomades, intralesional steroid injections, silicone compression garments, silicone gel and radiotherapy are used in the treatment. Itchiness due to hypertrophic scar especially in the pediatric age group, often does not respond to locally steroidal pomades, preventing the child from maintaining normal life and increasing mobility in the joint regions. Steroids can cause systemic effects, even though they are mostly used locally in dermatological diseases such as burns. We will try to describe the systemic side effect that developed in a child with intralesional steroid injection due to hypertrophic scar in this case. A 5-year-old girl admitted to our outpatient clinic with complaints of blistering, swelling and severe itching due to hot water burning of the right knee 6 months ago. Physical examination revealed a 15x20 cm hypertrophic scar tissue in the right knee. Triamcinolone acetonide 40 mg ampoule was applied intralesionally in the patient whose complaints did not regress with local pomade treatment by plastic surgeon. In the follow-up after 1 month, it was observed that the patient‘s itching passed but hypertrichosis developed in face, neck, back and chest. Therefore steroid treatment was discontinued. The areas with increased hair growth were seen to get normal after 3 months. Even though, intralesional steroid is quite effective in itching and blistering due to hypertrophic scar, it can cause systemic side effects and can even lead to cushing syndrome. Therefore, it should be kept in mind that severe systemic side effects may occur in patients treated with local steroid therapy, and patients should be closely monitored.

TJS. 2018;34(Suppl-1):S721.

PP-0974 [Wound, Wound Care and Burn]. Death Pits in Our Region: An Overview of Floor Furnace Burns

İskan Çallı ^1,^✉, İsmail Zihni ¹

Burn causes; boiling, flame (floor furnace), chemical, electrical and radiation exposure. Floor furnace is a special kiln used for baking bread with firewood in the eastern and southeastern Anatolia region. Floor furnace burns are traumas that are characterized by causing deep and large burns, which are related mostly with women and young children falling into them. Floor furnace burns have high morbidity and mortality. Floor furnace burns, as in other burns, are inversely proportional to the socio-economic and socio-cultural levels of the patients. The reason for the more common floor furnace burns in our region is that the families in the Eastern Anatolia region have a crowded population, the floor furnace are made by excavating the floor and covered with cardboard or simple sheet metal. While women usually cook bread, children are exposed to temperatures of about 450 degrees Celsius, which is the result of falling on the floor furnaces that are left to cool. Severe burns form as a result of high temperature for a long time in patients who often have difficulty saving themselves. It is seen in the literature that all studies related to floor furnace burns are conducted in the Eastern and Southeastern Anatolia region. In these studies conducted, the ratio of floor furnace burns to other burns varies between 2.1% and 9.9%. They are mostly confronted in children and women. Floor furnace burns are around 70% in children aged 0–6 years. In different studies the average age was found between 10.7 and 17. In all studies, it has been stated that it is more frequent in female population than males (61.5%–71%). It is observed that the total burned surface area and the depth of burn in floor furnace burns are higher than those in other burns. When hospital stays are compared, it is seen that the duration of hospitalization of the patients with floor furnace burns is significantly longer. Surgical interventions such as debridement, escarotomy and fasciotomy, autograft, reconstruction and amputations applied to the disease are also more common in floor furnace burns. We reviewed the in-patients who were treated between June 2016 and June 2017 in our clinic. The number of in-patients treated in one year was 635. Distribution of our patients according to etiology were as such; burning burns 495 (78%), flame-burns 109 (17%), electric shock 24 (0.03%), chemical and other burns 7 (0.01%). There were 93 (14.6%) adult patients and the number of pediatric patients was 542 (85.4%). Number of female patients was 295 (46%) and male patient was 340 (54%). The mean age of our patients was 8.7. The average duration of hospitalization for flame (floor furnace) burns was 9 days, and burning burns were 6.9 days. A total of 193 (1.77 per person) surgical procedures were performed in 109 patients with flame burn and 289 (0.58 per person) procedures were applied to 495 patients with boiling burn. Three patients with floor furnace burn had to undergo amputation and fasciotomy. Hyperbaric oxygen therapy to all of our patients admitted due to floor furnace burn was applied (2.0–2.5 ATA, 120 min per day, 100% oxygen for 15 days).

TJS. 2018;34(Suppl-1):S721–S722.

PP-0975 [Wound, Wound Care and Burn]. Our Necrotizing Fasciitis Cases Developing Associated with Perianal Abscess

Enes Şahin ^1,^✉, İlhan Ece ¹, Serdar Yormaz ¹, Bayram Çolak ¹, Akın Çalışır ¹, Halil Kirazlı ¹, Mustafa Şahin ¹

Introduction

The treatment of anal abscess which is one of the frequently encountered problems of the perianal region, is usually simple drainage. Drainage is usually adequate in patients admitting in the early stage and having been established early diagnosis. However, when patients admit late to the hospital, the clinic may progress very rapidly, so fournier gangrene and necrotizing fasciitis can develop within days. This process can develop even more rapidly especially in immunosuppressed patients or those with co-morbidities such as diabetes, which disrupt wound development. We aimed to describe the clinical course and treatment of our 3 patients who developed necrotizing fasciitis due to anal abscess in our clinic.

Case

Necrotizing fasciitis was diagnosed in patients who complained of pain in the breech region and who did not take this seriously at the beginning and later admitted to the hospital. One of the patients was found to have irregular diabetes mellitus. The other patient was found to be HIV-positive detected when the other patient admitted to the necrotizing fasciitis clinic. The patients was taken urgently to the operation and all of the necrotic tissues were debrided. Closed Patients‘ open wounds were covered with specially prepared pads and wrapped. At this stage, appropriate infection antibiotherapy was applied by consulting to the infectious diseases in order to fight infection effectively. In addition, vital signs and laboratory values were closely monitored to ensure that fluid losses were not missed. After the infection was completely reversed, the patient was transferred to the plastic surgery department for proper tissue grafting.

Conclusion

Early diagnosis and treatment of necrotizing fasciitis with high mortality and morbidity are life-saving. It should be taken into consideration that it is also difficult to treat patients with co-morbid diseases, which will accelerate progression in particular. It is of vital importance that necrotic tissue is removed surgically at once and to prevent sepsis development by controlling infection. In patients with severe debridement, fighting against infection becomes more difficult as the skin barrier is removed, and fluid losses can be at a serious level. For this reason, we think that it is very important that the patients are followed-up in experienced and equipment-advanced clinics in a comprehensive care.

TJS. 2018;34(Suppl-1):S722.

PP-0976 [Wound, Wound Care and Burn]. Recombinant Human Epidermal Growth Factor Use for Wound Site Reconstruction in a Patient with Open Abdomen

Çağrı Akalın ^1,^✉

Introduction

Open abdomen is accepted to be a situation by the World Society of the Abdominal Compartment Syndrome (WSACS) that the abdomen can not be closed after the abdominal operations and neither the skin nor the fascia of the abdomen can be closed. The mortality level gradually decreased over the years with the help of medical technologies advancing in the open abdomen. Closure of the open abdomen is considered wound healing and growth factors that positively affect the phases of wound healing can accelerate wound healing. In addition to treatment with vacuum assisted wound closure (VAC), we aimed to present our patient with an open abdomen in whom we performed dermis recombinant human epidermal growth factor (EGF).

Case

A 78-year-old male patient was evaluated at the outpatient clinic with the complaints of nausea and vomiting and inability to defecate for 5 days. She had an abdominal operation on his history 30 years ago. He had diabetes and chronic obstructive pulmonary disease as chronic diseases. On the physical examination, no bowel sounds were observed in the abdominal auscultation. The patient‘s standing direct abdominal graphy revealed air-fluid level. Computerized tomography revealed dilatation of ileal intestinal segments. Laparotomy was performed after the clinical picture of the patient did not heal and he was hospitalized with ileus diagnosis. Bridectomy + segmental ileum resection + small intestine end-to-end anastomosis was performed. On postoperative 8th day, VAC washing initiated to the patient who was diagnosed with open abdomen after opening the skin and fascial sutures. The open abdomen was in category 3a by WSACS classification. There was no signs of infection, debris or necrosis on the skin. The recombinant human epidermal growth factor gel was applied once a day to the patient‘s dermis. VAC administration and topical EGF application were performed for about 6 weeks. After these applications, his midline defect was repaired with a skin graft from the left thigh. The patient was discharged on the 6th day of the reoperation with healing.

Conclusion

Open abdomen, is a condition treatment and management of which requires attention and information and the mortality levels are still high. The purpose of the Open Abdominal treatment method, which is classified by WSACS, is to close the abdomen, so this phase includes wound healing phases. It has been reported that the epidermal growth factor affecting wound healing phases stimulates epithelization in studies performed, has a positive effect on dermis formation in the early stages of wound healing, and stimulates healing of chronic wounds. In our case, in addition to VAC administration, we used a gel containing recombinant human epidermal growth factor applied once daily. No reaction or side effects were observed in the dermis regions in our patient. Drugs containing EGF are mostly used in the treatment of diabetic foot, and the experience of using it in open abdomen is very low. We are convinced that the recombinant human growth factor can be used in the treatment of open abdomen.

TJS. 2018;34(Suppl-1):S723.

PP-0977 [Wound, Wound Care and Burn]. A Case of Necrotizing Fasciitis Occurring Secondary to Tooth Abscess

Ahmet Gürkan Uzun ^1,^✉, Murat Özdemir ¹, Gözde Ertunç ¹, Can Uç ¹, Yakup Işik ², Orhan Fahri Demir ², Levent Yeniay ¹

Introduction

Necrotizing fasciitis is a rapidly progressing deep tissue infection involving subcutaneous soft tissue and fascia. Surgical debridement and antibiotic treatment to be performed early can reduce mortality. We will have a case of progressive necrotizing facial necrosis, which starts from the submandibular area of the right second molar secondary to odontogenic infection and leading the involvement of neck, thoracic cortex anterior wall and bilateral breast tissue which is caused by tooth abscess having external orifice in the right mandibular inferior. The necessity of performing early and serial surgical debridement will be emphasized.

Case

A 49-year-old patient who had no self-care, was in depressive episode, who did not report any additional disease other than bipolar disorder, did not regularly use oral antibiotics started 15 days ago due to dental abscess, and admitted to the emergency service at Ege University Faculty of Medicine with a complaint of malodorous wound on the right submandibular region and on the front side of abscess and thorax starting10 days ago. He had no history of trauma, insect bite and any intervention. Physical examination revealed necrotizing, bullous lesions, crepitations and anesthesia starting from the submental area and spreading around the anterior chest wall and left breast areola. Computed tomography revealed an image consistent with necrotizing fasciitis that started from the anterior cervical area and descended to the anterior chest wall. Deep neck structures had no appearance of inflammation/abscess or mediastinitis. In the laboratory tests, blood glucose: 571 pH: 7,1, lactate 2.5, crp: 30 wbc: 26,000, neutrophil 92%, other examinations were normal and the patient had a newly detected diabetes mellitus and a diabetic ketoacidosis picture. Debridement including skin and subcutaneous tissues was applied up to submental area, anterior cervical region, bilateral clavicle and upper and inner quadrants of the left breast. Platisma, pleura and pericardium were intact. Specimens were sent to culture and pathology. In consultation with infectious diseases, meropenem+teicoplanin were initiated. Blood glucose of the patient was regulated by insulin therapy and his vital signs had a stable course. The surgical debridement and negative pressure wound care systems were applied regularly at 3 days intervals. In the first tissue culture, candida albicans and staphylococcus epidermidis reproduced and fluconazole was added to the antibiotherapy of the patient. A new culture sample was taken in every debridement and acinetobacter baumannii reroduction took place in the control culture of the patient. Previous 3 drugs were discontinued with antibiotherapy revision and tigecycline+colistin antibiotherapy was applied. There was no reproduction in the culture sample of the 14th day. Debridement was performed 8 times from the first debridement to the last debridement in the photographs. There was progression in the wound boundaries in the first 4 debridements. In the last 4 debridements, the borders were stable and significant blood build up and granulation tissues were formed. Afterwards the wound was reconstructed by plastic and reconstructive surgical team with a partial thickness skin graft (STSG) taken from the lower extremity. The patient was discharged with recovery.

