BACKGROUND:Distribution of the colonic diverticula differs in different populations, and right-sided colon diverticulitis (RCD) and left-sided colon diverticulitis (LCD) manifest distinct clinical features. Complicated diverticulitis (CD) mostly requires hospitalization and can be treated within a spectrum from observation to surgery. Treatment choice is formed depending on the patient's general condition, the presence of diffuse peritonitis, the localization of diverticulitis, Hinchey stage, and responsiveness to the prior treatment. Clinical disparities regarding right and LCD also led to the differences in the incidences of both emergency surgery and future elective surgery. AIM:To evaluate the clinical features of CD, display the differences according to colonic localizations, and present treatment approaches. METHODS:This was a retrospective study from a single centre analysing data from a prospective database. The 253 patients with history of hospitalization for CD were included and divided into two groups: RCD and LCD. To compare the differences between the two groups, the Student's t-test was used when the parametric test prerequisites were fulfilled, and the Mann-Whitney U test was used when such requirements were not fulfilled. RESULTS:The 208 (82.2%) patients were found to have LCD, and 45 (17.8%) had RCD. The majority of the patients had Hinchey 1A diverticulitis (49.8%). Male gender was significantly more common in patients who underwent surgery for LCD. While persistent abdominal pain was the main prior finding in the conservative treatment of both localizations, surgery was most performed due to abscess in RCD and perforation in LCD. The presence of an accompanying malignancy during colonoscopy was significantly more common in LCD cases who underwent surgery. Hartmann's procedure was the most performed technique in emergency settings (56.3%), while laparoscopic colectomy with anastomosis was in elective settings (53.9%). In addition, surgery was found to prolong the mean length of hospital stay in LCD patients. CONCLUSION:Although diverticulitis is a benign condition, the need for an individualized and evidence-based approach makes management challenging. Localization of the disease has an important role in determining the appropriate treatment.

Parathyroid adenoma is the most common cause of primary hyperparathyroidism and rarely reaches huge sizes. As the gland enlarges it may exhibit atypical morphology and extension to the mediastinum which may complicate the excision of the tumor while preserving the capsular integrity. We present a 35-year-old male patient who was referred to our department with a complaint of severe hypercalcemia. Neck ultrasound and parathyroid scintigraphy revealed an adenoma of 45x25 mm in size in the left parathyroid lobe extending to the retrosternal area. The patient underwent an uneventful parathyroidectomy. The patient remained well with no evidence of biochemical recurrence during the 4-year follow-up. Here, we presented a very original case of one of the largest parathyroid adenomas (8 cm) with atypical configuration (having multiple spicular extensions from the main body) ever reported in the literature which was completely retrieved from the posterior mediastinum via cervical route.

Von Hippel-Lindau (VHL) disease is an autosomal dominant syndrome and affects many organs. We aim to report an adult patient with VHL disease having bilateral adrenal pheochromocytoma and multiple neuroendocrine tumors of the pancreas who was successfully treated with simultaneous function-preserving adrenalectomy and pancreatectomy. A 27-year-old woman was admitted to hospital with hypertension. The computed tomography of the abdomen revealed a solid tumor in both adrenal glands with the sizes of 12x7 cm on the right and 4x4 cm on the left. She also had two pancreatic solid masses in the head and three in the tail with varying sizes. The laboratory tests are all within normal limits except elevated 24-hour urinary metanephrine and normetanephrine. I-123 MIBG scanning showed increased uptake in both adrenal glands. Fine needle aspiration biopsy of the tumor on head of pancreas via endoscopic ultrasonography showed neuroendocrine tumor. Those findings were compatible with bilateral pheochromocytoma and multiple pancreatic neuroendocrine tumors and genetic tests revealed the mutation which confirmed the diagnosis of VHL disease. After suppression with alpha-1 inhibitor, right total, left cortical-sparing adrenalectomy, Whipple procedure for the pancreatic head lesions and spleen-preserving distal pancreatectomy were performed and pancreatic corpus was preserved. This case showed that multiple function-preserving procedures can be safely performed with oncological principles in patients with VHL disease.

