Risk factors for peritoneal dissemination of gastric cancer
Yeldan E. 1, Oguz S. 2, Usta U. 3, Ilhan E. 1, Senlikci A. 1
1 Izmir Bozyaka Educational and Research Hospital, Izmir, Turkey;
2 Department of General Surgery, Trakya University, Edirne, Turkey;
3 Trakya University Medical Faculty, Edirne, Turkey
AIM: Tumor dissemination, lymphnode involvement and surgical resection technique are the most important factors affecting patient prognosis with gastric cancer. Peritoneal dissemination adversely affects the survival rate in patients. Microscopic peritoneal dissemination can be detected with peritoneal lavage cytological examination. Peroperatively detected microscopic peritoneal dissemination changes the treatment plan for patients and can be useful when selecting patients who should undergo adjuvant chemotherapy.
METHODS: At the Trakya Universtity Faculty of Medicine, General Surgery Department, a total of 41 patients who had macroscopic peritoneal dissemination during the dates January-December 2011 were included in the study. Perioperative peritoneal lavage was performed and cytological examination of peritoneal aspirate carried out. Using tumor markers the relationship between lymph node metastasis, prognostic type, tumor location and perineural invasion was investigated on the serum and peritoneal fluid.
RESULTS: Forty-one patients were operated on; 10 of them (24.4%) had positive malignant cytology and 31 (75.7%) had negative cytology. Just 1 (7.2%) patient was found to have positive cytology out of 13 (31.7%) that did not have serous invasion. Of the 28 (68.3%) patients with serous invasion, 9 patients (32.1%) were found to have positive cytology. No significant pattern was detected in the carcino-embryionic antigen, cancer antigen 19-9 and AFP levels in both the positive and negative cytology serum and peritoneal lavage fluid. Of the 41 patients operated on 5 (12.2%) were found to have cardia dissemination and 13 (31.7%) were found to have dissemination located at the corpus. Peritoneal dissemination was found to be significantly high in gastric cancer located in the cardia and corpus. Fourteen (34.1%) of the patients had stage I and stage II cancer and 27 (65.9%) of patient’s had cancer in stages III and IV. Just 1 (7.1%) patient with stage I or II cancer was found to have positive malignant cytology, however 9 (33.3%) patient’s of stage III and IV gastric cancer patients were tested positively for malignant cytology.
CONCLUSION: A positive relationship was detected in the positive peritoneal cell malignancy with cancer stage, age, invasion depth and tumor location in patients.
Comparison between electronic method and conventional method recording and follow-up of general surgery ward-round notes taken
Aydin I. 1, Yeldan E. 2, İbiş A. C. 3, Albayrak D. 3, Oğuz S. 3, Senlikci A. 2
1 General Surgery Clinic at the Faculty of Medicine of Trakya University, Edirne, Turkey;
2 Izmir Bozyaka Training and Research Hospital, General Surgery Clinic, Izmir, Turkey;
3 General Surgery Clinic, Faculty of Medicine of Trakya University Edirne, Turkey
AIM: Patient anamneses and ward-rounds notes taken are two key elements which have been and will be used to ensure accurate and reliable sustainability at surgery services. In this study, we aimed to find a new method which is capable of better addressing the needs in this process, simplifying it and also saving time. We also targeted to compare this new method used by us with the method, also known as conventional method, having been used for years.
METHODS: Thirty patients were included in the study. The prehospitalization anamneses of the patients were taken using the two methods and the durations were recorded separately for the two methods. Thereafter, the patients were visited by two methods in the morning on each day of their stay. The durations were recorded daily and separately for the two methods. The durations were statistically evaluated separately for the anamneses and ward-round notes taken.
RESULTS: Evaluations showed that the method using hand terminal (1.2250 minutes) is more advantageous in terms of duration in recording ward-round scores than the conventional method (1.3853 minutes). It was founded that in regard to the duration, the average duration of manual anamnesis taking (16.3350 minutes) is higher than that of taking anamnesis by means of hand terminal (15.4733 minutes). Furthermore, it was also seen that the use of this new technique eliminated the problems previously experienced in data transfer, access to historical data etc.
CONCLUSION: In conclusion, this method that is tested by use of hand terminal is more advantageous than the conventional method in terms of time saving and accurate data transfer. It is our opinion that it will provide advantages in many more aspects if it is worked on.