Conclusion

Early diagnosis of necrotizing fasciitis is life-saving. Early debridement should be performed when NF is suspected. Since the mortality and morbidity are high, the disease should be treated with high clinical suspicion and surgical intervention should be used for diagnosis if necessary. Reconstruction should be planned after the infection picture and necrotic spread have been controlled.

TJS. 2018;34(Suppl-1):S723–S724.

PP-0978 [Wound, Wound Care and Burn]. Recombinant Human Epidermal Growth Factor Use for Wound Site Reconstruction in a Patient with Decubitus Ulcer

Çağrı Akalın ^1,^✉

Introduction

Decubitus ulcer is commonly called pressure sore or bed sore and is an extreme and long-lasting pressure on the skin. It is the pressure, friction, irritation and ulcerations in the tissues that extend to the skin, under the skin and bones. Since ulcer healing involves wound healing phases, growth factors positively influencing these phases can positively contribute to wound healing. We aimed to present our case with decubitus ulcer in whom we applied recombinant human epidermal growth factor (EGF).

Case

A 66-year-old female patient having a history of decubitus ulcer for 5 months had a plegic condition due to cerebrovascular accident 3 years before her history. Hypertension among chronic diseases was present. The patient admitted to general surgery outpatient clinic due to decubitus ulcer. In the physical examination, stage 3 decubitus ulcer with 9x8x2 cm size in the right gluteal region including skin, subcutaneous and muscle fascia having debris on it was present and debridement was performed. Deep tissue culture was obtained, no culture was detected. Wound dressing was performed by applying topical recombinant human epidermal growth factor gel on dermis on the side of ulcer and and saline (SF) on the ulcer cavity. The patient was discharged on the second day after debridement. The ulcer size was measured as 6x4x1 cm at the end of the 30th day of the patient who was regularly dressed with gel dressing including SF + EGF.

Conclusion

Decubitis ulcer is a health problem that increases the risk of morbidity and mortality, prolongs the length of stay in the hospital, and has high treatment costs. With the advancement of medical technology, many options are added to the treatment of decubitus ulcers, one of which is the growth factors that positively affect wound healing. It has been reported that the epidermal growth factor plays an important role in cell growth, proliferation and differentiation, is involved in the differentiation and regeneration of many tissues including epithelial tissue, and has a positive effect on dermis formation in the early stages of wound healing. EGF-containing gel was applied topically on the dermis twice a day to the patient with decubitus ulcer who had no contraindications for the use of EGF. In our patient, no reaction or side effects were observed in the dermis areas applied with EGF gel. Topical-local drugs containing EGF are mostly used in the treatment of diabetic foot, and experience of use in decubitis ulcer is quite low. We believe that the recombinant human growth factor in decubitus ulcer treatment may be among the treatment options.

TJS. 2018;34(Suppl-1):S724.

PP-0979 [Wound, Wound Care and Burn]. Evaluation of Intralesional Epidermal Growth Factor Applications in Diabetic Foot Wounds

Gülsüm Tozlu Bindal ^1,^✉, Murathan Erkent ², İsa Sözen ³

Objective

Diabetic foot injuries are one of the most common complications of diabetes and are an important causes of morbidity and mortality in patients. Traditional wound care treatments such as debridement, revascularization, antibiotic treatment in the case of infection are not sufficient in the treatment of some patients. Supportive care is needed. We evaluated one of the supportive treatments we performed in our clinic.

Material and Methods

Material and Methods

Patients who were treated in our burn center of the Health Sciences University İstanbul Bağcılar Training and Research Hospital during 2016–2017 were retrospectively analyzed in terms of burn scales, sepsis developed, intensive care need, sepsis factors and related mortality and morbidity.

Results

There were 233 patients in our burn center who were interned t o the intensive care and intensive care unit, and 107 of them were hospitalized directly in the intensive care unit. The mean age was 38.6 years and the male to female ratio was 60/173. While the mean duration of hospitalization was 12.9 days, it was observed that this duration extended in intensive care hospitalizations. All of the l22 patients having a mortal course died in intensive care units. Sepsis factors were isolated in 14 of 22 mortal patients. Acinetobacter, Candida, Klebsiella, Pseudomonas and Serratia were isolated as 6, 2, 1, 4, and 1 respectively. Although these antibiotics have been given for these factors, these patients with extensive burns have died of severe sepsis. The factors could not be isolated and the remaining patients had mortal courses due to organ insufficiencies attached to co-morbidities, and especially lung problems.

Conclusion

As seen in our study, the mortality rate associated with complicated burns accompanying sepsis in the patients followed up in our burn intensive care unit is still high with 20.5%. Pre-sepsis is a critical period for burn patients. For this reason, it is important that wound care and infection control of burn patients who are open to infection are done carefully and in a controlled manner. Detection of sepsis factors and the use of specific antibiotics should be done timely and appropriately by burn clinicians.

TJS. 2018;34(Suppl-1):S726.

PP-0984 [Wound, wound care and burn]. Effect of Intraperitoneal N-Acetylcysteine and Ozone Treatment on Stasis Zone Necrosis

Ali Kağan Gökakın ¹, Mustafa Atabey ², Muahemmed Rasid Aykota ¹, Sevda Yılmaz ^1,^✉, Meriç Emre Bostancı ², Onur Avcı ²

The stasis zone is a critical area surrounding the coagulation field and determining the depth and width of necrosis in burns. Several agents have been suggested in the literature to protect the stasis zone. The positive effects of nacetylcysteine on hepatocytes, nephrotoxicity and multiple organ failure in human have been demonstrated. In this study, the effectiveness of nasetylcysteine and ozone in protecting stasis zone was investigated. Intraperitoneal application activities of nasetylcysteine and ozone were compared in the komp model. Additionally serum samples were taken and malondialdehyde levels were measured in these samples in order to measure the antioxidant properties of nacetylcysteine and ozone. As a result, in our study the possible effectiveness of nacetylcysteine and ozone in protecting stasis zone has been displayed and it has also been demonstrated that ozone may be more beneficial than nacetylcysteine.

TJS. 2018;34(Suppl-1):S726–S727.

PP-0985 [Wound, wound care and burn]. The Performance of Our Wound Care Clinic Which has Turned its First Year and the Selected Cases

Mehmet Fuat Çetin ^1,^✉, Sami Doğan ¹

The impairment of the integrity and functioning of the normal anatomical structure is called ‘wound’.

The wound is a condition inherent in the surgical branches that every surgeon must know and treat, but it is not liked by surgeons because of clinical conditions, material concerns and legal problems. It is not desirable to deal with these patients and if they are encountered, salvation remedies are sought. The wound care clinic, located in the Department of General Surgery in Düzce University School of Medicine, which is located in the middle of two large cities but is close to the industrial region and together with neighboring cities having large populations, has a large chronic and difficult wound potential has turned its first year. In this presentation, we wanted to state the diversity and numbers of the patients followed up in our clinic for one year and to explain the difficulties in their follow-up and treatments.

A total of 61 chronic and difficult wound care patients were followed during one year. Patient distribution is as follows:

-5 Fournier gangrene
-4 Necrotizing facade
-20 compression wounds
-19 open abdomen (1 enteroatmospheric fistula)
-6 diabetic foot
-7 patients were accepted from the external center

Statistically significant differences were found in favor of Group B as a result of comparison of scores between groups in terms of inflammatory cell and ulcer formation. Statistically significant results were obtained in terms of collagen accumulation and granulation tissue formation in both groups, but these results were more significant in Group A. Regarding reepithelization, there was no statistically significant difference between the two groups.

Conclusion

Topically applied rifampicin in experimental full-thickness skin defects does not show a positive effect on wound healing process.

TJS. 2018;34(Suppl-1):S731–S732.

PP-0993 [Wound, Wound Care and Burn]. 2 Years Experience of New Burn Unit

Nurullah Damburacı ^1,^✉, Barış Sevinç ¹, Murat Güner ¹, Ömer Karahan ¹

Objective

Burn is an important health problem caused by the effect of heat, electricity and chemicals on the epidermis and dermis layers of the skin which are the protective layer of the body, and in some cases, it occurs with the subcutaneous region, muscle and bone system affected by different depth and width. Tens of thousands of people from all ages in our country every year are burned in various forms and apply to health institutions. Most of these burns are healed by having outpatient treatment and more severe patients are treated with a specialized multidisciplinary approach in the burn units and burn centers which are in limited numbers. In this study, we aimed to evaluate our 2 years experience in our burn unit which was established in October 2015 and actively started to accept patients on March 2016.

Material and Methods

The data of patients who were hospitalized and treated due to burns in our unit between March 2016 and February 2018 were examined through patient file and hospital automation system. Patients’ sociodemographic data, burning pattern and percentage and the procedures performed, and judicial records were recorded.

Results

Hospitalization of a total of 155 burn patients were admitted to our unit. Of these patients, 54.8% (n:85) were male and 45.2% (n:70) were female. The mean age was 42,35±19,1, the burn percentage was 7.73±5.4; with minimum 2% and maximum 35%. Surgical treatment was required in 28.4% (n:44) of these burn patients. Early-stage cesarectomy and grafting were performed for these patients. Fasciotomy was performed in 2 of 5 patients admitted due to electrical burn. The duration of median hospital stay of patients who underwent escharatomy and grafting was 7 (2–21) days. The rate of judicial cases in our province was 29% (n:45) due to industrial development of the province. When the type of burns were examined, it was observed that the most frequent burn type was boiling (hot water and milk) in 67.7% (n:105) of the patients, followed by flame and explosion in 21.9% (n:34) of the patients and electricity burn in 3,2% (n:5) of the patients, contact burn in 3,2% (n:5) of the patients and freezing burns in 0,6% (n:1) of the patients. When type of burns were evaluated, hot water burns were seen more in female patients and flame burns were more in male patients. 77.8% of judicial cases were male patients and 22.2% of them were female patients and this difference was statistically significant (p:0.001). Four patients having burn percentage of 20% and over were referred to an advanced burn center, 2 elderly patients was exitus after surgical treatment due to their comorbid diseases.

Conclusion

Since the establishment of our unit, it has been accepting burn patients in coordination with 112 service. Burn patients having burn percentage over 20% are admitted to our unit having health care workers who have completed the necessary training in our unit according to the Ministry of Health legislation. Treatment of higher burns is also performed in our unit if necessary. When the number of patients who had inpatient and outpatient treatment in such a short time was taken into consideration, it was determined that early escharotomy and grafting increased the success rate in the treatment of burns and shortened the hospitalization period. Burning units seem to meet the high necessity especially in industrial cities like ours.

TJS. 2018;34(Suppl-1):S732.

PP-0994 [Wound, Wound Care and Burn]. Wound Management in Enteroatmospheric Fistula: Case Presentation

Fatma Suakan ^1,^✉, Özlem Gür ², Cengiz Tavusbay ², Mehmet Hacıyanlı ²

Enteroatmospheric fistula (EAF) can be seen as a wound complication in 25% of patients with open abdomen applied for various reasons. It is not a true fistula because it is not covered with tissue on the fistula and there is no fistula tract. It has a very high mortality (42%–75%). The development of EAF often occurs in association with fluid electrolyte disturbance, nutritional deficiencies, and life-threatening sepsis.