BACKGROUND Idiopathic omental infarction (IOI) is challenging to diagnose due to its low incidence and vague symptoms. Its differential diagnosis also poses difficulties because it can mimic many intra-abdominal organ pathologies. Although hypercoagulability and thrombosis are among the causes of omental infarction, venous thromboembolism scanning is rarely performed as an etiological investigation. CASE SUMMARY The medical records of the 5 cases, who had the diagnosis of IOI by computed tomography, were examined. The majority of the patients were male (n = 4, 80%) and the mean age was 31 years (range: 21-38). The patients had no previous abdominal surgery or a history of any chronic disease. The main complaint of all patients was persistent abdominal pain. Omental infarction was detected in all patients with contrast-enhanced computed tomography. Conservative treatment was initially preferred in all patients, but it failed in 1 patient (20%). After discharge, all patients were referred to the hematology department for thrombophilia screening. Only 1 patient applied for thrombophilia screening and was homozygous for methylenetetrahydrofolate reductase (A1298C mutation) and heterozygous for a factor V Leiden mutation. CONCLUSION IOI should be considered in the differential diagnosis in patients presenting with progressive and/or persistent right side abdominal pain. Investigating risk factors such as hypercoagulability in patients with IOI is also important in preventing future conditions related to venous thromboembolism.

Objective:Postoperative pancreatic fistula (POPF) affects 13-50% of patients undergoing pancreaticoduodenectomy (PD), and remains the main source of post-PD morbidity and mortality. Therefore, determining predictive risk factors for POPF remains popular today. This study aimed to determine the predictive risk factors for clinically related postoperative pancreatic fistula (CR-POPF) in the preoperative and early postoperative period in patients that underwent PD. Methods: This is a retrospective study involving 248 patients who underwent PD between January 2015 and December 2019 in our center. We compared the groups that did and did not develop CR-POPF. We determined the risk factors affecting CR-POPF by stepwise logistic regression analysis. Results:141 (56.8%) of the patients included in the study were male, and the median age was 63 (56-70)/year. The CR-POPF rate was 18.1%. We found a statistically significant difference (p <0.05) in the following parameters: diabetes, smoking, preoperative leukocyte, preoperative neutrophil, postoperative first day (POD1) amylase, POD1 AST, POD1 ALT, POD1 CRP, POD1 lymphocyte-CRP ratio (LCR), postoperative third day (POD3) lymphocyte, POD3 CRP, in POD3 neutrophil-lymphocyte ratio, POD3 platelet-lymphocyte ratio (PLR), POD3 AST-ALT ratio, POD3 LCR, surgeon experience, incision type, Wirsung diameter, pancreatic tissue and operation time. In the stepwise logistic regression model, we found POD1 AST, POD3 CRP, POD3 TLR, diabetes, surgeon experience, and Wirsung diameter as predictive risk factors. Conclusions: Despite some new methods to reduce the occurrence of POPF, the expected improvement in POPF rates is elusive. Predictive risk factors for POPF may also vary because the response of patients to trauma varies and the postoperative period is very dynamic. In our study, we found POD1 AST, POD3 CRP, POD3 TLR, diabetes, surgeon experience and Wirsung diameter as predictive risk factors for CR-POPF.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) are the most common mesencyhmal tumors of the gastrointestinal tract. Today surgical resection is still the treatment of choice for primary gastric GISTs. This study compares the laparoscopic versus open surgical resection approaches of gastric GISTs. METHODS: A retrospective chart review was conducted from our database, and 68 primary gastric GIST resections were found to be performed in our center between 2008- 2020. Of these 68 patients, 57 were included for the study. Open resection was performed in 32 patients, and laparoscopic resection was performed in 25 patients. The medical records were examined and compared for clinical, pathologic and surgical results according to preferred surgical method of choice. RESULTS: Fifty-seven patients were qualified for the study. The average diameter of the tumor was 4.8 +/- 1.91 cm in the laparoscopic group, and 6,8 +/- 4,27 cm in open group. Estimated blood loss during the surgery was significantly lower in laparoscopic group patients (100.7 ml vs 287.5 ml) (p< 0.001) and also length of stay was shorter compared with open at 4.4 versus 11.9 days (p < 0.001). Laparoscopic group patients needed less pain medication, and they had quicker return to daily life. CONCLUSIONS: Laparoscopic approach is safe and feasible with acceptable oncologic outcomes and certain benefits like decreased length of stay, less complication rates and better comfort. The preference of laparoscopic resection should be decided not only on tumor location or diameter but also surgeon's laparoscopic surgical experience.

