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Granulomatous lobular mastitis (GLM) is a rare and chronic benign inflammatory disease of the breast. Difficulties exist in the management of GLM for many front-line surgeons and medical specialists who care for patients with inflammatory disorders of the breast. This consensus is summarized to establish evidence-based recommendations for the management of GLM. Literature was reviewed using PubMed from January 1, 1971 to July 31, 2020. Sixty-six international experienced multidisciplinary experts from 11 countries or regions were invited to review the evidence. Levels of evidence were determined using the American College of Physicians grading system, and recommendations were discussed until consensus. Experts discussed and concluded 30 recommendations on historical definitions, etiology and predisposing factors, diagnosis criteria, treatment, clinical stages, relapse and recurrence of GLM. GLM was recommended as a widely accepted definition. In addition, this consensus introduced a new clinical stages and management algorithm for GLM to provide individual treatment strategies. In conclusion, diagnosis of GLM depends on a combination of history, clinical manifestations, imaging examinations, laboratory examinations and pathology. The approach to treatment of GLM should be applied according to the different clinical stage of GLM. This evidence-based consensus would be valuable to assist front-line surgeons and medical specialists in the optimal management of GLM., (© 2022. The Author(s).)

Aim: Although appendicitis is a disease of the young, it has been speculated that its incidence has increased among the elderly people. In this study, it was aimed to evaluate annual changes of appendicitis seen in older patients (≥60 years) throughout a 10-year period., Methods: All adult patients who were surgically treated for acute appendicitis were retrospectively analyzed with respect to pathological analysis, gender, age and proportion of the patients aged 60 or over in an annual base. Variability in the mean age and proportion of the older patients aged 60 or over throughout the study years were regarded as the main outcomes., Results: There were 3296 patients with a mean age of 30.42 ± 12 years. Distribution of gender was similar ( p  = 0.636). There was a significant positive correlation in the mean age of the patients throughout the study years ( p  = 0.043). Stratification by the age of 60 yielded a significant increase in percent of the older patients, from 0.93% at 2007 to 4.28% at 2016 ( p  = 0.019)., Conclusions: The mean age of the patients with acute appendicitis is going to increase. Therefore, it is expected that all surgeons are more likely to be confronted with elderly patients with appendicitis in the near-future.

Background: Live donor nephrectomy is an important donor source. Donor nephrectomy can be performed by laparoscopy or hand-assisted laparoscopy. Different types of hand port devices can be used for assistance. In the literature there are few studies about hand-assisted laparoscopy without a hand port. In this study, we aimed to evaluate the impact of not using a hand port for hand-assisted laparoscopic donor nephrectomy for kidney transplantation., Methods: Patients who were operated on for kidney donation between January 2011 and June 2018 evaluated retrospectively. The patients were divided into 2 groups: group A, on whom a hand port was used, and group B, whose surgeries did not involve a hand port. The groups were compared for sex, age, body mass index, amount of intraoperative bleeding, warm ischemia time, duration of surgery, perioperative complications, duration of hospital stay, and postoperative complications., Results: There were 159 patients in group A and 146 patients in group B. There was no difference between the groups considering intraoperative bleeding, warm ischemia time, duration of surgery and postoperative early complications (P > .05 for all)., Conclusion: Hand-assisted laparoscopic donor nephrectomy without a hand port can be considered an easy and effective method of laparoscopic nephrectomy., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: Routine histopathological examination after cholecystectomy for gallstones is performed despite the low rates of incidental findings of malignancy. The aim of this study was to assess predictive values of macroscopic examination of cholecystectomy specimens by surgeons in gallstone disease., Methods: A prospective multi-center diagnostic study was carried out between December 2015 and March 2017 at four different centers. All patients undergoing cholecystectomy for gallstone disease were consecutively screened for eligibility. Patients whose ages are 18 to 80 years, and preoperative imaging findings without any pathology except cholelithiasis were included. The gallbladder was first evaluated macroscopically ex situ by two operating surgeons and rated as macroscopically benign (group S1), suspicious for a benign diagnosis (group S2), and suspicious for malignancy (group S3). Thereafter, a pathologist made a final histopathological examination whose results are grouped as chronic cholecystitis (group P1), benign or precancerous lesions in which only cholecystectomy is the adequate treatment modality (group P2), and carcinoma (group P3). Diagnostic accuracy of the surgeon's assessment to the histopathological examination was evaluated using sensitivity, specificity, positive and negative predictive values, and accuracy, and correlated by a kappa agreement coefficient., Results: A total of 1112 patients were included in this trial. The specificity rates were 96.5%, 100%, and 98.7% for group S1-group S2, group S1-group S3, and group S2-group S3, respectively. Accuracy rates to detect malignancy were 100% and 95. 2% for group S1 and group S2, respectively. Kappa coefficient values were 1.0 and 0.64 for group S1-group S3 and group S2-group S3, respectively (p < 0.001 for both)., Conclusion: Assessment of the gallbladder specimen and selective histopathological examination may be adequate after cholecystectomy for gallstone diseases. Such a procedure would have the potential to reduce costs and prevent unnecessary loss of labor productivity without affecting patients' safety. However, higher number of patients in more centers is needed to confirm this hypothesis.

