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Aim: locally advanced distal rectal cancer (LADRC) patients managed with non-operative management (NOM) with complete clinical response following neoadjuvant treatment will experience local regrowth in about 25% of cases. The long-term risks of this strategy or local regrowth treatment have not been well established, and the main concern is the probability of impaired oncological outcomes after salvage surgery. This study aimed to evaluate the feasibility and clinical outcomes of salvage surgery in LADRC patients with local regrowth following NOM. Method: all locally advanced, distal rectal cancer patients managed with NOM after neoadjuvant therapy with clinical complete response, who developed local regrowth during surveillance, between May 2016 and November 2018, were enrolled in the study. Patients were analyzed for the rate of salvage surgery, disease-free survival and overall survival. Results: eleven out of 63 (17.5%) patients developed local regrowth after a mean of 8.4 (3-15) months. The mean surveillance period was 31.8 (14- 50) months. Eleven (100%) patients underwent salvage surgery due to the principles of total mesorectal excision. LE was not performed. No patients experienced local recurrence and three out of eleven (27.3%) developed carcinomatosis peritonei and/or distant metastasis after a mean surveillance period of 12.2 (3-26) months. At 30 months, the local and/or systemic recurrence rate, disease-free survival, and overall survival in the patients undergoing surgical treatment were 100%, 73%, 73% and 91%, respectively. Conclusion: the vast majority of patients with regrowth following NOM were suitable for salvage surgery with curative intent and justifiable pelvic tumor control., NA

Acinar cystic transformation (ACT) of the pancreas is a rare non-neoplastic cystic lesion. It is most frequently observed in the head of the pancreas. Despite advances in radiologic imaging methods, preoperative diagnosis of acinar cystic transformation is difficult, it is often confused with other cystic lesions. Here, we report three cases of acinar cystic transformation, one of which showed diffuse involvement of the pancreas, and the remaining two were multilocular localized cystic lesions. We analyzed their histomorphologic and immunohistochemical features. The patients’ ages ranged between 15 and 43 years and the ratio of females to males was 2:1. On microscopic examination, the cysts were lined by a single layer of flattened-cuboidal or columnar epithelial cells. The epithelial cells were diffusely positive with trypsin and keratin 7, but patchy with keratin 19. Due to its rarity and lack of radiologic and clinical awareness compared with other pancreatic cystic lesions, preoperative diagnosis of acinar cystic transformation is difficult and not definitive. All cases reported to date have been clinically benign and there is no evidence of recurrence or malignant transformation. The optimal treatment and whether to perform surgery remain controversial.

Rupture of a metastatic liver tumor associated with laryngeal cancer is a very rare complication with no previous case in the literature. We present a case of ruptured liver metastases which was treated conservatively. Dynamic contrast-enhanced computed tomography demonstrated active extravasation and discontinuity of liver capsule. When the patient came to our hospital from the external medical center, we did not see active extravasation on control computed tomography. This case highlights the role of radiologic imaging in the diagnosis and follow-up of ruptured hepatic metastases.

OBJECTIVES Treating aortic arch aneurysms with conventional open surgical and endovascular stent graft procedures is challenging due to the complex anatomy of the arch and the arteries arising from it that nourish the brain. Cerebral protection is of the utmost importance during the treatment of thoracic aneurysms involving the aortic arch. METHODS Between May 2014 and November 2018, 7 patients with thoracic aortic aneurysms involving the aortic arch who underwent aortic arch cervical debranching with our technique were reviewed retrospectively. Because all the patients being considered for conventional surgical aortic arch replacement had serious comorbidities, they were selected to receive hybrid therapy. The mean age of the patients was 71.2 ± 9.4 years. One patient was a woman and 6 patients were men. One patient was given general anaesthesia; the remaining 6 patients had a regional block. A crossover temporary bypass was performed between the external carotid arteries with a 6-mm polytetrafluoroethylene graft for cerebral protection in all patients. Thoracic endovascular aortic repair (TEVAR) was successfully performed in all patients except 1 following debranching. RESULTS Neurological complications did not occur during the procedures. Patients were followed for a mean of 18.3 ± 4.9 months. One female patient died of exacerbating chronic obstructive pulmonary disease within the first follow-up year. Three other patients died: 1 died of natural causes; 1 died of pneumonia followed by multiorgan failure; and 1 died of myocardial infarction during the mid-term follow-up period. The remaining patients are still being followed and are event free. CONCLUSIONS Endovascular treatment of thoracic aortic diseases involving the aortic arch is facilitated when the aortic arch is debranched. Our cerebral protection method with a temporary crossover bypass between the external carotid arteries provides continuous pulsatile blood flow to the brain; hence, neurologically, it is a reliable procedure. The follow-up results of the patients who underwent aortic arch cervical debranching followed by TEVAR depended on their comorbidities.