Background/aim: Accurate preoperative localization of the culprit gland is the key point for the surgical treatment of primary hyperparathyroidism. Conventional imaging techniques (ultrasound and Tc99m sestamibi scintigraphy) are usually adequate for preoperative localization. However, in some patient groups, additional imaging modalities may be required since noninvasive techniques may fail. In this study, we aimed to evaluate the diagnostic value of selective parathyroid venous sampling in patients with unclear noninvasive localization tests. Materials and methods: Among 513 cases who underwent parathyroidectomy due to primary hyperparathyroidism, twelve cases (2.3%) were undergone selective parathyroid venous sampling and were included in the study. Age, sex, presenting symptom, presence of a genetic disease, medical and surgical history, serum calcium (Ca)-parathormone (PTH) levels (preoperative, intraoperative, and postoperative), imaging reports (US, SM, and SVS), surgery reports, pathology reports, and complications were retrospectively reviewed. Results: Seven cases (58.3%) had persistent primary hyperparathyroidism and one patient (8.3%) had past surgical history of total thyroidectomy. The remaining four patients (33.3%) had no previous neck surgery. The sensitivity of selective venous sampling was 75%. According to the medical history, accurate localization was achieved in 85.7% of persistent cases and 60% of primary cases. Eight cases (66.6%) underwent unilateral neck exploration and four cases (33.3%) underwent four gland exploration. A single adenoma was detected in ten cases (90.9%) while one patient (9.1%) had double adenoma. Conclusion: Selective venous sampling is a prominent technique with high accuracy in persistent cases when the conventional imaging methods are negative or equivocal. Although the cost and invasiveness are the most common confusing facts about selective venous sampling, its benefits such as improving the surgical success and saving the patients from repeated operations may surpass them.

Lipodystrophy (LD) is an acquired or congenital rare condition consisting of hyperlipidaemia, glucose intolerance/ insulin resistance, and almost complete absence and storage of adipose tissue. Colon perforations can be observed in type 4 congenital LD. Here, we aimed to present a case of sigmoid colon perforation which developed in a young woman with the diagnosis of LD. Extensive purulent peritonitis, significant wall thickening, and oedema in the sigmoid colon were detected during surgical exploration. Anterior resection with end colostomy procedure was then performed. Although bowel perforation has been theoretically reported to occur in LD, the presented case is the first adult patient in the literature. These individuals tend to develop colon perforation as a result of histological changes in their gastrointestinal tract. This situation should always be taken into consideration in order to avoid delay in diagnosis, especially in patients who present with abdominal pain and have a history of LD. Key Words: Intestinal perforation, Congenital lipodystrophy, Peritonitis, Sigmoid colon.

Acar, Nihan M.D.; Etlik, Mete M.D.; Karaisli, Serkan M.D.; Acar, Turan M.D. Author Information

Background: Recent reports have shown that left-and right-sided colon cancers display different clinical and biological features. Chromosomal instability, epigenetic alterations, and defects in the deoxyribonucleic acid (DNA) mismatch repair (MMR) system may lead to the development of colorectal cancer (CRC). Besides microsatellite instability (MSI) caused by DNA MMR activity degradation increases the risk for CRC. Aim: We aimed to show the differences between CRCs in different locations, to research the cause of these differences, to present whether there is a relation between MMR and MSI, and to evaluate their effects on prognosis. Patients and Methods: 641 CRC cases were divided into three groups: Group 1 (right-sided), Group 2 (left-sided), and Group 3 (rectum). Demographics, cancer stages, location of the tumors, number of the lymph nodes removed, MMR deficiency or proficiency, MSI status, and survival were assessed by retrospective review of the patients. Results: Among 641 patients, 64.9% were males. Group 1, 2, and 3 comprised 31.2%, 45.7%, and 23.1% of all the cases, respectively. There was a significant difference in terms of survival and location only in stage II tumors. Stage II left colon cancer (LCCs) had a statistically significant lower survival rate. There was no significant difference in survival between both MSI and MMR statuses. In addition, cases were also stratified by stages. According to this data, 10.1, 45.7, and 44.2% of the patients had stages I, II, and III disease, respectively. Conclusions: Although it was not statistically significant, tumors with MMR deficiency (dMMR) and high microsatellite instability (MSI-H) are more common in right-sided colon tumors.