Objective: We aim to evaluate the effect of peritoneal closure on postoperative pain and life quality associated with open appendectomy operations., Methods: This is a single-center, prospective, randomized, and double-blinded study. Here, 18-65-year-old patients who underwent open appendectomy for acute appendicitis were included. Demographic data of the patients, operation time, length of hospital stay, pain scores using a 10 cm visual analogue scale (VAS) on the first postoperative day, quality of life assessment using the EuroQol-5D-5L questionnaire on postoperative 10th day, deep wound dehiscence, bowel obstruction, and mortality data were recorded., Results: In total, 112 patients were included in the study. The demographic data showed no significant difference between the groups. The median VAS score was lower in the group with open peritoneum, but this difference was not statistically significant (3 vs. 4, p =0.134). The duration of surgery was significantly shorter in the peritoneal nonclosure group (31.0 ± 15.1 vs. 38.5 ± 17.5 minutes, p =0.016). Overall complication rates and life quality test (EuroQol-5D-5L) results were similar between groups., Conclusion: Nonclosure of the peritoneum seems to shorten the duration of surgery without increasing complications during open appendectomy. Postoperative pain and life quality measures were not affected by nonclosure of the peritoneum. This trial is registered with NCT02803463.

Introduction: Hydatidosis is a zoonotic infection and treatment is mandatory to avoid complications. Surgery remains the first choice in the treatment especially for CE2-CE3b cysts. Open or laparoscopic approaches are available. However, comparative studies are limited., Materials and Methods: Data of patients who underwent cystotomy/partial cystectomy for liver hydatidosis between January 2012 and September 2016 (n=77) were evaluated retrospectively. Recurrent cases and the patients with previous hepatobiliary surgery were excluded. 23 patients were operated upon laparoscopically and named as Group 1. 48 patients operated conventionally named as Group 2. Demographics, cyst characteristics, operative time, length of hospital stay, recurrences, and surgery related complications were evaluated., Results: Groups were similar in terms of demographics, cyst characteristics, and operative time. The length of hospital stay was 3.4 days in Group 1 and 4.7 days in Group 2 (p=0,007). The mean follow-up period was 17.8 months and 21.7 months, respectively (p=0.170). Overall complication rates were similar in two groups (p=0.764). Three conversion cases occurred (13%). One mortality was seen in Group 2. Four recurrences occurred in each group (17% versus 8.3%, respectively) (p=0.258)., Conclusions: Laparoscopy is a safe and feasible approach for surgical treatment of liver hydatidosis. Recurrence may be prevented by selection of appropriate cases in which exposure of cysts does not pose an intraoperative difficulty.

Idiopathic granulomatous mastitis (IGM) is an inflammatory breast disease with unknown etiology and nonspecific symptoms. Differentiation of breast cancer from granulomatous disease is a diagnostic and clinical challenge. Imaging features and decision of the surgeon, based on these findings, may be important steps during diagnosis and follow-up period. Articles in association with imaging of IGM were evaluated using a PubMed search in August, 2017. Hypo-echoic or heterogeneous mass/es with or without tubular extensions were the most common ultrasonographic findings. Focal asymmetric density with or without skin thickening and parenchymal distortion were detected in most of the patients during mammography. Magnetic resonance imaging most commonly revealed focal or diffuse asymmetrical signal intensity changes without significant mass effect. Although a specified and standardised criteria list for each type of the imaging modality has been lacking, the most commonly detected imaging findings, especially in cases of multiple lesions in accordance with the decision of the surgeon and/or clinician, can be used for the diagnosis and follow-up of IGM with acceptable safety margins. However, in the presence of any suspicious findings during imaging or clinical examination, histopathological analysis should be performed.