GALLSTONE ILEUS IN UNEXPECTED LOCALIZATION: A CASE REPORT
Abdullah Şenlikci1, Eyüp Yeldan1, Ahmet Mücteba Öztürk1, Emrah Dadalı1, Uğur Gökçelli1, İbrahim Atasoy2, Enver İlhan1
1İzmir Bozyaka Eğitim Ve Araştırma Hastanesi, Genel Cerrahi Kliniği
2İzmir Bozyaka Eğitim Ve Araştırma Hastanesi, Radyoloji Kliniği
Memenin Nadir Görülen İntrakistik Karsinomu: İki Olgu Sunumu
İntrakistik papiller meme karsinomu (İPK) genellikle ileri yaş post menopozal kadınlarda görülmektedir. Prognozu diğer meme tümörlerine göre çok daha iyi olup genellikle invaziv komponentleri yoktur. Tedavisinde salim cerrahi sınırla eksizyonu ve aksiller sentinel lenf nodu örneklenmesi önerilmektedir. Burada tarafımızca tedavi edilen 2 intrakistik papiller meme karsinomlu olguyu sunduk. Olguların her ikisi de post menopazal, her ikisinde de östrojen ve progesteron reseptörleri pozitif, HER 2 negatif idi. Her iki olguya da meme koruyucu cerrahi uygulandı. Bir olguda invaziv odak olduğu için aksiller lenf nodu örneklemesi uygulandı ve sentinel lenf nodu metastatik değildi. Bu olguya hormonoterapi yanı sıra radyoterapi uygulandı. Diğer olguya ise invaziv odak olmadığı ve cerrahi sınırlar salim olduğu için ek cerrahi işlem uygulanmadı. Olgu hormonoterapi almaktadır. Klinik yada radyolojik olarak kuşkulu meme kistlerine sahip özellikle ileri yaş olgularda intrakistik meme karsinomu akılda tutulmalı, biopsi ve lokal eksizyon yönünden değerlendirilmelidir. İPK tanısı konan olgular da standart yaklaşım olmamakla birlikte mutlaka cerrahi yönünden değerlendirilmeli ve sonrasında adjuvan tedavi açısından her hasta bireysel olarak ele alınmalıdır.
Abstract
Introduction
Acute appendicitis is the most frequently observed disease requiring emergency surgery. The role of parasites in its pathogenesis has long been discussed. The signs of the parasitic infestations can mimic the signs of acute appendicitis. Therefore, it can cause a negative laparotomy.
Aim
To evaluate the parasitic infestations of the appendix vermiformis whether increas the rate of negative laparotomy.
Material and methods
The histopathology results of a total of 3863 patients who underwent appendectomy with clinically acute appendicitis were evaluated retrospectively. All appendectomy materials in which parasites were observed were evaluated with respect to the nature of the parasites and the findings of inflammation. Cases in which parasite tissue fragments and/or eggs as well as findings of inflammation were histopathologically observed in the appendix lumen were diagnosed with parasitic appendicitis.
Results
Evidence of parasites was observed in 19 (0.49%) of the evaluated appendectomy materials. In 9 (47.3%) of these specimens that had evidence for parasites, findings for acute appendicitis and localized peritonitis were identified. Findings of acute appendicitis had not been identified in the other ten (52.7%) of the specimens. Enterobius vermicularis was the most frequently identified parasite.
Conclusions
In parasitic acute appendicitis, appendectomy in itself is not sufficient for treatment. Pharmacological treatment should also be administered after surgery. Patients should be evaluated prior to surgery for parasites, and diagnosis of acute appendicitis should be considered more cautiously in order to avoid negative laparotomies.
Keywords: acute appendicitis, negative laparotomy, parasites, infestation
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Introduction
The aetiology of acute appendicitis includes fecaliths, lymphoid hyperplasia, fruit and vegetable seeds, barium enemas and tumours. Parasites are one of the more uncommon causes of acute appendicitis. Enterobius vermicularis, Ascaris lumbricoides, Schistosoma spp. and Taenia spp. are the parasites that can lead to a clinical picture of acute appendicitis. Enterobius vermicularis is the parasite that most frequently contributes to a clinical picture of acute appendicitis [1, 2].
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Material and methods
The files and electronic records of 3863 patients who underwent appendectomy at the Izmir Education and Research Hospital General Surgery Clinic between 2003 and 2012 were evaluated retrospectively. All appendectomy materials in which parasites were observed were evaluated with respect to the nature of the parasites and the findings of inflammation.
The appendectomy materials were subject to fixation with 10% formaldehyde, tissue follow-up and paraffin block embedding. The 4-micron-thick sections obtained from the paraffin blocks were stained with haematoxylin and eosin, and examined under a white light microscope. Cases in which parasite tissue fragments and/ or eggs as well as findings of inflammation were histopathologically observed in the appendix lumen were diagnosed with parasitic appendicitis
Results
A total of 3863 patients underwent surgery with clinically acute appendicitis. Parasites had been observed in 19 (0.49%) of all evaluated appendectomy materials. Of the patients with parasites in their materials, 12 (63.2%) were female and 7 (36.8%) were male. Their average age was 30.6 years (range: 17–83 years). Of these parasites, 16 (84.2%) were identified as E. vermicularis, and 3 (15.8%) were identified as Taenia saginata. Acute appendicitis and localized peritonitis had been identified pathologically in 9 (47.3%) out of a total of 19 appendectomy materials. Findings of acute appendicitis had not been identified in the other ten (52.7%) materials (Table I). None of the patients had developed any significant morbidity or mortality. All patients had been postoperatively started on anti-parasite treatment and discharged from the hospital between their 1st and 3rd postoperative days.