In this study, we aimed to share our experiences in the context of the current literature on the subject by presenting a patient operated due to colon cancer and in whom open abdomen and associated enteroatrophic fistula developed after anastomotic leakage.

TJS. 2018;34(Suppl-1):S732.

PP-0995 [Wound, Wound care and Burn]. Evaluation of Last 5-Year Mortality in an Experienced Burn Center

İsa Sözen ^1,^✉, Sencer Ergin ¹, Gülsüm Tozlu Bindal ², İbrahim Doğan ¹, Yunus Nadi Yüksek ¹, Ahmet Çınar Yastı ¹

Objective

Even though early excision and grafting procedures are generally accepted procedures with better understanding of burn pathophysiology and they are reported to decrease mortality, mortality in major burns is still a severe health problem. In this study the patients who had a mortal progress in the last 5 year among those who received inpatient treatment in the burn treatment center of our hospital were evaluated with regard to burn demographies and etiologies.

Material and Methods

The patients with a mortal progress in the burn unit between 2013 and 2017 were evaluated retrospectively.

Results

The mean age of a total of 80 patients were 49,96/year and total burned body surface area (TBSA) was 55,11%. Twenty seven (33,8%) of the patients were female and their TBSA was found as 46,52%. The mortalities of the 5 year was found beginning from 2013 as 16 (2,9%), 20(2,9%),12(2,1%), 18(4,1%) and 14(4,5%) respectively. A total of 64 patients were lost due to flame burn and it was the most common cause of death in all the years. TBSA in flame burns was 57,53% and it was not found different from burns except flame burns. Thirty seven (58,2%) inhalation injuries coexisted with flame burns. The TBSA percentage of the patients who were transferred to the clinic was found to be 59,17%, and they were found at the 2.39th day of the burn injury. Mean hospitalization duration of the transferred patients to the unit was shorter (10,76 days). The most commonly reproducing organisms were Pseudomonas Aeroginosa in the blood and Candida Albicans in the urine.

Conclusion

Flame burns are still causes of more common mortality. The patients’ applying our unit, as a reference center, in the late period, having their acute shock period in other centers and most of the patients’ having received antibiotics show that the initial resuscitation is not sufficient and that the patients were sent having been colonized. The transferred patients’ having larger surface area is an expected result.

TJS. 2018;34(Suppl-1):S733.

PP-0996 [Wound, wound care and Burn]. Evaluation of Patients Over the Age of 65 who are Followed in Our Burn Unit

Mehmet Uluşahin ^1,^✉, Reyyan Yıldırım ¹, Kadir Tomas ¹, Muhammed Selim Bodur ¹, Serkan Tayar ¹, Vural Argın ¹, Arif Burak Çekiç ¹, Mehmet Arif Usta ¹, Ali Güner ¹, Murat Livaoğlu ², Serdar Türkyılmaz ¹

Objective

In this study it was aimed to evaluate general characteristics and treatment results of the patients at the age of 65 and over, who were hospitalized and treated in our burn unit since its establishment.

Material and Methods

The patients at the age of 65 and over who were hospitalized and treated in our burn unit between 2009 and 2017 were found from the database retrospectively. The number of hospitalized patients by years, the patients’ gender, age, burn percentage, causes of burn, hospitalizing days and mortality results were evaluated.

Results

A total of 1808 patients were hospitalized and treated from 2009 when our burn unit was established till the end of December in 2017. Of these patients, 134 (7,4%) were at the age of 65 and over. Sixty three of the patients were male and 71 of them were female. Mean age was 76,08 (65–91). Of these patients, 92 (68,6%) were within the range of 65–79 and 42 (31,4%) of them were at the age of 80 and over. Mean hospitalization duration was 20,3 (1–105) days. While 8 of the patients were hospitalized again after being discharged from the hospital, all of the other patients were hospitalized once. When their burn etiologies are considered, it was seen that 69 of them had flame burn, 51 of them had hot water burn, 8 patients had electricity burn and the remaining 6 patients had chemical burn and other burns such as contact burn. Forty one (30,5%) of the patients had third degree burn. None of the patients had 4th degree burn. Mean burn percentage was detected as 22,5% (0–95). Thirteen of the patients had 41% and over, 16 of them had between%31–40 and 18 had a burn area of 21–30%. The mean burn area in the patients developing mortality was 41,3%. While general mortality rate was 3,8% with 70 patients for 1808 patients hospitalized in the burn unit, the said rate was 26,8% with 36 patients in the age group of 65 and over. While mortality rate was 21,7% with 20 patients in the age group of 65–79, it was detected as 38% with 16 patients in the age group of 80 and over. Thirty of the 36 patients developing mortality had flame burn, 3 of them had hot water burn and 3 of them had other kinds of burns. Thirty of the 36 patients developing mortality had third degree and 6 of them had second degree burns. While mortality rate in the patients hospitalized with burn percentage of 41% and over was 92,3% (12 mortalities/13 patients), this rate was 62% in the patients having burn percentage of %31–40. 61% of the mortality in a total of 36 patients occurred in burn percentage of 31% and over.

Conclusion

Burn patients of geriatric age group is a specific patient group and probability of occurrence of complications is higher. When mortality rates are considered, it is seen that mortality is a severe problem in geriatric age group. Advanced age and high burn percentage have a significant correlation with mortality.

TJS. 2018;34(Suppl-1):S733–S734.

PP-0997 [Wound, wound care and burn]. TRALI Syndrome Developing in A Patient with Major Burn

İsa Sözen ^1,^✉, Sadettin Er ¹, Sabri Özden ¹, Metin Yalaza ¹, Birkan Birben ¹, Mesut Tez ¹

Objective

There are lots of complications developing after blood and blood product transfusion.

Transfusion-related acute lung injury (TRALI) is one of the most common causes of mortality due to transfusion, but it is also the least known. In a UK study, it is seen in every 1/5000 transfusion and 1/625 patients. Consensus on TRALI is accepted as acute impairment of lung function, detection of symptoms within 6 hours of transfusion, bilateral infiltration when PaO2/FiO2≤300 or SpO2 is under 90% on chest X-ray, absence of acute lung injury before transfusion and absence of left atrial findings.

Material and Methods

In the examination of a 22-year-old male patient who was admitted to our clinic at the 48th hour of the explosion in the external center, there were 2nd and 3rd degree burn areas at the rate of 25%. His general condition was moderate, his conscious was open and he was oriented and cooperated. After FFP (fresh frozen plasma) given at the 5th day of the follow-ups of the patient who was performed burn resuscitation, respiratory distress began in hours, his general condition deteriorated, bilateral diffuse infiltration was detected in his chest X-ray, patient’s blood gas values deteriorated, and saturations regressed to 80%.

Results

TRALI diagnosis was established as a result of examination of patient. The supportive treatment was started, and he was intubated. It was paid attention that the patient did not remain hypovolemic.

Conclusion

TRALI should be considered in patients with sudden onset of respiratory distress, especially who are performed transfusion, and we should begin CPAP, mechanical ventilation and supportive treatment for the patient without losing any time. It is important to distinguish between pulmonary edema in differential diagnosis. The most important stage in the treatment begins with considering the diagnosis.

TJS. 2018;34(Suppl-1):S734.

PP-0998 [Wound, Wound care and Burn]. Chronic Wound Clinic; Our 7 Years of Experience

Bülent Çomçalı ^1,^✉, Gökay Serdar Terzioğlu ¹, İsa Sözen ¹, Ahmet Çınar Yastı ¹

Objective

In parallel with the increasing average life span, chronic wounds occurring rarely in the past are more common every day. In this sense, we aimed to retrospectively evaluate the patients who were hospitalized in our chronic wound service of our hospital since its establishment.

Material and Methods

Patients who received inpatient treatment at our chronic wound clinic were evaluated retrospectively between April 2010 and December 2017. Gender, age, diagnosis of admission, mean hospitalization day, number of amputations of the patients were recorded and statistically evaluated.

Results

The mean age of the 1014 patients who received inpatient treatment during the study was 60.04±13.30. 747 (73.7%) of the patients were male and their mean age was 59.13±13.06. 849 (83.72%) patients were admitted due to diabetic foot ulcer and it was detected to be the most frequent cause of chronic wound. A total of 155 patients were amputated. While one of the 2nd, 3rd and 4 th fingers of 41 (28.5%) of the patients were amputated, multiple finger amputation was performed in 37 (25.7%) of the patients and knee level amputation was performed in 20 (13.9%) of the patients. The mean duration of hospitalization was 32.07±30.6 days.

Conclusion

Chronic wound is an important health problem that is increasingly seen in our country. Considering that the treatment takes a long time and the number of troublesome and serious amputations is high, accurate determination of the under-risk patients and provision of proper precautions for protection are essential.

TJS. 2018;34(Suppl-1):S734–S735.

PP-1001 [16th Surgical Nursing Congress Reports]. The Effect of Regulations Made in the Department of Emergency Medicine on Patient Satisfaction

Aydanur Öztürk ^1,^✉, Serap Çelik ¹, Birgül Ödül Özkaya ¹, Sevda Polat ¹

Objective

Patient satisfaction is defined as the rate at which the desired outcome of a given illness care is increased and the possible unwanted consequences are reduced. Emergency services that provide 24 hours uninterrupted service are the vitrines of hospitals. Emergency services are required to provide health care services quickly and with quality. With this study, we aimed that the services provided in the emergency departments are organized well, carried out without any problems, served in good conditions and to increase patient satisfaction.

Material and Methods

A number of regulations were made in Istanbul to increase patient satisfaction in a Training and Research Hospital Emergency Medicine Clinic. Patients’ telephone information was updated in the registration areas of patients who applied to the emergency medicine clinic and information messages were sent to the patients’ phones. “Dear Patient name and surname Welcome to our emergency service. You will be called as soon as possible. We wish you a quick recovery” The number of health staff in the field of triage was increased, vital findings of the patient were taken with a digital monitor and a brief anamnesis inquiry was made and the patient was fitted with an identity wrist band. The number of seats in the patient waiting area has been increased. Tea and coffee machines were put in the waiting area. The number of patient welcoming personnel was increased and service was provided for the handicapped and elderly patients to be examined, treated and transferred to other services. The number of patient call screens was increased, the information that the examination turn of the patients have come was reflected on the screens both visually and aurally. The laboratory results screen was put and the information about whether the results are ready or not, or which results are ready and which results are waited were reflected to the screen. The anxiety of the patient was eliminated. A night pharmacy screen was created in the waiting area. The treatment was allowed to begin in a short time.

Conclusion

It was observed that the rate of patient satisfaction increased by 98% and that the white code (violence against health workers) decreased with these regulations made in Emergency Medical Clinic.

TJS. 2018;34(Suppl-1):S735.

PP-1002 [Surgical Area Infection, Surgical Intensive Care]. Preoperative Antibiotic Prophylaxis in Surgical Patients is a Problem that Needs to be Addressed

Hidayet Bilaloğlu İsayev ^1,^✉

Objective

In connection with the spread of multiresistant microorganisms, the rational use of antibiotics is acute all over the world. The reason for this situation is a long history of improper use of antibacterial drugs. One aspect of the rational use of antibiotics is antibiotic prophylaxis (ABP).

The aim of the study is to evaluate the rationality of using antibiotics in patients with surgical profile.

Material and Methods

A retrospective study of 200 medical histories of patients with surgical profile who were on inpatient treatment at the Scientific Center of Surgery of the Republic of Azerbaijan was conducted using random sampling. “ When assessing the history of the disease, the validity of prescribing antibacterial drugs, the time of administration of the first dose of antibiotic, the adequacy of the dose regimen were evaluated.