Aims: Appendiceal mucocele (AM) is a rare pathology, and its reported incidence is 0.3% in all appendectomy specimens. Here, we report a case series of AM and make a brief review of literature., Subjects and Methods: We conducted a retrospective review of a prospectively collected data of patients who diagnosed as AM by histopathological evaluation between January 2009 and June 2015 were demographic data including age and gender, intraoperative findings, and histopathological reports were recorded. All cases were followed-up by routine examination and telephone interview., Statistical Analysis Used: Definitive statistical methods (mean, standard deviation, median, frequency, and percentage) were used to evaluate the study data., Results: Twelve patients were examined in the study with diagnose of AM. The mean age was 51.8 ± 18.6 years (26-83). Female-to-male ratio was 1.4 (7/5). Indications for surgery were acute abdomen in 8 (72.7%) patients with presumptive diagnosis of acute appendicitis and were AM in four patients diagnosed by imaging. Histopathological evaluation revealed mucinous cystadenoma in eight patients, simple retention cysts in three, and borderline mucinous tumor (pseudomyxoma peritonei) in one. The neuroendocrine tumor was obtained on the remaining portion of the appendix in one of the simple retention cysts patients. None of the patients died because of the AM with an average follow-up of 43 months (range: 7-74)., Conclusions: Surgical resection is the first choice therapy for AM. Precise treatment modality can remain unclear in some patients because of insufficient preoperative diagnosis. It is nonmalign AM mostly however having mucocele matters because of the significant association with synchronous tumors., Competing Interests: There are no conflicts of interest

Background: the optimal duration of percutaneous cholecystostomy in patients with acute cholecystitis is unknown., Methods: this study was a retrospective analysis of patients (age ≥ 18 years) who underwent percutaneous cholecystostomy due to acute calculous cholecystitis. Patients were grouped according to treatment modality: percutaneous cholecystostomy as a definitive treatment (group 1), subsequent surgical treatment after the removal of the catheter (group 2) and those remaining in situ (group 3). The development of gallstone-related complications was the main outcome., Results: there were 24 females (43.6%) and 31 males (56.4%) included in the study with a mean age of 64.8 ± 15.9 years. There were 16 (29.1%), 19 (34.5%) and 20 (36.4%) patients in groups 1, 2, and 3, respectively. The catheter withdrawal time for group 1 and group 2 was 18.2 ± 6.9 and 20.7 ± 13.4 days, respectively. Surgical treatment was performed after a mean of 85.4 ± 93.5 days following catheter removal in group 2 and a mean of 64 ± 32.5 days while the PC tube was in place in group 3. There were one (6.3%) and two cases of a recurrence (10.5%) in groups 1 and 2, respectively. Two patients developed choledocholithiasis (10%) in group 3., Conclusion: maintaining percutaneous cholecystostomy tubes in place until the time of surgery in surgically fit patients may help to prevent a recurrence after acute calculous cholecystitis.

Aim: Cytological detection of peritoneal-free gastric cancer cells is considered as the gold standard with variable sensitivity. Seeding of cancer cells after radical surgery for gastric cancer is a controversial issue. In this study, it was aimed to detect the rate of positive peritoneal washing cytology and the incidence of spreading of tumor cells after radical surgery., Materials and Methods: Patients with pathologically proven and surgically treated gastric adenocarcinoma were enrolled. Three peritoneal washing samples were examined cytologically: at the beginning, after completion of resection, and before closure of the abdomen. Identification of peritoneal-free gastric cancer cells was regarded as the main outcome., Results: Thirty-four patients with a mean age of 60.7 ± 12 years were enrolled. T3 and N0 were the most common stages seen in 16 (47%) and 12 patients (35.3%), respectively. There were two positive results (5.9%) as the first peritoneal sample. Considering T3- or N-positive patients, the incidence increased to 9.1%. There was no conversion of negative to positive cytology. Cytological positivity remained only in one case (2.9%) after the second and the third peritoneal samples., Conclusion: Rate of positive peritoneal washing cytology in patients with gastric cancer is influenced by clinicopathological findings and the technique used. Use of cytology alone is thought to be failed to detect free cancers cells within the peritoneal cavity., Competing Interests: There are no conflicts of interest

Partial necrosis of the cecum is a rare form of ischemic colitis with unknown etiology. A 68-year female patient was admitted due to a severe pain in the right lower quadrant of the abdomen for one week. One month ago, she had coronary artery bypass graft surgery with carotid endarterectomy. During physical examination, tenderness and rebound tenderness at the right lower quadrant were detected. Computed tomography showed a 7-mm tubular structure extending from the back of the cecum to the lower border of the liver. Laparoscopic appendectomy was planned with a preoperative diagnosis of acute appendicitis. During laparoscopy, a 3x3 cm necrotic area was noticed on the lateral wall of the cecum. After conversion to open surgery, partial cecum resection and ileocolostomy with appendectomy were performed. She was discharged on the 6th postoperative day, uneventfully. An isolated non-occlusive mesenteric ischemic event should be thought as a differential diagnosis in elderly patients who have right lower quadrant pain with atypical presentation, if there is chronic cardiac or renal failure.