The importance of oncologic principles in colorectal cancer has been particularly emphasized in recent years. There are several studies on the quality of the conditions of emergency surgery and comparison of stage, mortality and morbidity rates between patient who underwent emergency and elective surgery. This study aimed to investigate and compare the clinicopathologic characteristics of patients with colorectal cancer according to their surgical conditions whether urgent or elective. Medical records of 564 patients, who underwent colorectal resection between January 2011 and March 2017 anddiagnosed with colon/rectum adenocarcinoma after pathological examination, were investigated ret-rospectively. There were 104 (18.4%) patients in the emergency surgery group and 460 (81.6%) patients in the electi-ve surgery group. Majority of the patients were male61.2%, and the mean age was 64.27. The patients who had rectal tumor were 19.7% of all cases, and the tumor was located in colonic segments in the remaining 80.3%. Low anterior resection was determined as the most common procedure with the percentage of 23.2%. Anterior resection was the most common procedure in emergency surgery group (27.9%). There was no significant difference between the mean lymph node count in terms of the type of the operation, on the basis of surgical condition. When the factors such as age, gender, tumor location, type of the operation and stage of cancer that have effects on adequate lymph node dissection, were analyzed; the only statistically significant difference was found between emergency and elective cases of the transverse colon tu-mors (p<0.05). While postoperative complications had no effect on the length of hospital stay, having an os-tomy and an advanced cancer found to be prolonging this duration (p<0.05). Surgical conditions have been shown to not affect the lymph node dissection which is an important factor determining the oncological process of the patient.

OBJECTIVE To evaluate the clinical, laboratory and imaging data of patients who underwent pancreatoduodenectomy (PD) for proven benign pathologies. STUDY DESIGN Descriptive study. PLACE AND DURATION OF STUDY Department of General Surgery, İzmir Katip Celebi University, School of Medicine, Turkey between January 2015 and June 2020. METHODOLOGY All patients who underwent PD, and were found to be benign histopathologically, were included in the study. Patients who had to undergo PD due to trauma during operations performed for other reasons, were also included in the study. The data was collected as per objective. RESULTS Diagnosis of benign pathologies was made histopathologically in 27 of the 248 patients (10.89%). It was found that 8 of 17 patients, who had biopsy in the preoperative period, were operated with a pre-diagnosis of malignancy, nine were performed PD due to accompanying clinical findings despite the detection of non-diagnostic cytology, and ten patients were taken into surgery; because of the malignancy risk could not be ruled out. CONCLUSION Patients with benign pathology were found to have better parameters of CRP and total bilirubin. PD was performed in patients with mass in the pancreas; and whose cancer risk could not be ruled out. To reduce PD due to benign causes, patients with undiagnosed lesions should be evaluated with a multidisciplinary approach, and diagnostic tools should be cross-checked. PET/CT may also be useful in the differential diagnosis. Key Words: Benign, Diagnosis, Pancreas, Pancreaticoduodenectomy, Pathology.