Discussion
Acute appendicitis is the most frequently observed disease requiring emergency surgery, and it affects nearly 7% of the population. It is observed more frequently in developed countries than in developing countries. The main cause of acute appendicitis is the obstruction of the appendix lumen. The underlying cause for its greater frequency in developed countries can hence be explained by hard stools, intracolonic pressure and fecalith formation, which are caused by diet. The obstruction of the appendix causes an increase in intraluminal pressure, leading to mucosal ischaemia. In conjunction with vascular congestion, the appendix mucosa becomes hypoxic and ulcers begin to form. This in turn leads to the invasion of the appendix wall by intraluminal bacteria [3, 4].
Parasitosis is asignificant health problem in endemic countries. Although parasitic diseases are mainly observed in tropical countries, they have also started to become a significant health problem in developing countries due to increasing migration and travel [5]. Enterobius vermicularis, Ascaris lumbricoides, Schistosoma spp. and Taenia spp. are among the parasites that lead to aclinical picture of acute appendicitis. The gastrointestinal infections associated with E. vermicularis are the most frequently encountered helmintic infections worldwide [1, 6]. Although it can be observed in all ages and across all socioeconomic levels, it is seen more frequently among children and the young. The infections are generally asymptomatic in children, and the most commonly observed symptom is itching around the anus. Moreover, E. vermicularis infections may cause ileocolitis, enterocutaneous fistulas, urinary tract infections, mesenteric abscesses, salpengitis and appendicitis. The mature form of E. vermicularis is most frequently observed in the proximal section of the ascending colon, the cecum, the appendix and the terminal ileum [7, 8].The relationship between E. vermicularis and acute appendicitis was first discovered towards the end of the 19th century [9, 10]. It has been observed that E. vermicularis can cause pathological changes to the appendix, ranging from lymphoid hyperplasia to acute phlegmonous appendicitis, gangrenous appendicitis and peritonitis [1]. Appendectomy is not sufficient in itself for treatment since it is not able to resolve the main cause of the disease. To obtain the best treatment results, antihelmintic treatment should be provided following surgery [11].
Teniasis, on the other hand, is a well-known tapeworm infection characterized by the presence of Taenia saginata or Taenia solium in the human intestines. Infection generally occurs as a result of consuming raw or undercooked meat [12]. Teniasis may sporadically lead to a clinical picture of acute or subacute appendicitis or cholangitis. A clinical picture of acute appendicitis occurring in association with Taenia is a very uncommon condition [13]. In the event that Taenia is the cause of acute appendicitis, albendazole treatment is provided to the patient following surgery [12].
The identification of intraluminal parasites in appendix material is usually an accidental finding. Such findings are generally observed concomitantly with an appendix that does not display any signs of inflammation. However, the parasitic invasion of the appendix may lead to the clinical symptoms of acute appendicitis, causing colic-like repetitive pain in the right lower quadrant. As a parasitic infection is actually present within the intestinal system, the clinical and laboratory findings will be suggestive of an infection. However, acute appendicitis will not be histologically present [5]. In our study, acute appendicitis and localized peritonitis were observed in 9 (47.3%) out of a total of 19 materials. The remaining ten (52.7%%) materials did not demonstrate any findings of acute appendicitis, and the laparotomies that had been performed were hence considered as negative laparotomies.
In a study presented by Engin et al. in Turkey, parasites were observed in 9/1969 (0.45%) appendectomy materials [3]. In a study presented by Karatepe et al. in Turkey, parasites were observed in 24/5100 (0.5%) appendectomy materials, and the rate of no inflammation with appendix specimen was determined as 6/24 (25%) [4]. Similarly, Aydın 6/190 (3.15%) and 4/6 (66.6%) [5], Da Silva et al. 24/1600 (1.5%) and 12/24 (50%) [1], Sah and Bhadani 9/624 (1.62%) and 6/9 (66.6%) [14], Gialamas et al. 7/1085 (0.64%) and 6/7 (85.7%) [7], and Ramezani and Dehghani 144/5048 (2.9%) and 68/144 (47.2%) [15] reported the rates, respectively (Table II).
The identification of parasites in 19/3863 (0.49%) of the appendix materials of cases operated with a clinically acute appendicitis in our study was consistent with the literature.
As can be seen in the literature and in our study, the rate of absence of acute inflammation in patients operated with a clinically acute appendicitis and having parasites in their appendix lumen is very high. This is indicative of the high rate of negative laparotomy that has been performed on these patients.
In conclusion, E. vermicularis is the most frequently found parasite in the appendix lumen of patients operated with a clinically acute appendicitis. In cases where parasites are present in the appendix lumen, the rate of negative laparotomy becomes higher. In order to avoid the surgical side effects associated with negative laparotomy, patients applying for complaints of abdominal pain should be examined also for intestinal parasites. Patients whose medical history as well as clinical and laboratory findings are positive should be considered and evaluated more carefully. In addition to this, patients with acute appendicitis caused by parasites should receive anti-parasitic treatment following surgery.
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