Objective Breast cancer awareness month increases public awareness in association with increased rates of screening and new diagnoses. This study aimed to evaluate the effect of breast cancer awareness month on primary diagnosis of breast cancer. Methods Asymptomatic women with the intention of breast cancer screening were included. The non-BCAM (Breast cancer awareness month) group were screened from February to September 2016 and the BCAM group during October 2016. Ultrasound and mammography were performed in all women and in those aged ≥ 40 years, respectively. A BIRADS (Breast Imaging Reporting And Data Systems) score of ≥4 and solid palpable masses without features suggestive of malignancy and/or the physician's preference were regarded as indications for histopathological analysis. Requirement for histopathological analysis and detection of breast cancer were identified as the main variables. Results There were 198 women with a mean age of 49.3 ± 9.5 years. Sixty-nine and 129 women were in the non-BCAM and BCAM groups, respectively. Percutaneous biopsy was performed in seven (10.1%) and three patients (2.3%) in the non-BCAM and BCAM groups, respectively ( P = 0.035). Pathological examinations were benign. Conclusion Although public awareness campaigns lead to increased rates of screening, they may lose their impact on detecting breast cancer because of widespread use of routine screening programs.

Objective To compare urinary iodine excretion levels in patients with breast cancer and control subjects. Methods In this prospective pilot study, patients with breast cancer and normal controls were recruited. Age and menopausal status were recorded. Levels of serum thyroid-stimulating hormone, blood urea nitrogen and creatinine and urine iodine concentration (UIC) were measured. UIC levels were divided into three categories: low (<100 µg/l), normal (100-200 µg/l) or high (>200 µg/l). Results A total of 24 patients with breast cancer and 48 controls were included in the study. There were no statistically significant differences between the two groups with regard to thyroid-stimulating hormone, blood urea nitrogen or creatinine levels. When considered overall, there was no statistical difference in UIC between patients and controls. However, comparisons within each category (low, normal or high UIC) showed a significantly higher percentage of patients with breast cancer had a high UIC compared with controls. Conclusions A high UIC was seen in a significantly higher percentage of patients with breast cancer than controls. UIC may have a role as a marker for breast cancer screening. Further studies evaluating UIC and iodine utilization in patients with breast cancer are warranted.

Introduction: Despite recent advances in surgical techniques, pancreatic fistulas are common. We aimed to determine the role of C-reactive protein in the prediction of clinically relevant fistula development., Materials and Methods: Data from patients who underwent pancreaticoduodenectomy between 2012 and 2015 is collected. Postoperative 1st, 3rd, and 5th day (POD1, POD3, and POD5) C-reactive protein (CRP) levels, postoperative pancreatic fistula (POPF) development, other complications, length of hospital stay, and mortality were recorded., Results: Of 117 patients, 43 patients (36.8%) developed complications (including fistulas). Of the patients developing fistulas, 21 (17.9%) had POPF A, 2 (1.7%) had POPF B, and 7 (6.0%) had POPF C. POD5 CRP and POD3 CRP were shown to be significantly correlated with mortality and development of clinically relevant POPF ( p = 0.001 and p = 0.0001, resp.) and with mortality ( p = 0.017), respectively. The development of clinically relevant POPFs (B and C) could be predicted with 90% sensitivity and 82.2% specificity by POD5 CRP cut-off level of 19 mg/dL and with 100% sensitivity and 63.6% specificity by the difference between POD5 and POD1 CRP cut-off level of >2.5 mg/dL., Conclusion: CRP levels can effectively predict the development of clinically relevant pancreatic fistulas.