Results

Of the 300 cases analyzed, antibiotic prophylaxis was shown in 274, which was 91.3%. Among them, the percentage of ABP conducted in compliance with the basic rules was 12.7% (38 cases). The use of ABP with incomplete adherence to the basic rules was 14.3% (43 cases), of which unreasonable prolongation of the antibiotic administration period for prophylaxis beyond 24 was 37.2% (16 cases). ABP was not performed in 74.3% (patients (222 cases), 67.6% of them (150 cases) were cases of unreasonable prescribing of antibacterial therapy after an operation for 5 to 20 days. Thus, the results of the study showed that in most cases, in the presence of indications, ABP was not performed, while there was a replacement of preoperative ABP with postoperative antibiotic therapy. This leads to a significant overexpenditure of antibacterial drugs in surgical sections, an increased risk of developing adverse adverse reactions, as well as to the selection of resistant flora. The presented results demanded a number of administrative decisions, namely, the clinical pharmacologist conducting an educational medical conference on the main aspects of ABP, issuing an order to optimize the use of antibiotics in surgical sections, the inclusion of routine checks on the rationality of antibiotic prescribing in surgical sections in the work plan of the clinical pharmacologist.

Conclusion

In the work of surgical sections, the unjustified prescription of antibiotics in the postoperative period was 50.5%. To increase the rationality of the use of antibacterial drugs, it is necessary to conduct additional educational activities, the administrative restriction of prescribing antibiotics in the postoperative period, and regular expert evaluation of pharmacotherapy.

TJS. 2018;34(Suppl-1):S735–S736.

PP-1004 [Emergency Surgery and Trauma]. Late Presentation of Microperforation Secondary to Blunt Abdominal Trauma: Two Case Reports

Ahmet Necati Şanlı ^1,^✉, Deniz Esin Tekcan Şanlı ², Ali İşler ¹, Mehmet Sertkaya ³, Arif Emre ¹

Introduction

Late presentation of microperforation after small intestinal ischemia due to blunt abdominal trauma is very rare. In this article, we aimed to present the patients having no abdominal pathology in initial admission after the accident and who were admitted to the hospital with late acute abdomen picture.

Case 1

A 24-year-old male patient with a history of traffic accident about 1.5 months ago applied to our emergency service with complaints of abdominal pain 4 times during this period. The patient was discharged without any acute abdominal pathology. In physical examination performed at his last admission, defense and rebound were positive, infection parameters were high, diffuse pathology wall thickening was detected in distal ileum and a long intestinal segment in iv contrast abdominal tomography, there was an increase in mesenteric vascularity at this level and the finding of scalloping, there was clustering in the bowel loops which was higher in the right lower quadrant of the abdomen and appendix and cecum were normal. The patient was operated urgently with the diagnosis of acute abdomen.

In the operation, the appendix was observed to be normal and the small intestines appeared like an edematous and red mass at 20 cm proximal area of the cecum. Small intestinal resection and appendectomy were performed when the mass could not be opened with blunt and sharp dissection. Pneumonia and wound site infection have developed in post-operative follow-ups. The wound of the patient whose treatment was completed, was sutured and the patient was discharged

Case 2

A 23-year-old male patient with an in vehicle traffic accident history about 1.5 months ago was admitted to our emergency department due to increasing intermittent abdominal pain complaints in the last two days. In the abdominal ultrasonography, there was an increase of echogenity in the surrounding mesentric tissues in an almost 6x3,5 cm region of the lower right quadrant of the abdomen and free fluid between bowel loops; a tubular structure with a length of 4 cm having single wall thickness of 4,5 mm and unclear wall integrity and (perforated appendicitis). The patient having been established the diagnosis of perforated appendicitis was operated after anesthesia preparation was made. It was observed in the operation that the appendix was normal, but it appeared that the small intestines formed a conglomerate structure about 5 cm proximal to the cecum. This area was separated by blunt and sharp dissection. Leakage control was made. A drain was placed in the operation area of the patient in whom no leakage was detected and the abdominal wall was closed. No complication was observed in the postoperative follow-up, and drain of the patient was removed and he was discharged.

Conclusion

We think that the picture in both of our cases is such that late presentation of microperforation developing after the ischemia developing in the small intestine after blunt abdominal trauma caused acute abdomen. The diagnosis of small intestine ischemia and microperforation associated with abdominal blunt trauma is difficult to establish at an early stage and early diagnosis and treatment is very important in reducing mortality and morbidity. A possible intestinal ischemia and micro-perforation should be kept in mind in cases experiencing such blunt abdominal trauma. Close clinical follow-up and appropriate radiological imaging should be performed.

TJS. 2018;34(Suppl-1):S736.

PP-1005 [Emergency surgery and trauma]. The Torsion of a Wandering Pelvic Spleen: a Case Report

Tolga Kalayci ^1,^✉, Serhat Binici ¹, Özkan Yılmaz ¹, Necat Almalı ¹

Introduction

Wandering spleen is a rare clinical picture because the spleen is not found in the normal anatomical location and ligaments enabling the attachment to the surrounding tissues are loose and absent. Wandering spleen torsion should also be included among the pre-diagnoses that should be considered for patients having acute abdomen developing suddenly and when there is a mass in the abdomen examination. The actual diagnosis should be established with the help of additional imaging and acute abdomen should be treated as soon as possible. In our case, our patient was admitted to the emergency service due to acute abdomen and healing was achieved conducting splenectomy after establishing the diagnosis of wandering spleen torsion by examination and abdominal ultrasonography.

Case

A 27-year-old female patient was admitted to our emergency service due to abdominal pain which started the same day. She did not have any comorbidity or surgery in her medical history. There was a mass filling the pelvis and diffuse tenderness in the examination. The patient’s fever was normal, mild dyspneic-tachycardic and normotensive. In the blood count, the number of white cells was 8,6 10^3/μL and C Reactive Protein was 110 mg/L. Other laboratory parameters were normal. In the ultrasonography performed under emergency conditions, the spleen was pelvic and the long axis dimension of the spleen was approximately 16 cm and there was (infarct?) of about 7*4 cm in the inferior part of the spleen. The patient underwent emergency laparotomy. At exploration, it was observed that the spleen filled the pelvis, there was infarct in the inferior part of the spleen, and the splenic artery-vein rotated 2 full turns (720 degrees). Splenic vende had a diffuse thrombus on palpation. After detorsion of the splenic vascular structures, splenectomy was completed by isolating and connecting the splenic artery and vein from the pancreatic tail. The patient was discharged on postoperative 3rd day without any complication.

Conclusion

Wandering spleen torsion should be considered in differential diagnosis of a patient who presents with an abdominal pain complaint of sudden onset, and have an acute abdomen and a palpable mass in the examination. Additional imaging techniques should be used to confirm the diagnosis and emergent surgical intervention should be performed once the diagnosis is confirmed. It should not be forgotten that wandering spleen torsion causes rarely acute abdomen.

TJS. 2018;34(Suppl-1):S737.

PP-1006 [Gastrointestinal System Surgery (esophagus, stomach, small intestines)]. Malignant Melanoma Gastric Metastasis; Case Report

İsmail Tırnova ^1,^✉, Özgen Işık ¹, Ersin Öztürk ¹

Case

A 46-year-old male patient presented with weight loss, nausea and vomiting complaints. He had a history of excision of malignant melanoma on the left forearm about 60 months ago. In the following months at different times, mass excision invading the left frontal bone and mass excision from the right thigh and right thorax wall were performed. The pathologies were compatible with MM. In the same period, he received radiotherapy (RT) for ankle, knee and pelvic metastases. On developing dyspeptic complaints, ulcerovegetan mass with irregular margin extending from the corpus to the antrum was detected. His biopsy was compatible with MM metastasis. Hemoglobin was measured at 8 gr/dL. No other pathological laboratory findings were found. Computerized tomography (CT) revealed an increase in wall thickness at the antrum level. The liver was normal. In PET-CT, metabolic activity at malignancy level was detected in antrum. The patient with severe nausea and vomiting was operated due to distal gastric MM causing gastric outlet syndrome and anemia. At the exploration, a tumor attached to transverse colon and pancreas in antrum was detected. The tumor caused gastric outlet syndrome. Palliative subtotal gastrectomy and segmental colectomy were performed. On the fifth postoperative day, the patient tolerating normal oral intake was discharged without any problems. 8x3.5 cm malignant melanoma (pT3) was detected. A minimum of 1 cm clean surgical margin was obtained and 5 benign and 7 malignant lymph nodes were detected.

MM is the most common metastatic tumor to GIS. It was found that the most frequent metastases were small intestine (50%), colon (31.3%), and anorectum (25%) respectively. Clinical metastases were detected in only 1–4% of these patients while autopsy examinations revealed a GIS metastasis rate of 6%. MM gastric metastases are very rare. It is quite difficult to detect them since they progress with nonspecific symptoms and significantly shorten the survival time. Patients with MM history, GIS symptoms and anemia have a good chance of being diagnosed with endoscopic evaluation. Median survey in gastric metastases is between 4 and 6 months. In our case, gastric metastasis was detected 60 months after primary skin lesion. There are intervals in the literature that extend to 10 years. Surgical indications in our case are gastric outlet syndrome and development of anemia. It is obvious that gastrectomy will not provide curative expectations at the R2 level in the metastatic patient. However, when complications such as the ones we encounter develop, surgery may be the only intervention. In Ollila’s study, 124 MM patients with GIS metastasis were examined and found to have a 6-fold increase in survival in whom resection was performed. In selected cases, surgery can improve both survival and quality of life.

Conclusion

As a result, MM tends to metastasize and the possibility of GIS metastasis in patients with nonspecific dyspeptic complaints and anemia should be kept in mind. Surgery may be the only effective option in selected cases.

TJS. 2018;34(Suppl-1):S739.

VP-006 [Obesity]. Pre-Operative Management of Adverse Situations in Laparoscopic Mini Gastric Bypass Surgery

Uğur Bulut ^1,^✉, Tülay Diken Allahverdi ¹

Abdominal CT scan result

The left renal vein was localized between the superior mesenteric artery and the aorta, and a significant thinning was observed at this level of calibration. The stomach, the first and second parts of the duodenum were slightly dilated. The duodenum was collapsed in the third part. In the result of the investigation of the superior mesenteric artery syndrome, the aorta mesenteric angle was measured at 18 degrees. Aorta mesenteric distance was 4 mm at the 3rd part of the duodenum. The findings support the superior mesenteric artery syndrome. An operation was planned for the patient who had been hospitalized many times before and had not benefited from the medical treatment. The duodenum was cauterized in the laparoscopic surgery by using 3 trocars and a duodenojejunostomy was performed with laparoscopic linear stapler at approximately 20 cm from the treitz. The patient whose oral feeding was started on the postoperative 4th day and discharged on the postoperative 5th day was seen to have significantly improved appetite and oral feeding in the postoperative outpatient clinic controls. We wanted to show in this case that laparoscopic surgery can provide good results in patients with SMA syndrome who do not respond to medical treatment.

TJS. 2018;34(Suppl-1):S740.

VP-017 [Gastrointestinal Surgery (esophagus, stomach, small bowel)]. Laparoscopic Resection of a Difficult Benign Gastric Tumor

Cengiz Eriş ^1,^✉, Yasin Duran ², Nertila Hysenaj Cevheroğlu ³, Roya Alp ⁴

Objective

We aimed to show that difficult tumor operations in the stomach may be possible with the endoscopy-assisted laparoscopic resection.

Content Description

The resection of a 6-cm benign tumor located close to the gastroesophageal junction in a 32-year-old male patient with the video endoscopy-assisted laparoscopic surgery technique after releasing it completely from the gastroesophageal junction is shown in the video.

