Amaç: Bu çalışmada yetişkinlerde çok sık görülmeyen Morgagni hernisi nedeniyle cerrahi tedavi yaptığımız hastalarımızın sonuçlarını sunmak amaçlanmıştır.Materyal ve Metod: Kliniğimizde Eylül 2009 ile Eylül 2020 tarihleri arasında Morgagni hernisi nedeniyle cerrahi tedavi uygulanan hastaların dosyaları geriye dönük incelendi. Hastaların demografik özellikleri ve cerrahi tedavi sonuçları kaydedildi. Hastalar laparoskopik ve açık cerrahi yapılan hasta grubu olarak ayrıldı. Gruplara İstatistik analizlerde Mann-Whitney U testi kullanıldı, p<0,05 değeri istatistiksel olarak anlamlı kabul edildi.Bulgular: Cerrahi yapılan 6 hastanın 3’üne (%50) açık cerrahi, 3’üne (%50) laparoskopik cerrahi yapıldı. Hastaların hepsine (acil ameliyata alınan 1 hasta hariç) propropilen ve dual mesh uygulandı. Hastaların 2’sinde (%33) postoperatif komplikasyon (minimal pnömotoraks ve atelektazi) görüldü. Hasta grupları (açık ve laparoskopik) karşılatıldığında postoperatif hastanede kalış süreleri arasında istatistiksel olarak anlamlı bir fark vardı (p< 0,037).Sonuç: Bu çalışma göstermiştir ki, Morgagni hernisi nadir görülen bir durumdur. Hastalar non spesifik semptomlarla başvururlar. Bunun yanında çeşitli cerrahi tekniklerle tedavisi mümkündür. Bunlar içinde laparoskopik cerrahi, hastanın hem ameliyat sonrası konforunu artırmakta, hem de hastanede kalış süresini kısaltmaktadır.

Objective: End-stage liver disease (ESLD) is a devastating condition, which leads to liver transplantation (LT).There are various proposed predisposing factors for ESLD.A significant proportion of ESLDs is of undetectable (cryptogenic) origin.Accumulation of heavy metals is a proposed but not thoroughly researched predisposing factor for ESLD.In this study, we measured the concentration of accumulated heavy metals in the explanted liver tissue of ESLD patients.Apart from various accompanying etiologies, such as rare hereditary diseases, infections, and tumors were also evaluated.Method: This prospective study aimed to evaluate the concentrations of heavy metals in the explanted liver of consecutive patients with ESLD and different etiologies who underwent elective and/or emergency LT.Bioaccumulation of nine heavy metals (Hg, As, Zn, Cr, Pb, Cu, Ni, Mg, and Fe) was evaluated by atomic absorption spectrophotometer in the explanted liver tissue of ESLD patients.Also, histopathologies of explanted livers and etiologies of patients were evaluated using data from histopathological techniques, medical records, or genetic counseling processes. Results:The male/female ratio was 33:15.The results of our study showed no statistical significance in terms of total heavy metal levels in the explanted livers (p > 0.05), including patients with cryptogenic etiology.However, four patients with Wilson's disease had copper levels of 250 uq/g dried liver tissue.Histopathological examinations of explanted livers revealed that four (8%) patients had Wilson's disease, one (2%) patient had tyrosinemia, 15 (31%) patients had unknown/undetectable (cryptogenic) etiology, 24 patients had viral infections (20 had hepatitis B virus infection, one had hepatitis C virus infection, three had multiple viral infections at once), one patient had a metastatic tumor, one patient had an unidentified autoimmune disease, and one patient had polycystic liver disease. Conclusion:Accumulated total heavy metal levels in explanted livers of ESLD patients do not appear to be a differential diagnosis tool, except the copper levels for Wilson's disease.More research is needed to further elucidate the different roles of heavy metal concentrations in both normal and disease states of heavy metals in the liver.