Context: Colorectal cancers are frequent among cancers of gastrointestinal system. Whether there are any differences between survival in rectum and colon cancer patients is controversial., Aims: In this study, we aimed to compare survival in surgically treated rectum and colon cancers and determine the factors affecting survival., Subjects and Methods: The patients with colon and rectum cancer operated between 2009 and 2013 were examined retrospectively using prospective database. Patients were categorized as colon and rectum according to the tumor's location. Survival was identified as the primary outcome. Kaplan-Meier survival analysis and log-rank tests in survival assessment were used., Results: One hundred and sixty-one patients with a mean age of 62.8 ± 12.7 years were included in the study. Male/female ratio was 1.6. Colon and rectum patients were counted as 92 (%57.1) and 69 (%42.9), respectively. Both groups were similar in demographic data (P > 0.05). It was observed that in 46 months (mean) of follow-up, 39.7% (n: 64) died, and 60.3% (n: 97) survived. Median survival time was 79 months, and 5-year cumulative survival rate was 60.8%. Five-year cumulative survival rates in stages for 1, 2, 3 and 4 were 88.2%, 64.7%, 48.5%, and 37.0%, respectively. It was noted that median survival time for colon cancer was 78 months and for rectum cancer was 79 months. Five-year cumulative survival rates for colon and rectum cancers were calculated as 56.7% and 63.4%, respectively. There were no significant differences in colon and rectum cancers in the means of survival rate (P: 0.459)., Conclusions: While location of colorectal cancers shows no significant effect on survival, treatment in the early stages increases survival rate., Competing Interests: There are no conflicts of interest.

Purpose: Although there are several surgical methods for treatment of sacrococcygeal pilonidal sinus, there is no widespread consensus. In this study, we aimed to compare primary closure, Limberg, and modified Limberg flap techniques, with each performed by each of 3 surgeons., Methods: A total of 802 patients who were operated on for pilonidal sinus disease were included in this retrospective cohort study. Patients were evaluated in 3 groups: group 1 (limited excision + primary closure), group 2 (large excision + Limberg flap technique), and group 3 (large excision + modified Limberg technique). Development of early or late period complications was accepted as primary outcome., Results: Mean patient age was 28.1 ± 6.7 years. Operation time in group 1 was 44.0 ± 14.5 minutes, and was shorter in comparison to other 2 groups (P < 0.001). One or more complications developed in 171 patients (21.3%) within study group. Highest complication rate was in group 1, with a rate of 30.7% (P < 0.001). Rate of wound dehiscence and recurrence in group 1 were differed significantly from other groups (P < 0.001 and P = 0.001, respectively)., Conclusion: Based on the same technique-the same surgeon approach, comparison of surgical methods for treatment of pilonidal sinus showed that modified Limberg and Limberg techniques are superior to primary closure technique in terms of general complication, wound dehiscence, and recurrence rates., Competing Interests: CONFLICTS OF INTEREST: No potential conflict of interest relevant to this article was reported.

Aims: Hereditary nonpolyposis colorectal cancer (HNPCC) is a subgroup of colorectal cancer (CRC) which should be differentiated because of the high risk for additional cancers and risk evaluation for other family members, especially for CRC. It is not practical to perform genetic testing for all CRC patients; therefore, various prediction modalities, for example, Bethesda guideline (BG) were studied in the literature. We aimed to assess the association of microsatellite instability (MSI), histology scores, and BG for predicting HNPCC risk., Subjects and Methods: Data were collected from CRC patients between 2009 and 2012. A total of 127 patients were retrospectively reviewed for BG status and the MSI scores, MsPath, and PathScore., Statistical Analysis Used: Definitive statistical methods (mean, standard deviation, median, frequency, and percentage) were used to evaluate the study data. Comparison used Student's t-test, Continuity (Yates) correction, Fisher-Freeman-Halton test, Pearson correlation, and receiver operating characteristics curve analysis., Results: Patients who were detected as Bethesda-positive had significantly higher MsPath and PathScore scores (P = 0.001 and P = 0.007, respectively). According to the cut-off value of 2.8 and 2.9 for MsPath and PathScore, respectively, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 90%, 43%, 22.8%, 95.8%, and 50.4% for MsPath, and 55%, 83.2%, 37.9%, 90.8%, and 78.7% for PathScore, respectively., Conclusions: The MSI scoring systems, MsPath, and PathScore, are reliable systems and effectively correlated with BG for predicting patients who need advanced analysis techniques because of the risk of HNPCC.

Amyand's hernia is defined as protrusion of the vermiform appendix in an inguinal hernia sac. It is a rare entity with variable clinical presentation from normal vermiform appendix to abscess formation due to perforation of acute appendicitis. Although surgical treatment includes appendectomy and hernia repair, appendectomy in the absence of an inflamed appendix and use of a mesh in cases of appendectomy remain to be controversial. The aim of this study was to review the experience of mesh inguinal hernia repair plus appendectomy performed for Amyand's hernia with noninflamed appendices. There were five male patients with a mean age of 42.4 ± 16.1 years in this retrospective study in which Amyand's hernia was treated with mesh inguinal hernia repair plus appendectomy for noninflamed appendices. Patients with acute appendicitis and perforated vermiform appendix were excluded. There were four right sided and one bilateral inguinal hernia. Postoperative courses were uneventful. During the follow-up period (14.0 ± 7.7 months), there was no inguinal hernia recurrence. Mesh inguinal hernia repair with appendectomy can be performed for Amyand's hernia in the absence of acute appendicitis. However, presence of fibrous connections between the vermiform appendix and the surrounding hernia sac may be regarded as a parameter to perform appendectomy., Competing Interests: Emin Kose, Abdullah Sisik, and Mustafa Hasbahceci declare no conflict of interests.