Conclusion

In today’s surgical practice, when considering the results, it is obvious that the laparoscopic surgery is superior to the conventional surgery in selected suitable patients with shorter hospitalization, shorter duration for return to work, less postoperative intra-abdominal cohesions and ileus, lower wound infection rate, more comfortable postoperative process, more cosmetic outcomes and lower risk of postoperative hernia in the long term. In equipped centers with high laparoscopic surgery experience, video endoscopy-assisted laparoscopic surgery may be considered in the first plan when the treatment of the gastrointestinal system lesions following a detailed preoperative examination is scheduled.

TJS. 2018;34(Suppl-1):S741.

VP-018 [Gastrointestinal Surgery (esophagus, stomach, small bowel)]. Laparoscopic Radical Subtotal Gastrectomy in a Case with Early Stage Gastric Cancer; Video Presentation

Mehmet Akif Türkoğlu ¹, Çağrı Büyükkasap ^1,^✉, Saygın Altıner ¹, Emre Gülçek ¹, Mehmet İbiş ², Metin Alkan ³, Abdulkadir Bülent Aytaç ¹

Introduction

Laparoscopic surgery has increasingly been taking the place of the open surgery in the early stage gastric cancer surgeries, and the studies have been continuing for the advanced stage gastric cancer. However, adequate lymph node dissection due to tumor localization and type makes the laparoscopic gastric surgery technically difficult. In this article, we aimed to present the case who underwent Laparoscopic Distal Subtotal Gastrectomy and D2 Lymph node dissection for the lesion in the gastric antrum and the operation technique.

Case

A 2.5-cm polypoid lesion with raised edges and a collapsed center and located in the gastric antrum was detected through endoscopy in 52-year-old female patient who was admitted to our center with dyspeptic complaints. A diagnostic and therapeutic endoscopic submucosal dissection (ESD) was planned for the entire lesion upon the detection of low-grade dysplasia on the biopsy. However, upon the detection of muscularis propria invasion in the lesion in the endoscopic ultrasonography, ESD was cancelled and surgery was scheduled. In the abdominal computed tomography examination for staging, no distant metastasis and pathologically enlarged lymph nodes were detected in the patient and D2 lymph node dissection with laparoscopic distal subtotal gastrectomy and Roux-N-Y gastrojejunostomy were performed in the patient. The operation lasted 320 minutes. The total amount of bleeding during the operation was 220 ml and no blood transfusion was performed. The patient was allowed for oral fluid intake on the 3rd postoperative day and discharged on the 7th day without any problems. The pathological examination revealed that the lesion contained multiple foci of high grade dysplasia and 17 reactive lymph nodes were removed.

Conclusion

The safety of laparoscopic radical gastrectomy for early stage gastric cancer has been proven clinically and accepted as the standard approach. However, oncologic results and adequate staging in the laparoscopic gastrectomy depends on the adequate lymph node dissection and it should be performed in experienced centers.

TJS. 2018;34(Suppl-1):S741.

VP-019 [Gastrointestinal Surgery (esophagus, stomach, small bowel)]. Revision of the Nissen Fundoplication and Mid-Gastric Plication Procedure with Partial Gastrectomy and Laparoscopic Roux En Y Gastric Bypass

Müfit Şansal ^1,^✉, Egemen Çiçek ¹, Fatih Sümer ¹, Cüneyt Kayaalp ¹

Gastric bypass is the gold standard for morbidly obese patients with gastroesophageal reflux. However, it is not suitable for the 1st and 2nd stage obese patients. Mid-gastric plication and nissen fundoplication are defined for this group of patients. We aimed to share a video of the gastric bypass revision surgery of a patient who was admitted to our clinic for the reason of inadequate weight loss even though he/she underwent this operation. Revision surgery after gastric plication is in the literature. However, the revision of mid-gastric plication and nissen fundoplication combination surgery have not been reported previously. Patient with 48 kg/m2 (120 kg) body mass index underwent nissen fundoplication and mid-gastric plication lost 28 kg in the first 6 months and complaints of reflux disappeared. In the following period he/she quickly regained the weight he/she had lost. Patient with of 45 kg/m2 (112 kg) body mass index underwent laparoscopic partial gastrectomy and gastric bypass revision procedures. Khazakka et al first applied a procedure consisting of a combination of gastric plication and nissen fundoplication to gastroesophageal reflux patients with 32–35 kg/m2 body mass indexes in the 1st and 2nd stage obesity groups. The patients’ complaints of reflux were reduced and they herewith lost about 10 kg. Same results were obtained in other similar studies, but various complications and revisions were reported.

We preferred the revision with gastric bypass, considering that the patient had no arterial feeding from the large curvature and that the symptoms of reflux can reoccur if sleeve gastrectomy is performed.

TJS. 2018;34(Suppl-1):S742.

VP-020 [Gastrointestinal Surgery (esophagus, stomach, small bowel)]. Minimally Invasive Intragastric Laparoscopic GIST Excision

Volkan Sayur ^1,^✉, Özgür Fırat ¹, Taylan Özgür Sezer ¹, Sinan Ersin ¹, Can Uç ¹

Stomach stromal tumors constitute 1–2% of the stomach tumors. A 67 year old woman was admitted with dyspeptic complaints. Endoscopic USG: A stapled intragastric laparoscopic gastric wedge resection was planned for the patient with 25*15 mm mesenchymal tumor.

Objective

The aim of our study is to increase the awareness of the intragastric laparoscopic technique that can be applied on the lesions in the lumen of the stomach and especially in the sections of cardia and fundus, and to share our experience.

Preoperative Findings

A polypoid lesion about 2–2.5 cm in the incisura cardialis at the gastric cardia level.

Surgical Procedure

The abdominal wall was opened with an approximately 3-cm superior incision. Two suspension sutures were implemented in the stomach. The stomach lumen was entered with a cautery through the suspensions. The externally prepared glove port was advanced through the opening. The stomach was insufflated. The tumor was reached and a suspension was placed on it. Its root was transected together with the submucosal surface by using endo-GIA stapler. The tumor was taken out of the opening in the stomach. The stomach was closed in a double layer closure.

Conclusion

The patient was discharged on the 3rd postoperative day without any problems. There are very few examples in the literature. This method was successfully applied several times in our clinic before. Less post-operative pain, earlier return of respiratory gastrointestinal functions, shorter length of hospital stay, no need for large laparotomy, and a much clearer identification of the lesion with intragastric exposure are the advantages because of its minimal invasive nature. We think that, with the spread of the operation, it can be performed safely in experienced hands on selected eligible patients.

TJS. 2018;34(Suppl-1):S742.

VP-021 [Gastrointestinal Surgery (esophagus, stomach, small bowel)]. Robotic-Assisted Transthoracic Esophageal Diverticulectomy: 3 Case Series

Bengi Balci ^1,^✉, Gizem Kılınç ¹, Bülent Çalık ¹, Gökhan Akbulut ¹

Introduction

Esophageal diverticulum is a rare disease that causes symptoms such as dysphagia, halitosis, chest pain and regurgitation. The surgical indications can change and the operation is performed in the presence of a diverticulum greater than 3 cm in size because any of these symptoms leads to an increased risk of malignancy and aspiration. Surgery is the preferred treatment method and can be performed with different approaches such as open/robotic or laparoscopic, transhiatal/transthoracic ways.

Case

Three patients who were examined preoperatively by using esophagogastroduodenoscopy, esophageal manometry and computerized tomography and diagnosed with epiphrenic diverticulum were taken to the operating theatre. Robotic-assisted transthoracic esophageal diverticulectomy was performed on the patients. The mean operation time was 211 minutes, no blood loss was observed, and no intraoperative complications developed. Postoperative complications during the follow-up procedures of the patients and additional procedures are explained in the case report in detail.

Discussion

Robotic assisted transthoracic esophageal diverticulectomy was performed for the esophageal diverticulum for the first time and it is a method that can be performed safely and effectively in selected patients.

TJS. 2018;34(Suppl-1):S742–S743.

VP-022 [Colon and Rectal Surgery]. Robotic Complete Mesocolic Right Hemicolectomy Technique

Fatih Altıntoprak ^1,^✉, Mustafa Yener Uzunoğlu ², Enis Dikicier ¹, Kemal Gündoğdu ², Yasin Alper Yıldız ²

Introduction

Complete mesocolic excision in colon cancers was described by Hohenberger et al. in 2009 and it became the gold standard surgical technique in the surgical treatment of colon cancer. Studies showed that more lymph nodes were removed with this technique than with the classical excision. In this presentation, we aimed to share the details of the surgical technique applied to a patient who underwent robotic complete mesocolic excision for right-sided colon cancer.

Case Report and Technical Details

In the colonoscopic examination applied to a 41-year-old man due to anemia, an intraluminal lesion was detected in the colon and biopsy result was determined as adenocarcinoma. Surgical procedure decision was made for the patient who did not have metastasis in the screening examinations and the robotic complete mesocolic excision for right-sided colon cancer was performed. Following the endotracheal intubation, the patient was positioned (supine, arms closed, 150 tilt to the right, and Trendelenburg position). Da-Vinci S Robotic System (Intuitive Surgical System, USA) was used in the operation. A 12-mm camera port was inserted from 7–8 cm on the left side of umbilicus by using open method and the abdomen was inflated with CO2 gas. Docking procedure was completed following the completion of laparoscopic exploration and removal of the small bowel loops from the dissection site. The dissection was started from the bottom to the top starting from the medial. The ileocolic artery and vein, the right colic vein, the superior mesenteric artery and the vein exit site were ligated and cut. The right branch of the middle colic artery was connected from the bifurcation level and cut. After vascular control, the right colon was released by advancing from medial to lateral. Right ureter was seen and preserved. Transverse colon mesos were prepared and lumens were closed with endoscopic linear stapler from the terminal ileum and cut. Following the completion of the resection, the resected material were taken to the lower left quadrant. Ileum loop and transverse colon were anastomosed side-by-side using endoscopic linear stapler. After anastomosis, stapler openings were closed with continuous sutures. The place of resected material port was enlarged and the resected material was taken out of the abdomen. Postoperative follow-up was smooth and the patient was discharged on the 4th day. In the result of the pathologic examination, the patient was evaluated as T3N1M0 and taken to the chemotherapy program.

Conclusion

The three dimensional image provided by the robotic surgery, its maximum range of motion capacity up to 540 degrees and its conveniences for the surgeon with the elimination of the tremor help making the surgical anatomy to be perceived more easily, and these distinctions allow the operation without leaving the embryological plans. Robotic surgery, which also includes the classic advantages of minimally invasive surgery, will find more areas of utilization in the following years with the elimination of its disadvantages.

TJS. 2018;34(Suppl-1):S743.

VP-023 [Colon and Rectum Surgery]. Wide Local Excision for Perianal Paget’s Disease

Özgen Işık ^1,^✉, Burak Bakar ¹, Tuncay Yılmazlar ¹

Objective

Primary perianal Paget’s disease (PPD) is extramammary Paget’s disease on the perianal skin area where no other underlying malignancy such as rectal or anal canal cancer is detected. In this video, extensive local excision treatment of PPD is presented.

