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Pancreaticoduodenectomy (Whipple's procedure) remains the only definitive treatment option for tumors of the periampullary region. The most common and life-threatening complications following the procedure are pancreatic anastomotic leakage and subsequent fistula formation. When these complications occur, treatment strategy depends on the severity of anastomotic leakage, with patients with severe leakages requiring reoperation. The optimal surgical method used for reoperation is selected from among different options such as wide drainage, definitive demolition of the pancreaticojejunal anastomosis and performing a new one, or completion pancreatectomy. Here we present a novel, simple technique to manage severe pancreatic leakage via ligamentum teres hepatis patch.

Xanthogranulomatous inflammation (XGI) is a rare chronic inflammatory condition most commonly involving the kidneys and gallbladder. The condition is histopathologically characterized by the presence of foamy histiocytes, lymphocytes, and plasma cells. A few reports describing appendicitis caused by XGI have appeared in the English-language literature. However, no study has yet focused on the imaging features of xanthogranulomatous appendicitis (XGA). We present a pathologically confirmed case of XGA with an endometrial abscess; the patient underwent ultrasonography, computed tomography, and magnetic resonance imaging. To the best of our knowledge, this is the first case of XGA with uterine and right adnexal involvement presenting as a complicated pelvic abscess on radiological imaging.

Amyloidosis is a disorder caused by extracellular deposition of insoluble protein fibrils in various tissues. Colonic amyloidosis is a rare clinical manifestation which can mimic tumor, inflammatory bowel disease, or ischemic colitis. The most common symptoms of colonic amyloidosis include bleeding, ulceration, diarrhea, and abdominal pain. However, colonic obstruction due to extensive submucosal amyloidosis is extremely rare. Considering the wide variety of symptoms and potentially effected organs, the diagnosis can be challenging particularly in emergent conditions. In this paper, a case with mechanic bowel obstruction due to extensive amyloidotic involvement of the left colon is presented.

Traumatic perforation of the esophagus due to blunt trauma is a rare thoracic emergency. The most common causes of esophageal perforation are iatrogenic, and the upper cervical esophageal region is the most often injured. Diagnosis is frequently determined late, and mortality is therefore high. This case report presents a young woman who was admitted to the emergency department (ED) with esophageal perforation after having fallen from a high elevation. Esophageal perforation was diagnosed via thoracoabdominal tomography with ingestion of oral contrast. The present report discusses alternative techniques for diagnosing esophageal perforation in a multitrauma patient.

A small-bowel enteroatmospheric fistula (EAF) is an especially challenging complication for patients with open abdomens (OAs) and their surgeons. Manipulation of the bowel during treatment (e.g. dressing changes) is one of the risk factors for developing these openings between the atmosphere and the gastrointestinal tract. Unlike enterocutaneous fistulae, EAFs have neither overlying soft tissue nor a real fistula tract, which reduces the likelihood of their spontaneous closure. Surgical closure is necessary but not always easy to do in the OA environment. Negative pressure wound therapy (NPWT) has been used successfully as an adjunct therapy to heal the wound around EAFs. This review discusses many aspects of managing EAFs in patients with OAs, and presents techniques that have been developed to isolate the fistula and divert effluent while applying NPWT to the surrounding wound bed., (© 2014 The Authors. International Wound Journal © 2014 Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Background/aims: Development of pancreatic fistula after distal pancreatectomy is still a major problem. Various methods have been defined to prevent the development of the fistula. In this study, the results of suture closure of pancreatic duct and closure of pancreatic stump with “U” sutures passing through each other and the risk factors affecting the development of fistula are studied., Methodology: Fifty-one patients with prospectively collected data were included in the study. In all patients, pancreatic stump was closed with the same surgical technique. Risk factors that may affect fistula formation were studied between groups with and without fistula. Pancreatic fistula definition was made according to the International Study Group on Pancreatic Fistulas classification., Results: Eight (15.7%) of the 51 patients had fistula. Clinically significant fistula ratio was 9.8% (according to ISGPF B and C). Additional organ resections were performed in 18 patients (35.3%). In multivariate analysis, the soft texture of pancreatic parenchyma (OR: 12.420, p = 0.048) and over 150 mL of blood loss (OR: 1.003, p = 0.043) were found as risk factors for the development of fistula., Conclusions: Closure of pancreatic stump after distal pancreatectomy with “U” shaped sutures passing through each other is a method that can be performed safely.