Introduction: Surgery is a major stress factor for patients, and is associated with significant anxiety or depression. The Hospital Anxiety and Depression Scale is one of the most common instruments used for assessment of patients' psychological stress. Here, we aimed to identify predictors of anxiety and depression in surgical inpatients., Methods: The study group consisted of consecutive two-hundred patients who completed the Hospital Anxiety and Depression Scale questionnaire. A patient scoring more than cut-off values (10 for anxiety and seven for depression) was considered as being at risk of anxiety or depression. Demographical data, socioeconomic status, education level and diagnoses were recorded. The Chi-square, Fisher's exact, Mann-Whitney, Kruskal-Wallis tests and binary logistic regression analysis were used to identify the predictive parameters for anxiety and depression., Results: It was found that female patients, patients older than 35 years, patients with low socioeconomic status and low education level had a relatively higher risk of anxiety. In addition, patients with low education and a hospital stay greater than seven days were at risk of depression. Logistic regression analysis revealed that socioeconomic status and education level were strongly predictive for anxiety. However, presence of anxiety was shown to be strongly predictive for depression., Conclusion: Healthcare providers should be aware of their patients' psychology and, therefore, it is recommended to consider predictive factors for anxiety and depression., (Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.)

Introduction: Inflammatory myofibroblastic tumor as a rare neoplastic lesion is seen most commonly in the pulmonary system. Beside the presence of limited number of inflammatory myofibroblastic tumors of the gastrointestinal tract in the literature, co-existence with acute appendicitis has not been reported before., Presentation of Case: A 27-year-old woman admitted to emergency department with acute abdominal pain at the right lower quadrant. The initial diagnosis was as acute appendicitis. Intraoperatively, a mass with a diameter of almost 5 cm originated from the distal ileal segments neighboring the appendix was seen. The patient was managed by segmental resection of the small intestine including the mass with appendectomy. Histologically, there were bundles of spindle cells accompanied by lymphoplasmocytic infiltration. The immunohistochemical studies showed that tumor cells were positive for smooth muscle actin, vimentin, perinuclear activity for anaplastic lymphoma kinase and CD 68. The final pathologic diagnosis was inflammatory myofibroblastic tumor., Discussion: Concomitant resection of tumoral lesions detected in the neighbor intestinal segments during appendectomy should be considered to diagnose and treat. For the diagnosis of inflammatory myofibroblastic tumor, immunohistochemistry pattern including positivity for actin, vimentin, CD 68 and anaplastic lymphoma kinase plays a crucial role. Therefore, detailed immunohistochemistry analysis should be performed in suspicious cases., Conclusion: Coexistence of inflammatory myofibroblastic tumor located in the gastrointestinal system with acute appendicitis is a rare event. Complete surgical excision should be regarded as the mainstay of the treatment. Long-term follow up with serial imaging techniques is recommended.

Objective: The purpose of this study was to evaluate the accuracy of diffusion weighted magnetic resonance imaging (MRI) in preoperative assessment of metastatic lymph nodes of gastric cancer., Methods: A total of 23 gastric cancer patients with a mean age of 59.4±10.9 years were analyzed. Lymph nodes were grouped as perigastric lesser curvature (Group Ia), perigastric greater curvature (Group Ib), D1+/D2 lymph nodes (Group II). Identification of histologically metastatic lymph nodes by diffusion weighted MRI was regarded as the main outcome., Results: A total of 1,056 lymph nodes including 180 histologically proven metastatic lymph nodes were dissected. Although diffusion weighted MRI could identify the metastatic lymph nodes in 18 out of 23 patients (77.8%), only 69 of total 1,056 nodes (6.53%), either metastatic or non-metastatic, could be detected. There was no correlation between histopathology and diffusion weighted MRI with regard to lymph node groups (P>0.05 for all). Overall accuracy was calculated as 69.56, 65.21 and 52.17 for Groups II, Ib and Ia lymph nodes, respectively. Apparent diffusion coefficient (ADC) values could not be helpful to differentiate metastatic lymph nodes (P=0.673)., Conclusions: Diffusion weighted MRI has low accuracy to detect or to differentiate metastatic and non-metastatic lymph nodes based on their ADC values in gastric cancer.