Video Content

The results of gastroscopy, colonoscopy, mammography, thorax and abdominopelvic computed tomography (CT), PET-CT and gynecological examinations made for the investigation of underlying malignancy in a 53-year-old female patient with PPD confirmed by skin biopsy were normal. According to the laboratory results, only carcinoembryogenic antigen (CEA) level was high (10,6 ng/mL, reference range: 0–5 ng/mL). Mechanical bowel cleansing was performed for the patient before the surgery. Wide local excision was performed on the perianal skin affected by PPD involving approximately 1 cm of healthy skin in the lithotomy position. The defect was closed with a split thickness skin graft (STSG). A rubber rectal tube was placed following the procedure. The oral intake of the patient was started on the 1st postoperative day, the dressing was opened and the rectal tube was removed on the 3rd day, and she was discharged on the 4th day. Pathology was compatible with PPD. In the 3rd postoperative month follow-ups, there was no recurrence or newly discovered malignancy in the patient.

Conclusion

Extensive local excision is the most preferred surgical method in the treatment of primary PPD. STSG is useful in closing the skin defect that occurs.

TJS. 2018;34(Suppl-1):S743–S744.

VP-025 [Colon and Rectum Surgery]. Laparoscopic Ventral Mesh Rectopexy in the Patient with Rectal Prolapse

Fatma Ayça Gültekin ^1,^✉

Objective

In the treatment of external rectal prolapse (ERP), the laparoscopic ventral mesh rectopexy (LVMR) has gradually become a common surgical technique especially in the USA, albeit at a slower rate in Europe. In the video, LVMR operation for the patient with ERP is presented.

Case

A 65-year-old woman is admitted to the hospital with a complaint of chronic rectal prolapse during defecation. The physical examination of the patient complaining of stool leakage several times a week and gas incontinence shows that she has Oxford grade 4 rectal prolapse caused by straining. Patient with normal colonoscopy result was prepared for the operation with the risk of ASA III. The patient underwent LVMR. The patient starting oral feeding on the first postoperative day is discharged on the 3rd day.

Conclusion

LVMR is a technique that can be preferred as a safe and minimally invasive method in the treatment of ERP.

TJS. 2018;34(Suppl-1):S744.

VP-026 [Colon and Rectum Surgery]. Transperineal Mesh Repair in the Patient with Isolated Rectocele

Fatma Ayça Gültekin ^1,^✉

Objective

There are different repairs applied by different disciplines in the treatment of rectocele which is among the obstructive defecation syndromes (ODS). However, what should be considered here is that there may be other pelvic organ impairments that often accompany ODS syndromes. In the video, the transperineal mesh repair is shown in a patient who underwent abdominal surgery previously and had only rectocele detected in dynamic MR-defecography.

Case

A 69-year-old woman was admitted to our hospital with frequent bowel movements, fecal impaction, and the need for manual intervention complaints. The patient had hypertension and past surgical history due to hysterectomy and perforated appendicitis. In the physical examination, median incision scars were found under and above the umbilicus and a rectocele was found in the rectal examination. The patient with normal colonoscopy result underwent a dynamic MR defecography for pelvic organ pathology. A 4.5 cm isolated rectocele was determined and a surgical operation was planned in ASA II risk group. The patient underwent transperineal mesh repair. On the first postoperative day oral feeding was started and she was discharged on the third day without any problems.

Conclusion

In the cases where there is no accompanying pelvic floor pathology in the rectocele treatment, transperineal mesh repair is a treatment option that can be preferred.

TJS. 2018;34(Suppl-1):S744.

VP-039 [Hepatobiliary Surgery]. Robotic Cholecystectomy and Choledochal Stone Extraction

Video Content

In the rectal examination of the 54 year old male patient with rectal bleeding and difficulty in defecation, a mass with smooth surface and soft tissue located approximately 2 cm proximal to the anus was found and palpated. A 7x6x5 cm wellcircumscribed mass with a cystic and solid component growing towards the right pararectal area was reported in the pelvic MR examination. According to the result of transrectal biopsy performed with endoanal ultrasonography, it was reported as a GIST.

The patient underwent a mechanical bowel cleansing and an operation in prone jackknife position. Paracoccygeal incision was performed. The coccyx was removed, the anococcygeal ligament was incised and the fibers of the levator ani were eliminated by pushing them to both sides to reach the mass. With blunt and sharp dissections, the mass was liberated from the mesorectal tissues and the rectum was excised together with the posterior wall. The opening on the posterior wall of the rectum starting from the anal canal and continuing to 6 cm proximal was repaired by continuous suture technique. One drain was placed in the region and the muscular and subcutaneous tissue was closed in the anatomical plane. The patient was placed in the supine position and the operation was concluded with the laparoscopic loop ileostomy. The patient was discharged without any problems on the 5th postoperative day.

Conclusion

Distal rectal GISTs are usually appropriate lesions for the transsacral approach. This rather rare disease of the rectum requires that the Kraske procedure, an old surgical technique, should be remembered in practice in current colorectal surgery.

TJS. 2018;34(Suppl-1):S748.

VP-158 [Endoscopy (Gastroscopy, Colonoscopy, ERCP)]. Installation of Endoscopic Ultrasonography Unit in General Surgery Clinics and Its Contribution to Case Management

Murat Çilekar ^1,^✉

Introduction

The aim of our study is to investigate the effect and contribution of endoscopic ultrasonography unit installation to treatment plan in general surgery clinics.

Case

Endoscopic ultrasonography (EUS) was developed in the 1980s for only imaging, and it was started to be used in fine needle aspiration biopsy with the development of the linear EUS scopes in the 1990s, and in the interventional and therapeutic procedures with the development of accessory devices. Two faculty members in our clinic received training on EUS and the unit started to be used in our hospital on Jan 03, 2018. EUS processor, echoendoscopes (radial, linear, rectal), miniprobe and echo-endoscopy needles (19G - 22G - 25G) should be kept as basic equipment in the EUS room. We performed EUS in a total of 24 patients and FNAB in 7 of them. We performed cyst aspiration (inflammatory hC-amylase over 500) in 2 and pancreatic mass biopsy in 5 of these procedures. We made 6 choledocholithiasis and 2 chronic pancreatitis diagnoses. One biopsy result was reported as inadequate material, and pancreatic biopsy of 2 patients is still in process. Choledocholithiasis or mass resection that could not be performed in 3 patients was accomplished with EUS. The operability that could not be clarified by other imaging methods for 3 patients with pancreas ca prediagnosis was clarified by the detection of the invasion of portal vein and superior mesenteric artery on EUS. The stages of 2 papillary tumors were also clarified with EUS and treatment plans were changed.

Conclusion

We believe that the installation of EUS units is inevitable due to both the cancer staging procedure and the effectiveness of treatment algorithms.

TJS. 2018;34(Suppl-1):S748.

VP-159 [Endoscopy (Gastroscopy, Colonoscopy, ERCP)]. The Repair of Rectal Injury Caused by a Foreign Body with Endoclip in a Patient Admitted at the 72nd Hour

Cemal Seyhun ^1,^✉, Mehmet Abdussamet Bozkurt ¹, Ali Kocataş ¹, Savaş Bayrak ¹, Mehmet Emin Güneş ¹

Rectal injuries caused by foreign bodies are evaluated in a wide range of methods ranging from minimally invasive surgery to abdominal surgeries accompanied by stoma. If the patient is admitted to the hospital in the acute phase and there is no abscess accompanying the wound (first 6 hours), it is repaired by endoscopic methods. Our patient is a 17 year old male who was admitted to the hospital in the 72th hour after the incident; he was evaluated to have rectovesical fistula in the tomography, it was repaired with endoclip. A Foley catheter was applied to the patient for bladder injury and he was followed up for 7 days with clinical and laboratory findings and discharged after the procedure. The repair of delayed rectal injury with endoclip is the first case in the literature. This study was prepared to show that the patient can be treated with minimally invasive methods instead of a surgery with high morbidity and mortality.

TJS. 2018;34(Suppl-1):S749.

VP-161 [Endoscopy (Gastroscopy, Colonoscopy, ERCP)]. Gastroscopic Perforation of the Stomach, Case Report

Hasan Bektaş ¹, Hüsnü Şevik ¹, Ufuk Oğuz İdiz ^1,^✉, Bünyamin Gürbulak ¹, Serkan Sarı ¹

Introduction

Gastroscopy is a commonly used method in the diagnosis and treatment of upper gastrointestinal system diseases. Stomach perforations that occur during the procedure are very rare (0.03%–2%) but can lead to severe mortality and morbidity. In this study, it was aimed to present a case of gastric perforation during gastroscopy in a video.

Case

A 73-year-old male patient was admitted to our polyclinic with dyspeptic complaints that lasted for several months. Anamnesis indicated that the patient had advanced COPD. An iatrogenic gastric perforation about 6 cm in size extending along the small curvature of the stomach occurred during gastroscopy and it was tried to be repaired with endoscopic clips, but when the procedure failed, an emergency surgery decision was made. In the operation, a perforation focus extending from the incisura angularis to the cardia was detected. No contamination was detected in the abdomen. The primary repair was applied on the perforation focus with double layer suturing technique. The patient was followed up in ICU in the postoperative period. The patient with COPD exacerbation and Acinetobacter baumannii in tracheal aspirate culture during intensive care follow-ups died on the 5th postoperative day.

Conclusion

Diagnostic and therapeutic endoscopy is a commonly used method in gastrointestinal system diseases. Iatrogenic perforation is one of the rare but serious complications of endoscopy. Endoscopic perforations are less common in the stomach than in the colon due to the gastric compliance. Endoscopic treatments should be tried first when a perforation occurs. Iatrogenic perforations can be mortal especially in the people with comorbid diseases despite their low frequency.

TJS. 2018;34(Suppl-1):S749–S750.

VP-162 [Gastrointestinal Surgery (esophagus, stomach, small bowel)]. Atypical Massive GI Bleeding

Çağdaş Karaman ^1,^✉, Oğuz Hançerlioğulları ¹, Ömer Kurt ², Ali Kağan Coşkun ¹

Introduction

Wegener’s granulomatosis is a necrotizing granulomatous type vasculitis with indefinite cause that can usually occlude small or medium sized vessels as well as lead to systemic involvement. It can be seen in common vasculitis pictures occluding small arteries and veins. WG can occlude the upper and lower respiratory tracts, kidney and other organs. GI bleeding is rare. Urinal findings, nodules or infiltrations in the lungs, high sedimentation rate, unexplained anemia and c-ANCA positivity and the biopsies of the occluded organs can be required for definite diagnosis.

Case

A 43 year old female patient who was admitted to the nephrology polyclinic with the complaints of arthralgia, purpuric rash in knee, ankle and hip, extensive bullous lesion in mouth, fatigue and weight loss about 2 months ago was hospitalized with the prediagnosis of vasculitis. The patient underwent renal biopsy and he was diagnosed with WG and discharged after starting steroid therapy. Upon the complaints of acut epigastric pain, hematochezia or melena and deterioration in the general condition during the follow-up period, she was hospitalized and followed up in ICU. Upper and lower GI endoscopy, colonoscopy, angiography, and erythrocyte scintigraphy were performed for the bleeding focus, but no focus was detected. The patient was given 1000 mg methylprednisolone, 500 mg cyclophosphamide and 400 mg Mesna (detoxifacin) 2 times. Due to the impairment in her general situation despite plasmapheresis 3 times and 20 units of blood and blood product transfusion, she was referred to our clinic. The patient was followed up in a surgical intensive care unit. In the examinations performed (HbB 3.9), there was deep anemia, coagulation disorder due to massive blood transfusion. Consultation was requested from gastroenterology, hematology, and rheumatology clinics. Upper and lower GI endoscopy-colonoscopy was repeated. Intravenous immunoglobulin therapy was started. Upon the ongoing massive GI bleeding and worsening general condition, emergency exploration was performed. Approximately 500 cc hemorrhagic fluid in the abdomen was detected in the exploration. Entire colon and small intestines were explored, but no bleeding focus or area of necrosis was detected. In all segments of the small intestine, lesions in the cobblestone appearance were detected. Thereupon, preoperative colonoscopy was performed; subsequently, intraoperative ileoscopy-jejunoscopy was performed after performing a tomy in the proximal, approximately 20 cm from the cecum, and no active bleeding focus was detected. Ankaferd blood stopper was applied to the oozing style bleeding foci. It was detected that the mucosa and submucosa of the lesions in the small bowels disappeared, and only the serosal structures were normal. Since these lesions were available to be perforated, primary suture was performed, and an ileostomy was opened. On the 3rd postoperative day, a reoperation was performed because of the low hemoglobin level despite the massive blood transfusion. Necrotic areas were observed in the small bowels, and segmental resection with anastomosis was performed. The general condition of the patient worsened in the postoperative period and she was connected to the mechanical ventilation. The patient was given a total of 35 ES 38 TDP blood transfusions. She died on the 7th postoperative day.