Department of General Surgery, Katip Çelebi University Atatürk Training and Research Hospital, Izmir, Turkey Funding/Support: None reported. Financial Disclosure: None reported. A written informed consent for publication was obtained from the patient. Correspondence: Nihan Acar, M.D., Department of General Surgery, Katip Çelebi University Atatürk Training and Research Hospital, Karabağlar, Izmir, Turkey. E-mail: [email protected]

Background/aim: Paget's disease (PD) of the breast is a very rare presentation of breast malignancy, accounting for 1%-3% of all primary breast tumors. We aimed to evaluate and compare the clinicopathological features and clinical outcome of PD accompanied by in situ carcinoma and invasive cancer. Materials and methods: We used the archive of our pathology laboratory retrospectively for age, sex, history of surgery, histopathological findings, treatment modalities, and follow-up information. We used the Kaplan-Meier method for survival analysis. Results: There were 46 female patients diagnosed with PD. In 39 (84.7%) patients, invasive carcinoma accompanied PD, while 7 (15.3%) patients had ductal carcinoma in situ. The median age at diagnosis was 53.5 years. The median follow-up period was 47 months. Of the 39 invasive carcinoma, 10 (25.6%) died during the follow-up period. Invasive ductal carcinoma group had a mean overall survival of rate of 57.8 +/- 6.6 months. According to univariate analysis, only the tumor type was found to impact overall survival (p < 0.001). Conclusions: The current study displayed the tumor type as the only parameter affecting overall survival in the invasive carcinoma group. Although it was not statistically significant, breast cancers accompanied by PD were found to be predominantly advanced stage tumors, high grade, hormone receptor negative, and HER2 positive.

Purpose: The sinusoidal obstruction syndrome (SOS) of the liver is an obliterative vasculitis that involves the terminal branches of the hepatic venules and sinusoids. When it is not treated, it will be a serious risk of mortality. Here, we aim to present our patient who has been associated with recurrent cholangitis attacks due to cholelithiasis and choledocholithiasis and is associated with sinusoidal obstruction syndrome with the literature. Description of the case: A 30 years old male patient had complaints of abdominal pain and nausea for a long time. The patient had a history of choledocholithiasis and cholangitis attacks. Although ERCP was performed and a stent was placed in the biliary tract, his jaundice did not disappear. Liver function tests were high. Tumor markers were negative. Methods: We could not make a definitive diagnosis with imaging methods and biopsy and we planned surgery. We performed segmental liver resection and biliary diversion in the surgery. Histopathological examination of the resected liver tissue was compatible with SOS. Conclusion: Many studies have been done on the etiology of SOS and different causes have been revealed. Accompanied with clinical findings, a definitive diagnosis is made with the exclusion of the presumptions considered. Surgery can be performed for both diagnostic and therapeutic purposes. If patients with elevated liver function tests and bilirubin have long-term abdominal pain, SOS should be bear in mind.

Objectives: Although cervical incisions are usually sufficient in mediastinal located thyroid and parathyroid pathologies, sometimes mediastinal approaches are required. In recent years, less invasive methods have been used instead of median sternotomy. In this study, the adequacy of the incision and morbidity in patients who underwent split sternotomy due to retrosternal goiter (RG) and mediastinal parathyroid pathology in our clinic were investigated. Methods: The files of patients who underwent split sternotomy in addition to cervical incision or split sternotomy extending from the sternal notch to the third intercostal space with a separate vertical incision due to retrosternal thyroid pathology or mediastinal ectopic parathyroid adenoma between January 2010 and January 2021 were retrospectively reviewed. Operative success, exposure provided by split sternotomy, and complication rates were investigated. Results: Twelve patients who underwent split sternotomy were included in the study. The mean age of the patients was 57.25±12.62 (44–83) years. Eight (66.7%) of the patients were female and 4 (33.3%) were male. The indication for surgery was multinodular goiter (MNG) in 3 (25%) patients, recurrent MNG in 3 (25%) patients, hyperparathyroidism in 3 (25%) patients, and thyroid cancer in 3 (25%) patients. Transient hypocalcemia in 6 (50%) patients and unilateral vocal cord paralysis in 1 (8.3%) patient developed postoperatively, and all complications resolved spontaneously in an average of 3 weeks. Median sternotomy was not required for any of the patients. Conclusion: Split sternotomy is an adequate and applicable method for the success of the surgery in RG and mediastinal parathyroid pathologies that cannot be excised with the cervical approach.