Pheochromocytomas and paragangliomas are neuroendocrine tumors that arise from chromaffin cells of adrenal medulla and extra-adrenal paraganglia, respectively. The recurrence of these neuroendocrine tumors as a jejunal mass causing obstruction in the small intestine is an exceptional entity. The present study reports the case of a 70-year-old male who presented to the Emergency Department of Bezmialem Vakif University Hospital with abdominal pain and vomiting. The patient possessed a history of left nephrectomy due to malignant pheochromocytoma that had invaded into the left kidney eight months prior to presentation. Bowel obstruction was diagnosed and the patient underwent a laparoscopic procedure. Partial resection of the jejunum was performed and immunohistochemical studies revealed the lesion to be malignant paraganglioma. The majority of paragangliomas are chemo- and radioresistant. Surgical excision remains the primary treatment. Metachronous paraganglioma arising from the small intestine is an extremely rare entity and may be a relevant consideration in patients presenting with bowel obstruction.

Background/aims: Although mortality rates decreased in recent years, pancreaticoduodenectomy is still associated with high morbidity rates. Pancreatic fistula is the leading cause of morbidity after pancreaticojejunal anastomosis and commonly occurs in soft pancreas. The objective of this study is to compare outcomes of conventional modified invaginated end to side pancreaticojejunostomy with a new practical method using V-Loc 'rM 180 wound closure device in soft pancreas., Methodology: Between December 2011 and August 2013, a total of 90 pancreaticoduodenectomy procedures were performed in our hospital. 28 of them were defined as soft pancreas according to attending surgeon and included in this study. Patients were divided into two groups consecutively and analysed for postoperative pancreatic fistula (POPF) rate, length of stay, operation time, cost and particular duration of anastomosis. Pancreatic fistulas were classified according to International Study Group on Pancreatic Fistula (ISGPF) definition., Results: 1 grade A and 2 grade B fistulas appeared in V-Loc group (Group 1), whereas 1 grade A, 2 grade B and 1 grade C fistulas appeared in conventional anastomosis group (Group 2)., Conclusions: Pancreaticojejunostomy with V-Loc suture is a convenient method in soft pancreas and can be performed safely.

Background and Purpose: Repair of giant incisional hernia is still associated with high postoperative morbidity and recurrence rates. We evaluated the effectiveness of placing the hernia sac between the viscera and the polypropylene mesh in the repair., Methods: The subjects of this study were patients with an incisional hernia at least 15 cm in diameter, diagnosed between June 2004 and October 2010 and treated with on-lay polypropylene mesh at least 25 cm in length. We operated using a simplified method of placing the hernia sac between the viscera and the mesh, and fixing the mesh with interrupted trans-fascial U sutures. We evaluated the patient demographics and postoperative complications retrospectively., Results: A total of 25 patients (mean age 57.1 ± 10 years) were included. The mean length of hospital stay was 1.8 ± 1.2 days. Seroma developed in four patients (16 %), but only two with cystic seroma required excision of the cyst wall with preservation of the mesh. Twenty-two patients (88 %) were followed up for a mean period of 42.6 ± 23 months. There was no incidence of chronic pain, hospitalization for intestinal obstruction, or enterocutaneous fistulization. There was only one recurrence (4.55 %)., Conclusion: The hernia sac can be interposed in all patients undergoing giant incisional hernia repair if direct contact between the polypropylene mesh and intestine is unavoidable.

Objective: Fatty tumours of the pancreas are rarely reported. With the advent of the imaging techniques, diagnosis of such tumours based on radiologic imaging is increasing., Materials and Methods: Between June 2006 and June 2012, four patients with pancreatic lipomas that were diagnosed by computed tomography were reviewed retrospectively with regard to their imaging findings. There were 3 male and one female patient with a mean age of 60.8 years (from 53 to 67 years)., Results: A single well-bordered nodular fatty lesion with well-delineated thin homogeneous capsule was seen in all patients. The mean densitometric measurement of the lesions was -76 Hounsfield units (HU) (from -83 HU to -63 HU). The size of the lesions was from 7 mm to 12 mm with a mean of 8.75mm. They were located in the tail, body and neck of the pancreas in two, one and one patient, respectively. There was no associated pancreatobiliary pathology. Histopathologic evaluation was not planned because of their incidental diagnosis in these asymptomatic patients., Conclusion: Pancreatic lipomas are silent lesions, incidentally found during imaging procedures. They have specific computed tomography findings and do not require any additional diagnostic imaging.