Conclusion

WG is a highly mortal disease that can also cause systemic involvement that can occlude the gastrointestinal system, and needs a multidisciplinary approach for its treatment.

TJS. 2018;34(Suppl-1):S750.

VP-228 [Hernia Surgery]. Laparoscopic Transabdominal Preperitoneal Repair in Inguinal Hernia

Sami Doğan ^1,^✉, Mehmet Fuat Çetin ¹

Objective

Inguinal hernias can be repaired with “onlay” or laparoscopic (IPOM) techniques, but due to the reasons such as recurrence and adhesion, preperitoneal “sublay” or “underlay” synthetic patch application can be preferred to intraperitoneal placement. Because of the technical difficulties, preperitoneal repair is not common in the world. There are no studies published yet about this application in Turkey. Our aim in this study is to investigate the feasibility and success of laparoscopic preperitoneal repair in the inguinal hernias.

Material and Methods

Six patients with different types of inguinal hernia problems underwent hernial repair with laparoscopic transabdominal preperitoneal synthetic patch between March and October 2017. The data collected prospectively from these patients were evaluated. In the preperitoneal repair, all abdominal adhesions were dissected with “harmonic” dissection after creating the conditions for standard laparoscopic hernia repair. Hernia contents were reduced. A curved incision was performed on the peritoneum towards the lateral and vertical side at least 5 cm away from the edge of the facial defect. Preperitoneal dissection for paraumbilical hernias involves the risk of peritoneal perforation. For this reason, a retromuscular area was formed in front of the posterior rectus sheath in case of umbilical and paraumbilical hernia. Especially peritoneum and fat tissue are apparent in the superior and inferior of the paraumbilical area. For this reason, it is easy to create a preperitoneal area. Polypropylene mesh is fixed in this area and the peritoneum is closed.

Results

The mean age of 5 male and 1 female patients in whom repairs were performed was 50 (33–63). Hernia defects are located in the midline. Three umbilical, 2 midline incisional hernias and an epigastric hernia were repaired. The defect size is about 3.8 x 2.5 cm (2–5) and the patch size is about 12.5 x 12.17 cm² (12–15). The mean duration of operation is about 96.67 (70–140) minutes. Postoperative hospital stay is about 1.8 (1–3) days. Seroma occurred in two patients as a complication. The average follow-up period is 8.5 (6–13) months. There was no recurrence of hernia in the early follow-up period.

Conclusion

Laparoscopic inguinal hernia repair with preperitoneal patch minimizes the complications due to intraperitoneal placement of synthetic material. The mechanical advantages of the natural intra-abdominal pressure are utilized to keep the synthetic patch in the preperitoneum in place. Peritoneum prevents the formation of adhesions by forming a barrier between the patch and the bowels, and provides additional safety in keeping the patch in place. Laparoscopic preperitoneal inguinal hernia repair is a safe and feasible choice in experienced hands. Zero contact of the synthetic material with the abdominal organs and the use of laparoscopic technique ensure a safe and comfortable repair with low complication rates. Although this surgical approach has not become the gold standard yet, it ensures that the abdominal organs are not exposed to the mesh and adhesions. This method suggests innovative components of Laparoscopic comfort.

TJS. 2018;34(Suppl-1):S750–S751.

VP-229 [Hernia Surgery]. Simultaneous Laparoscopic Orchiectomy and Tapp Repair in Adult Patient with Inguinal Hernia and Undescended Testicles; Video Presentation

Mehmet İlker Turan ^1,^✉, Bülent Dinç ², Umut Rıza Gündüz ³, Özgür Cem Müsri ²

Objective

Approximately 7% of patients with inguinal hernia in childhood also experience undescended testicular problems. Although undescended testicles are rare in adulthood, its incidence along with inguinal hernia is reported as 0.7% in some studies in the literature. In this video presentation, we aimed to present the effectiveness of laparoscopic orchiectomy and hernia repair performed in a 26-year-old male patient with undescended right testis and inguinal hernia.

Material and Methods

After placing a 10-mm trocar in the right paramedian line and a 5-mm trocar in the left paramedian line, the peritoneum was liberated over the hernia line starting from 1 cm medial of the spina iliaka anterior superior to the medial umbilical ligament. After the lateral working space was created, the dissection of the space of Bogros in the medial was completed. Vas deferens and gonadal vascular structures were isolated after the hernia sac was released. The testis was taken into the abdomen and liberated from the surrounding tissues. Vas deferens, testicular vascular bundle and cord were ligated with Hem-O-Lock clips and the specimen was taken out through the 10-mm trocar site in the right paramedian. Subsequently, the hernia line was attached to the Cooper ligament first and then to the posterior abdominal wall by using prolene mesh graft and the operation was ended by closing the peritoneum.

Conclusion

We think that the laparoscopic orchiectomy and hernia repair offer better cosmetic results than the open surgery and can be performed safely in patients with undescended testis and inguinal hernia and with orchiectomy indications due to undescended testis.

TJS. 2018;34(Suppl-1):S751.

VP-230 [Hernia Surgery]. Bilateral Inguinal Hernia Repair and Orchiectomy in Testicular Feminization

Erman Sobutay ^1,^✉, Çağrı Bilgiç ¹, Serkan Zenger ¹, Uğur Can ¹, Ender Anılır ¹, Bülent Gürbüz ¹, Tunç Yatlı ¹

Introduction

TJS. 2018;34(Suppl-1):S752–S753.

VP-241 [Endocrine Surgery]. Laparoscopic Cyst Excision in an Aortocaval Paraganglioma Case

Nihat Aksakal ^1,^✉, Umut Barbaros ¹, Alp Bozbura ¹

Paragangliomas are neuroendocrine tumors arising from neural crest cells. They may arise in different localizations such as abdomen, thorax and neck with different findings. Retroperitoneal paragangliomas are very rare. The risk of complications due to the surgical treatment in the cases with critical involvement increases, although they are usually benign tumors. Especially in the cases with aortocaval involvement, both the risk of vascular injury and the adrenergic hormone discharge due to further manipulation of the mass increase the risks of surgical complications and hypertensive crisis at the same time.

The exact treatment of the paragangliomas is complete surgical excision. Surgical methods vary according to the localization and size of the mass. The primary goal in the surgical treatment is complete excision with as little manipulation as possible. In the cases with abdominal involvement, laparoscopic surgery can provide a better field of vision, safer dissection plan, and minimize the manipulation on the mass. In the 24 hour urine of a 38 year old patient who had been examined upon the complaints of occasional headache, palpitations, sweating for about 5 years was diagnosed with hypertension, and the levels of catecholamines and metabolites were high. On the imaging with prediagnosis of pheochromocytoma, a 5-cm solid mass lesion with aortocaval involvement and increased vascularity was detected in the retroperitoneal space. Upon the diagnosis of paraganglioma, alpha blockage therapy was initiated and blood pressure was controlled. The localization of the mass was quite difficult in terms of the opening and the laparoscopic surgery. However, the large and hormonogenic formation of the mass was increasing the risk of hypertensive crisis due to the manipulation during the operation despite the alpha blockade. For this reason, we agreed on the laparoscopic intervention for the patient. However, atypical location of the mass posed a problem in terms of the patient positioning, dissection planning and navigation. In order to overcome these difficulties; after performing 3D reconstruction and contrasted abdominal CT of the patient; the mapping, patient positioning and dissection plan were prepared thanks to the PVC print of the mass and the aortocaval place. The patient underwent a laparoscopic excision of paraganglioma. The surgery was completed without complications. On the 3rd postoperative day, the patient was discharged without any problems. Laparoscopic excision can be preferred in selected cases because of better visual field in benign paraganglioma cases, less risk of hypertensive crisis with less manipulation and lower incidence of postoperative complications due to smaller incision.

TJS. 2018;34(Suppl-1):S753.

VP-247 [Hernia Surgery]. Combined Laparoscopic TAPP and IPOM-Plus Techniques for Multiple Synchronous Hernia

Halil Afşin Taşdelen ^1,^✉, Banu Karapolat ¹

Introduction

It was aimed to present the combined TAPP and IPOM-plus techniques for recurrent left inguinal, ipsilateral femoral and obturator hernia, epigastric and recurrent umbilical hernia in a female patient.

Video Content

The 45-year-old female patient was hospitalized with the diagnosis of recurrent inguinal hernia, umblical hernia, and epigastric hernia. It was found out from the patient’s history that she had left inguinal hernia 9 years ago, cesarean 6 years ago, umbilical and recurrent left inguinal hernia surgery 1 year ago. In the operation under general anesthesia, the abdomen was entered with a trocar through the umbilical fascial defect. The preperitoneal area was disrupted. Hernia incision was peritonealized. The round ligament was excised. Femoral and obturator hernia were detected in the explorization. The polypropylene mesh was fixed. The peritoneum was closed with absorbable tacker. Umbilical trocars were removed and the fascial defect was closed. Additional trocars were inserted from the right. Falsiform ligament was dissected. The epigastric fascial defect was brought into view. The defect was closed with 3 extracorporeal polypropylene sutures by using endoclose. The defect was closed with 3 pairs of no 1 extracorporeal sutures by using endoclose. A 15x10 cm dual mesh was attached with 2 transabdominal sutures and absorbable tackers. The patient was discharged without any complication on the 2nd postoperative day. The patient was clinically asymptomatic at the end of 6-month follow-up.

Conclusion

Multiple synchronous hernias can be treated simultaneously by observing the entire peritoneal cavity with a laparoscope. In such cases, we think that different laparoscopic repair techniques can be applied together.

TJS. 2018;34(Suppl-1):S753–S754.

VP-248 [Endocrine Surgery]. First Plica Prolene Mesh Application in Laparoscopic Total Extraperitoneal Hernia Repair

Şükrü Çolak ^1,^✉, Fatih Dal ¹, Hasan Bektaş ¹, Ekrem Çakar ¹, Savaş Bayrak ¹

Inguinal hernia repair is one of the most common surgeries performed by surgeons. E.Bassini described inguinal hernia repair technique which is known by its name in 1887. Since that time, approximately more than 70 inguinal hernia repair techniques have been defined due to the complications and recurrence rates in inguinal hernia repairs. Considering the chronological order, the most commonly used and applicable scientific techniques today are as follows; Shouldice in repair with suture, lichtenstein in repair with anterior mesh, and tepp and tapp technique in laparoscopic repair. All these techniques have advantages as well as disadvantages. The expectations in the technique used in contemporary inguinal hernia repair are minimally invasive technique, low recurrence rate, short recovery period, less pain in the short and long term and low operation costs.