Objective: Seroma is the most common complication after breast surgery. Several methods have been proposed to prevent seroma, but none of these provided a significant effect. A prolonged wound healing process is the most important cause of seroma. Microporous polysaccharide hemospheres (MPH) are used to achieve hemostasis. They may also accelerate wound healing. In this study, the effects of MPH on seroma formation were investigated., Material and Methods: Female Wistar rats weighing between 200 g and 250 g were used. There were eight rats in each of the control and study groups. Right breast mastectomy and axillary dissection were performed in all rats. While no application was performed after the operation in the control group, MPH was locally applied to the surgical site in the study group. Ten days after the operation, seroma fluid was aspirated and the total volume was recorded. The aspirates were analyzed and tissue samples were obtained from the surgical site., Results: Seroma was significantly lower in the study group (p=0.001). The mean albumin and lactate dehydrogenase levels were significantly lower in the study group (p=0.003). Pathological examination revealed that increase in fibrous tissue was significantly greater in the control group (p=0.032)., Conclusion: MPH may reduce seroma after mastectomy.

Background: The aim of the study was to evaluate the available breast nomograms (MSKCC, Stanford, Tenon) to predict non-sentinel lymph node metastasis (NSLNM) and to determine variables for NSLNM in SLN positive breast cancer patients in our population., Materials and Methods: We retrospectively reviewed 170 patients who underwent completion axillary lymph node dissection between Jul 2008 and Aug 2010 in our hospital. We validated three nomograms (MSKCC, Stanford, Tenon). The likelihood of having positive NSLNM based on various factors was evaluated by use of univariate analysis. Stepwise multivariate analysis was applied to estimate a predictive model for NSLNM. Four factors were found to contribute significantly to the logistic regression model, allowing design of a new formula to predict non-sentinel lymph node metastasis. The AUCs of the ROCs were used to describe the performance of the diagnostic value of MSKCC, Stanford, Tenon nomograms and our new nomogram., Results: After stepwise multiple logistic regression analysis, multifocality, proportion of positive SLN to total SLN, LVI, SLN extracapsular extention were found to be statistically significant. AUC results were MSKCC: 0.713/Tenon: 0.671/Stanford: 0.534/DEU: 0.814., Conclusions: The MSKCC nomogram proved to be a good discriminator of NSLN metastasis in SLN positive BC patients for our population. Stanford and Tenon nomograms were not as predictive of NSLN metastasis. Our newly created formula was the best prediction tool for discriminate of NSLN metastasis in SLN positive BC patients for our population. We recommend that nomograms be validated before use in specific populations, and more than one validated nomogram may be used together while consulting patients.

Aim: To assess the validity of the Milan and University of California San Francisco (UCSF) criteria and examine the long-term outcome of orthotopic liver transplantation (OLT) in patients with hepatocellular carcinoma (HCC) in a single-center study., Methods: This study is a retrospective review of prospectively collected data. Between 1998 and 2009, 56 of 356 OLTs were performed in patients with HCC. Based on pathological examination of liver explants, patients were retrospectively categorized into 3 grou-ps: Milan + (n = 34), Milan -/UCSF + (n = 7) and UCSF - (n = 14)., Results: Median follow-up period was 39.5 (1-124) mo. The 5-year overall survival rates in the Milan +, Milan -/UCSF + and UCSF-groups were 87.7%, 53.6% and 33.3%, respectively (P < 0.000). Within these groups, tumor recurrence was determined in 5.8%, 14.3% and 40% of patients, respectively (P < 0.011). Additionally, the presence of microvascular invasion within the explanted liver had a negative effect on the 5-year disease free survival (74.7% vs. 46.7%, P < 0.044)., Conclusion: The Milan criteria are reliable in the selection of suitable candidates for OLT for the treatment of HCC. For cases of OLT involving living donors, the UCSF criteria may be applied.