Purpose To determine technical feasibility and results of stent-assisted coiling of visceral artery aneurysms (VAAs) with self-expandable LEO PLUS neurointerventional stent. Materials and Methods In this retrospective study, 11 consecutive patients (mean age 61.9 y ± 8.9; range, 45–76 y) with VAAs (splenic, n = 3; common hepatic, n = 2; renal, n = 5; celiac, n = 1) treated with neurointerventional stents were included. MR angiography was evaluated for aneurysmal occlusion and patency of the parent arteries. Results Technical success was 90.9%. A minor technical complication developed in 1 patient (9%), and thrombosis of the distal part of the stent was seen just after deployment in another patient, but it resolved after tirofiban injection. Complete occlusion was determined in all patients on MR angiography at 6-month follow-up. Conclusions Self-expandable LEO PLUS neurointerventional stents could become a useful tool in the treatment of VAAs. Studies with larger groups of patients, including control groups, are needed to assess the true outcome of this treatment method.

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

Purpose Among various staple-line reinforcement methods applied during sleeve gastrectomy (SG), although data on full-thickness-continuous-suturing (FTCS) is nearly nil, it has been considered as potentially harmful. The safety/efficacy profile of FTCS is assessed. Methods All consecutive SGs completing 3-month follow-up were studied. Data on peri-operative parameters, complications, and follow-up were prospectively recorded. All reinforcements were completed by FTCS utilizing barbed suture. Super-super obese, secondary SGs, SGs performed in patients with prior anti-reflux surgery, and SGs performed with additional concomitant procedures were evaluated as “technically demanding” SGs. Student’s t/chi-square tests were used as appropriate. Results Between January 2012 and July 2020, 1008 SGs (941 “primary-standard,” 67 “technically demanding”) were performed without mortality/venous event. Single leak occurred in a patient with sleeve obstruction (0.1%). Thirteen bleedings, 4 requiring re-surgery (0.4%), and 17 stenoses (1.7%) were encountered. Four stenoses were treated with gastric bypass (1 emergency), 6 by dilatation(s), and one required parenteral nutrition. Six patients with stenosis chose not to have any treatment. No statistically significant difference was observed in postoperative complications between “primary-standard” and “technically demanding” SGs (p > 0.05). The median follow-up was 44 months. The excess weight loss % at 5th year was 80.1%. Suturing added 28.4 ± 6 minutes to the SG, 3 or fewer sutures were used to complete the reinforcement in > 95%. No mishap/complication occurred related to suturing. Conclusion FTCS produced excellent result in terms of leakage/hemorrhage with an acceptable stenosis rate at a low cost with half-an-hour increase in the operating time. In contrast to previous allegations, no harm attributable to stitching itself occurred. Supplementary Information The online version contains supplementary material available at 10.1007/s00423-021-02161-5.