Detection of mesh in laparoscopic TEP repair in inguinal hernia is one of the biggest disputes. In the beginning, the fear for the laparoscopic inguinal hernia repair was the recurrence of the hernia. For this reason, the mesh was fixed in the preperitoneal area with a tucker. Soon afterwards, it was understood that these mesh fixings performed can cause nerve entrapments and chronic pains. Attentions have shifted to the incidence of chronic pain rather than recurrence with the reduction of the recurrence rate with the TEP method performed by detecting the mesh. Alternative methods such as different meshes and fibrin glue were used to reduce the incidence of this chronic pain. In these methods, either the mesh itself sticks to the wall of the abdomen or the fibrin glue is used for adhesion.

In this article, we aimed to present a more economical approach reducing both recurrence and post-operative pain by plicating the prolene mesh without using either special mesh or adhesive in TEP method.

TJS. 2018;34(Suppl-1):S754.

VP-249 [Endoscopy (Gastroscopy, Colonoscopy, ERCP)]. Endoscopic Submucosal Dissection Experiences in Mucosal and Submucosal Lesions of the Stomach Using Synchronic Double Endoscope Technique

Oğuzhan Tekin ^1,^✉, Şükrü Çolak ¹, Ekrem Çakar ¹, Serkan Sarı ¹, Hasan Bektaş ¹

Objective

Endoscopic submucosal dissection (ESD) is a minimally invasive procedure that can be effectively applied in the mucosal and submucosal lesions of the stomach and a popular procedure in recent years. Especially, in early stage gastric cancers (less than <2 cm, not invading the muscularis mucosa layer, T1a) it can be preferred. Since standard ESD requires one hand operation, the operation is difficult and long, and the complication rate is high. It requires an experienced and skilled endoscopist. It is possible to overcome these problems with the double endoscope method. Two endoscopes are inserted in at the same time in the double endoscope technique. While the lesion is elevated with one endoscope, the dissection is performed with another one. In this study, we aimed to introduce the technique performed in a patient who underwent ESD with double endoscope technique and to transfer our experience.

Material and Methods

We performed the process on 5 patients in total with this technique in the Surgical Endoscopy Service in our hospital between May 2017 and February 2018. The duration of the procedure was about 60 minutes. Bleeding occurred in two patients as a complication and it was stopped with a clip. A suspicion of perforation occurred in a patient and the suspected area was brought closer with clips.

Video Content

An intramuscular adenocarcinoma was detected in the stomach antrum on the gastroscopy applied for the 71 year old male patient with dyspeptic complaints. Then, the patient underwent EUS and it was decided that he was eligible for ESD. The patient underwent ESD by using the double endoscope method and the lesion was excised with clear surgical margins.

Conclusion

Double endoscope ESD is an expensive method because it requires double light source, double endoscope and double endoscopist. However, it is a more reliable, shorter and less complicated method than the standard ESD. Excision of the lesion with en-bloc and clean surgical margins is more effective. Because, since the traction is provided by one endoscopy, submucosal dissection can be performed easier. Therefore, double-endoscopic ESD is a more preferred method for mucosal and submucosal lesions of the stomach, especially for early gastric cancers.

TJS. 2018;34(Suppl-1):S754–S755.

VP-295 [Hepatobiliary Surgery]. Laparoscopic Approach in the Treatment of Pancreatic Pseudocyst: Case Report

Sedat Tan ^1,^✉, Erkan Oymacı ², Hilmi Yazıcı ¹, Burak Dede ¹, Orkun Subaşı ¹, Mehmet Yıldırım ¹

Introduction

Pancreatic pseudocysts are the lesions that are bordered by fibrous tissue containing necrotic debris and pancreatic fluid secretions but not a real epithelial tissue. Pancreatic pseudocysts can be seen in approximately 2–10% of acute pancreatitis cases and 10–30% of chronic pancreatitis cases. Large (> 6 cm) symptomatic pancreatic pseudocysts that do not regress in the interval period after the attack of acute chronic pancreatitis should be treated with various interventional methods. Minimally invasive methods are preferred more frequently according to the cystic site and its relation with the other internal organs due to the developing techniques. In this case, we share the application of laparoscopic cystogastrostomy for the treatment of pancreatic pseudocyst developing after acute pancreatitis.

Case

A 45 year old female patient was admitted to the hospital with acute biliary necrotizing pancreatitis. On the abdominal CT of the patient, there was an image compatible with necrosis areas at a rate of more than 50% in pancreatic corpus. The patient was followed up by medical treatment and discharged. During the follow-up visit, approximately 30 cm asymptomatic pseudo-cyst development was detected and followed up. During the follow-up period, decreased oral intake and complaints of nausea and vomiting developed. The abdominal CT applied in the 6th month of the follow-up revealed a 150x96 mm lesion and cholelithiasis compatible with pancreatic pseudocyst without septation in pancreatic corpus. It was seen that the cyst was pressuring the stomach and 1st part of the duodenum anteriorly. In addition, the splenic vein was also obliterated due to cystic pressure. Laparoscopic cystogastrostomy with anterior approach was decided for the patient who would undergo cholecystectomy. The 4-trocar method was used to enter the abdomen. The anterior wall of the stomach was opened through the antrum-corpus junction. The Veres needle was inserted into the cyst and after aspirating the cyst fluid, the stomach was opened through the posterior wall of the stomach and the cystic cavity was entered. Cystogastrostomy was performed with two 60-mm endoscopic staplers. Cyst contents and debris were evacuated. The front wall of the stomach was closed with two 60-mm staplers. Regular cholecystectomy was performed. On the 6th postoperative day, the patient was discharged without any problems. It was seen in the follow-ups that the cysts regressed.

Conclusion

Pancreatic pseudocysts are seen in acute and chronic pancreatitis and approximately 30–60% of them resolve and regress spontaneously in the follow-up period after attack. Approximately 10–30% of them require intervention. Percutaneous, endoscopic and surgical methods can be used in the treatment of pancreatic pseudocysts. Percutaneous drainage is not preferred because of the frequent occurrence of pancreatic fistulas. The rate of recurrence and the probability of complication are increased in endoscopic interventions performed on giant pseudocysts with necrosis greater than 50% and cyst greater than 15 cm. For this reason, if cholecystectomy is to be added to the procedure in these types of cysts, we believe that laparoscopic cystogastrostomy should be performed as the first step due to low complication and recurrence rate.

TJS. 2018;34(Suppl-1):S755–S756.

VP-299 [Transplantation]. The Evaluation of the Organs Sent from Other Centers in Cadaveric Organ Extraction

Yücel Yüksel ^1,^✉, Deniz Yüksel ², Levent Yücetin ³, Mehmet Sarıer ⁴, Halil Erbiş ¹, Asuman Yavuz ⁶, Sabri Tekin ¹, Melten Demir ⁵, Alper Demirbaş ¹

Objective

The number of patients waiting for organs is increasing. About 35–40% of brain deaths in our country are used as organ donors. The cadaver donation rate in our country is 3–3.5 per million population. Organs are very valuable because of the limited number of cadavers and care should be taken for the extraction.

Material and Methods

Organs sent from the other centers to Antalya Medical Park Hospital Organ Transplantation Department between November 2016 and January 2018 were evaluated. During this period, 13 liver and 36 kidneys were sent to our center. The organs were evaluated in terms of PACKAGING, EXTRACTION, PERFUSION (GOOD-BAD). PACKAGING; direct contact of the organ with ice was evaluated as BAD.

EXTRACTION; the presence of superficial capsular laceration, parenchymal injuries, vascular injuries, portal vein thrombosis were evaluated as BAD for the liver (L). For the kidney; cutting the renal artery and vein 1–1.5 cm away from the hilus and cutting of the ureter from 4 cm were evaluated as BAD (Injuries that would not complicate the renal artery and venous anastomosis were not included in the study). PERFUSION; clotted blood from the veins when the organ was perfused again during the back table was considered as BAD.

Results

Packaging of 13 livers sent from other centers was evaluated as GOOD. The extraction of 4 of these livers were considered BAD. Four of them had 5x4 cm hepatic capsular defects. In 2 lungs, approximately 4x3 cm lacerations were detected and a portal vein thrombosis occurred during the organ extraction in 1 of the same livers. The liver with thrombosis was not used. During the same period, 36 kidneys were sent from the other centers. PACKAGING of 3 of the kidneys sent was evaluated as BAD. There was ice around the kidney. The extraction of 7 kidneys were evaluated as BAD. Hilar injury in the renal artery and vein, dissection in the renal artery, dissection of the ureter form the renal pelvis, very short (1.5–2 cm) dissection of the renal arteries were the injuries we encountered. Perfusion of 6 kidneys having clotted-blood leakage from the renal veins was evaluated as BAD.

Conclusion

The number of cadaveric donors for organ transplantation is low and every stage of these operations requires attention. Every step from the extraction of the organs to the packaging requires attention.

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PERMALINK

21st Turkish Surgical Association Annual Congress Abstract Supplement

OP-001 [Endocrine Surgery]. The Properties Related to the Recovery Time of Parathyroid Function in Hypoparathyroidism After Thyroidectomy

Zeynep Gül Demircioğlu

Mahmut Kaan Demircioğlu

Mehmet Taner Ünlü

Mert Tanal

Ozan Çalışkan

Nurcihan Aygün

Mehmet Mihmanlı

Mehmet Uludağ

Objective

Material and Methods

Results

Conclusion

OP-002 [Endocrine Surgery]. Our Experience of Transoral Endoscopic Thyroidectomy/Parathyroidectomy Vestibular Approach

Baran Mollavelioğlu

Yiğit Soytaş

İsmail Cem Sormaz

Yasemin Giles Şenyürek

Fatih Tunca

Objective

Material and Methods

Results

Conclusion

OP-003 [Endocrine Surgery]. Does Primary Hyperparathyroidism Lead to Unnecessary Diagnosis of Thyroid Papillary Cancer?

Cem Batuhan Ofluoğlu

Kenan Çetin

Önder Altın

Selçuk Kaya

Objective

Material and Methods

Results

Conclusion

OP-004 [Endocrine Surgery]. The Predictive Value of Parathormone Measurement for the Risk of Hypocalcemia Development in the First Hour After Total Thyroidectomy

Baran Mollavelioğlu

İsmail Cem Sormaz

Fatih Tunca

Yasemin Giles Şenyürek

Objective

Material and Methods

Results

Discussion

OP-005 [Endocrine Surgery]. What is the Diagnostic Value of Thyroid fine Needle Aspiration Biopsies in Which Liquid-Based Cytology (Sure-Path) Method Applied?

Canan Sadullahoğlu

Objective

Material and Methods

Results

Conclusion

OP-008 [Obesity]. The Effect of Laparoscopic Sleeve Gastrectomy Surgery on Early and Late Glucose Homeostasis in Diabetic Morbidly Obese Patients

Emre Bozkurt

Sinan Ömeroğlu

Cemal Kaya

Mehmet Mihmanlı

Objective

Material and Methods

Results

Conclusion

OP-009 [Obesity]. Is Bile Stone Formation After Sleeve Gastrectomy Associated with Weight Loss? Case-Control Study

Abdullah Şişik

Objective

Material and Methods

Results

Conclusion

OP-010 [Obesity]. The Role of p53 Gene Polymorphism in Obese Patients

Mehmethan Cihan

Hakan Buluş

Serpil Oğuztüzün

Onur Dirican

OP-011 [Breast Diseases and Surgery]. Can Axillary Dissection be Avoided in Patients in whom Sentinel Lymph Node Biopsy is Performed after Neoadjuvant Chemotherapy?

Selman Emirikçi

Neslihan Cabıoğlu

Didem Trabulus

Enver Özkurt

Mustafa Tükenmez

Selim Doğan

Abdullah İğci

Vahit Özmen

Ahmet Dinççağ

Mahmut Müslümanoğlu

21^st Turkish Surgical Association Annual Congress Abstract Supplement