A 28-year-old woman underwent a pylorus preserving Whipple procedure for pancreatic serous cystadenoma located on the head of the pancreas. During the operation, an internal stent (7F silastic catheter, 9 cm in length) was placed within the pancreatic duct in the area of pancreaticojejunal end-to-end Dunking type anastomosis to prevent development of fistula. The stent was positioned so that one third of its length would lie into the pancreatic duct, and it was anchored to the periductal pancreatic tissue with only one rapidly absorbable chromic suture. Leakage from the anastomosis was not observed, and she was discharged without any complaint. Early postoperative abdominal CT examination revealed that the stent was retained within the normal caliber pancreatic duct (Fig. 1a). Six months after the operation, she began to complain to epigastric pain triggered by the meals. The laboratory analysis was normal, particularly liver biochemical tests and serum amylase. The internal pancreatic stent within the dilated pancreatic duct was detected by an additional CT examination (Fig. 1b). The stent was removed endoscopically at the third attempt. The pain was resolved after its removal. Control CT examination which was taken at the 18th month after removal of the stent showed dilatation of the pancreatic duct (Fig. 2a). The patient remained free of any complaint, although regressed pancreatic duct dilatation has persisted over 4 years of follow-up (Fig. 2b).

Hepatoid adenocarcinoma (HAC) is a very rare type of extrahepatic adenocarcinoma which has a clinicopathologic and morphologic similarity to hepatocellular carcinoma (HCC). Although it is not common, it can be seen in organs other than the liver. The correct diagnosis can be a challenge because of its clinically similarity to HCC and the diagnosis is usually achieved by pathological examination following the surgery. We present a 48-year-old woman who was following with the diagnosis of stage 5 hepatic hydatic cyst. In her routine blood examinations, her alpha feta protein level was found higher than normal and her abdominal computed tomography and magnetic resonance findings did not reveal any pathological findings rather than hepatic hydatic cysts. There was a high activity of FDG on PET CT in the hepatic region so we performed a right lateral hepatectomy to the patient and final pathology was adrenal hepatoid adenocarcinoma. In this paper we aimed to present a rare case of hepatoid carcinoma of the adrenal gland.

Background. The exact nature of learning curve of totally extraperitoneal inguinal hernia and the number required to master this technique remain controversial. Patients and Methods. We present a retrospective review of a single surgeon experience on patients who underwent totally extraperitoneal inguinal hernia repair. Results. There were 42 hernias (22 left- and 20 right-sided) in 39 patients with a mean age of 48.8 ± 15.1 years. Indirect, direct, and combined hernias were present in 18, 12, and 12 cases, respectively. The mean operative time was 55.1 ± 22.8 minutes. Peritoneal injury occurred in 9 cases (21.4%). Conversion to open surgery was necessitated in 7 cases (16.7%). After grouping of all patients into two groups as cases between 1-21 and 22-42, it was seen that the majority of peritoneal injuries (7 out of 9, 77.8%, P = 0.130) and all conversions (P = 0.001) occurred in the first 21 cases. Conclusions. Learning curve of totally extraperitoneal inguinal hernia repair can be divided into two consequent steps: immediate and late. At least 20 operations are required for gaining anatomical knowledge and surgical pitfalls based on the ability to perform this operation without conversion during immediate phase.

Midgut malrotation is a congenital anomaly of intestinal rotation and fixation that is generally seen in neonatal population. Adult cases are rarely reported. Early diagnosis is crucial to avoid life threatening complications. Here, we present an adulthood case of midgut volvulus as a rare cause of acute abdomen.

Paraduodenal hernia, the most common type of internal herniation, is rare in the etiology of intestinal obstruction. Delayed diagnosis and surgical intervention may result in significant morbidity and mortality risk. This report presents a case of left paraduodenal hernia resulting in acute intestinal obstruction. A 43-year old male patient was admitted with a diagnosis of acute intestinal obstruction. A left paraduodenal hernia was identified by computed tomography findings of an encapsulated cluster of dilated small bowel loops occupying the left upper quadrant between the stomach and pancreas, and the presence of an engorged and displaced vascular pedicle at the orifice of the hernia. Upon further investigation, the dilated proximal jejunal segments were found in the left paraduodenal fossa, enclosed in a hernia sac. After reducing the intestinal segments to the abdominal cavity, the orifice of the hernia sac was closed by suturing to the retroperitoneum. Paraduodenal hernia should be considered as a possible etiology in cases of acute intestinal obstruction with unremarkable presentations. Physicians should be familiar with the demonstrative imaging findings of computed tomography of a paraduodenal hernia. Early surgical intervention is critical to prevent the significant morbidity and mortality associated with this condition.