Amaç: Bu çalışmada, torasik stent greft uygulanmış hastaların uzun dönem sonuçlarının değerlendirilmesi amaçlanmıştır. Gereç ve Yöntem: Kliniğimizde sadece stent greft ile ya da hibrid yöntem (cerrahi sonrası endovasküler girişim) ile tedavi edilmiş torasik aort patolojili, yaş ortalaması 67,1 (20-82) olan 25 hastayı retrospektif olarak değerlendirdik. Bulgular: Hastalardan 23’ü elektif olarak tedavi edilirken, 2’si acil olarak işleme alınmıştır. Kontrol görüntülemelerde 5 hastada tip 1A endoleak izlenmiştir. Bu hastalardan 3’üne ek girişim uygulanmıştır. Hastalardan birisinde endoleak takip sırasında kendiliğinden regrese olmuştur. 1 hastada ise post-op 6. günde MI nedeniyle ex olmuştur. Toplam 7 hastada hibrid işlem uygulanmıştır. Debranching uygulanan hastalardan bir tanesinde endovasküler işlem sırasında majör komplikasyon gelişmiştir. Hibrid girişim uygulanan 7 hastadan 1’i olan tip B diseksiyon hastasında işlem sonrası kontroller sırasında nörolojik komplikasyon izlenmiştir. Sonuç: Endovasküler torakal stent greft işlemi torakal aort patolojilerinde yüksek teknik başarı ve sağ kalım oranları ile uygulanmaktadır. Tek başına TEVAR’a uygun olmayan anatomiye sahip hastalarda hibrid girişim tercih edilmektedir. Objective: The aim of this study was to evaluate the long-term results of patients who underwent thoracic stent grafting. Material and Method: We retrospectively evaluated 25 patients with a mean age of 67.1 (20-82) with thoracic aortic pathology treated with a stent graft or the hybrid method (endovascular intervention after surgery) in our clinic. Results: 23 patients were treated electively and 2 of them were treated urgently. Type 1A endoleak was observed in 5 patients in control imaging. Additional intervention was performed in 3 of these patients. In one patient, the endoleak spontaneously regressed during follow-up. One patient died on the 6th postoperative day due to MI. A total of 7 patients underwent hybrid procedures. One of the debranching patients developed major complications during endovascular procedure. In the type B dissection patients, neurological complications were observed during post-procedure controls in 1 of the 7 patients who underwent hybrid intervention. Conclusion: Endovascular thoracic stent grafting is performed with high technical success and survival rates in thoracic aortic pathologies. Hybrid intervention is preferred in patients with non-suitable anatomy for TEVAR alone.

Transarterial embolization of liver hemangiomas has not been considered to be consistently effective.The charts of 25 patients who underwent superselective transarterial chemoembolization with the bleomycin-lipiodol emulsion were evaluated retrospectively.Twenty-two patients had abdominal pain; asymptomatic/vaguely symptomatic enlargement was the treatment indication in three patients. A single session was conducted in 17 patients, two sessions in 7 and three sessions in one. After the first session, lesion volume decreased by median (range) 51% (10-92%) from median (range) 634 (226-8435) to 372(28-4710) cmTransarterial chemoembolization with the bleomycin-lipiodol emulsion is a potential alternative to surgery for symptomatic/enlarging liver hemangiomas. Volume reduction is universal, and symptom control is satisfactory. Centrally located and very large (1000 cm

Treatment of thoracic aortic aneurysms constitutes high mortality and morbidity rates despite improvements in surgery, anesthesia, and technology. Endovascular stent grafting may be an alternative therapy with lower risks when compared with conventional techniques. However, sometimes the branches of the aortic arch may require transport to the proximal segments prior to successful thoracic aortic endovascular stent grafting. Atherosclerosis is accounted among the etiology of both aneurysms and occlusive diseases that can coexist in the same patient. In these situations stent grafting may even be more complicated. In this report, we present the treatment of a 92-year-old patient with aortic arch aneurysm and proximal descending aortic aneurysm. For successful thoracic endovascular stent grafting, the patient needed an alternative route other than the native femoral and iliac arteries for the deployment of the stent graft. In addition, debranching of left carotid and subclavian arteries from the aortic arch was also required for successful exclusion of the thoracic aneurysm.

Marfan syndrome is an inherited connective tissue disorder affecting mainly eyes and skeletal and cardiovascular systems. Cardiovascular involvement may lead to life-threatening aortic pathologies including aneurysms and/or dissections. In this report, the authors present images of a patient with Marfan syndrome with a history of Bentall-De Bono procedure followed by aortic arch and infrarenal aortoiliac replacements who strongly refused conventional open repair and underwent abdominal debranching followed by thoracoabdominal endovascular stent grafting for the treatment of thoracoabdominal aneurysm.

Amac: Diyabetli hastalarda baslica olum nedeni olan koroner arter hastaligi (KAH) hastalarin bir bolumunde sessiz seyreder. Bu calismanin amaci asemptomatik tip II diyabetli hastalarda gizli KAH prevalansini, mevcut plaklarin yayginligini, lokalizasyonunu ve ozelliklerini cok kesitli bilgisayarli tomografi anjiografi (CKBTA) ile degerlendirmektir. Gerec ve Yontem : Tip II diyabet tanili KAH acisindan asemptomatik olan 100 hasta CKBTA ile prospektif degerlendirildi. Kalsiyum skorlama amaciyla kontrastsiz goruntuler elde edildikten sonra i.v. kontrast madde verilerek 64 dedektorlu BT ile koroner anjiografik goruntuler alindi. Kontrastsiz goruntuler uzerinden koroner arter kalsiyum skoru hesaplandi ve plaklarin kalsiyum icerigi incelendi. Koroner angiografik goruntulerden elde edilen reformat goruntulerden ise plaklarin yayginligi, lokalizasyonu ve olusturduklari darlik dereceleri degerlendirildi. Kategorik degiskenlerin istatistiksel degerlendirilmesinde Pearson ki-kare testi ve Fisher gerceklik testi kullanildi. Bulgular: Calismaya dahil edilen 80 hastanin %72’si erkek (n=58) ve %27’si (n=22) kadindi. Ortalama yaslari 53±8 ve cekim esnasinda kalp hizlari ise 64±7 idi. 49 hastada (%61) aterosklerotik plak saptandi; Kalsifik plak en cok saptanan aterosklerotik plak tipiydi (%35), soft plak 9 (%11.3) hastanin en az bir koroner arter segmentinde saptandi. 14 (%17.5) hastada orta darlik, 11 (%13.7) hastada ciddi darlik ve boylelikle 25 (%31.3) hastada anlamli darlik (≥ %50) saptandi. Tek damar hastaligi (19, %23.7), iki damar hastaligi (15, %18.7), uc damar hastaligi (15, %18.7) saptandi. Sonuc: Diyabetli hastalarda asemptomatik KAH’in ortaya konmasinda CKBTA noninvazif ve guvenilir bir yontem olarak kullanilabilir

Dacron grafts are frequently used during surgical revascularization procedures. Complications including graft thrombosis and infection are well known; however, aneurysm formation is extremely rare. In this report, we describe dilatation of a Dacron graft detected four years after aortobifemoral bypass procedure in a 50-year-old male patient who was treated with endovascular stent grafting.

Purpose We aimed to determine the feasibility and effectiveness of agent emission imaging - high mechanical index (AEI-High MI) mode ultrasonography (US) compared with gray-scale and color Doppler US, alone or in combination, for the diagnosis of urolithiasis with reference to unenhanced computed tomography (CT). Methods This prospective study included 72 consecutive patients (40 males, 32 females; mean age, 45.9±14.7 years) referred by the department of urology for acute or elective symptoms of urolithiasis and confirmed to have urinary calculi on unenhanced abdominal CT, between January 2015 and June 2015. Gray-scale, color Doppler, and AEI-High MI US were performed by two radiologists to determine the effectiveness of these methods in the diagnosis of urinary stones and to compare them with the reference modality. Results A total of 189 calculi were detected on CT examination. Gray-scale US had a sensitivity of 66.1% and positive predictive value (PPV) of 88.7% for detecting calculi, while twinkling artifact of color Doppler had a sensitivity of 70.4% and PPV of 94.3%. The scintillation artifact of AEI-High MI mode had a sensitivity of 75.1% and PPV of 95.9%. When all ultrasound-based modalities were combined, the sensitivity and PPV rose to 83.1% and 88.2%, respectively. When calculi were grouped according to their size ( 10 mm), AEI-High MI mode had a higher sensitivity (60%) compared with gray-scale (32.5%) and color Doppler (41.3%) for calculi Conclusion AEI-High MI mode had a higher sensitivity compared with gray-scale and color Doppler for the detection of calculi smaller than 5 mm, but it did not make a significant contribution to detection of larger calculi. The combined use of gray-scale US with AEI-High MI mode could increase the detection rate of calculi smaller than 5 mm and provide a method for verification of suspected calculi on gray-scale US.

Background: Cardiac tamponade (CT) is a dreadful complication of laparoscopic antireflux surgery (LARS) with unknown incidence, and preventive measures are yet to be defined. Incidence during LARS with respect to usage/configuration of graft deployment is analyzed. Three-dimensional (3D) analysis of tack distribution provided anatomical insight to prevent cardiac injury. Materials and Methods: Data regarding the usage and configuration of graft deployment are retrieved from the prospective database. Grafting was posterior or posterior + anterior. Incidence of CT in all hiatoplasties is calculated. Tomography is reconstructed in 3D, showing the spatial distribution of the tacks. Tacks are numbered in the surgical video. Corresponding numbering is applied to the tacks in any particular tomography slice, utilizing the 3D images as an interface. A numbering-blinded radiologist is asked to identify the offending and the nonoffending tacks as the cause of tamponade. Tack-to-pericardium distances are recorded. Tacks having no measurable distance from the pericardium are regarded as offensive. Results: One CT occurred in 1302 consecutive LARS (0.076\%). The incidence is 0\% when no (379) or posterior (880) graft is used as opposed to 2.3\% rate in posterior + anterior (43) grafting. The distribution of offensive, nonoffensive but nearest, and safe tacks followed a pattern. All offensive tacks belonged to the anterior graft fixation, which we referred as the critical zone. Conclusion: CT during LARS is rare, and associated with graft fixation anterior to the hiatal opening. Avoiding graft fixation to the critical zone may prevent cardiac injury.

Background While administering medication through intramuscular injection, the ventrogluteal site must be used instead of the dorsogluteal site, and it is of great significance to locate the ventrogluteal site correctly. Objective To determine the reliability of two different methods used to determine the ventrogluteal site in intramuscular injection practice. Design A cross-sectional study. Settings A university hospital in Istanbul. Participants The study population comprised 120 randomly selected healthcare personnel at a university hospital. Methods The ventrogluteal site was determined using the geometric (G method) and V method and these sites were scrutinized under ultrasonography. It was investigated whether there was any anatomic vessels or neural structure present, and also determined the thickness of subcutaneous tissue, musculus gluteus medius, and musculus gluteus minimus. Results Of the participants, 65.8% were female and the average age was 32.30 years and body mass index was 25.31kg/m 2 . The results showed that G and V methods were statistically significant in terms of variables. It was also found that sex affects subcutaneous tissue thickness and the skin-bone margin in the G and V method, and that body mass index determines subcutaneous tissue, musculus gluteus medius thickness and skin-bone margin. Conclusion When the ventrogluteal site is used for intramuscular injection purposes, the site must be determined in line with the geometric method.

Duplicated common bile duct, often associated with conditions like lithiasis, biliary cysts and pancreatobiliary maljunction, could result in highly morbid and potentially fatal biliary injuries. Precise preoperative diagnosis and classification still remain a challenge. A female patient undergoing emergency laparoscopic cholecystectomy for acute calculous cholecystitis sustained iatrogenic bile duct injury. A drainage tube was placed into the injured duct for post-operative conservative management. Post-operative tube cholangiogram revealed a double common bile duct with cystic duct opening distally. This was identified as a new variant not previously reported or classified. However rare, duplicated common bile duct could result in serious iatrogenic bile duct injury if unidentified during surgery. Knowledge of its existence is essential to avoid such injuries as preoperative diagnosis still remains a challenge. A thorough clinical and morphological study of previously reported variants is needed for a comprehensive classification to encompass newly discovered variants.

Aortic aneurysms and stenosis are widely treated with endovascular procedures in the current era. In this report, we present endovascular stent grafting for symptomatic treatment of severe thoracic aortic stenosis caused by an aortic sarcomatoid carcinoma in a 73-year-old female. The peri- and post-operative courses were complicated with tumor embolisms that were managed by both endovascular and surgical measures.