Purpose This study aims to provide an overview of the literature on carcinoma arising from giant perianal condyloma acuminatum. Methods We present a new case of squamous cell carcinoma arising from giant perianal condyloma acuminatum. We also conducted a systematic search of the medical literature using PubMed, Medline, Google, and Google Scholar related to carcinoma arising from giant perianal condyloma acuminatum. The following search terms were used in various combinations: condyloma acuminatum, giant condyloma acuminatum, Buschke-Lowenstein tumor, squamous cell carcinoma, and verrucous carcinoma. The search included articles published before in the English language November 2020. Results A total of 55 article concerning 97 patients with carcinoma (squamous cell carcinoma, verrucous carcinoma, basaloid cell carcinoma, carcinoma insitu) arising from giant perianal condyloma acuminatum meeting the aforementioned criteria were included. The patients were aged from 24 to 82 years (median: 49.6, IQR: 21); 20 were female (median age: 52.5, IQR: 20.5), and 75 were male (median age: 53, IQR: 17.5). The gender data of the remaining two patients could not be obtained. The histopathological features of tumors arising from giant condyloma acuminatum are as follows: squamous cell carcinoma (n = 56), squamous cell carcinoma in situ (n = 16), verrucous carcinoma (n = 19) and basaloid cell carcinoma (n = 1), squamous cell carcinoma + verrucous carcinoma (n = 1), squamous cell carcinoma + squamous cell carcinoma in situ (n = 1), squamous cell carcinoma + basaloid cell carcinoma (n = 1) and malignant behavior (n = 2). Conclusion Giant condyloma acuminatum is a rare variant of anogenital warts. It is known that this tumor, which is mostly thought to be benign, has a high potential for local recurrence and transformation into invasive cancer. Therefore, it is vital that the tumor is resected with clean surgical margins, even if it looks benign, and that aggressive treatment options are not avoided when necessary.

BACKGROUND/AIMS The goal of the present study was to determine the factors affecting strangulation and necrosis in incarcerated abdominal wall hernias (AWHs). MATERIAL and METHODS This was a retrospective study conducted by reviewing the medical records of 44 patients who underwent surgery for incarcerated abdominal wall hernia at a university hospital between April 2009 and January 2018. RESULTS Of the 44 study patients, 28 were men and 16 were women of mean age 68.95 years. Of all, 30 patients (68.2%) had groin hernias (femoral: 7, inguinal: 23) and 14 (31.8%) had ventral hernias (incisional: 8, umbilical: 5, epigastric: 1). The intraoperative findings were strangulation in 24 (54.5%) and necrosis in 20 (45.5%) cases. Accordingly, omental resection was performed in 4, small bowel resection in 14, and large bowel resection in two patients. The hernia was repaired using a polypropylene mesh in 33 patients (of them 20 were Lichtenstein, 8 were on-lay, and 5 were plug-mesh) and without using a mesh in ten patients. The hernia was not repaired in one patient. The mean duration of hospitalization was 7.43 (range: 1-5) days. The mortality rate was 13.6%. In univariate analysis, the mortality was positively related to necrosis (p=0.045). The duration of these symptoms was the only factor that affected strangulation and necrosis. CONCLUSION The mortality rate was high in incarcerated abdominal wall hernias, while necrosis was the most significant variable associated with mortality. The duration of the symptoms was the most significant factor that affected necrosis; therefore, it is essential to perform surgical intervention within the first 24 h of admission.

OBJECTIVES:The most common intra-abdominal complication following loop ileostomy closure (LIC) is postoperative ileus (POI). The aim of the study was to determine the risk factors of POI development following LIC and make recommendations for its prevention.MATERIAL AND METHODS:In this study, patients having undergone LIC with peristomal incision following distal colorectal surgery were included. Clavien-Dindo classification was used to evaluate postoperative complications. POI and postoperative leakage were defined based on clinical and radiological criteria. The Centers for Disease Control and Prevention 2017 criteria were used to diagnose surgical site infection (SSI). Postoperative bleeding was diagnosed one day after surgery if there was a >2 g/dL or ≥15% decrease in the hemoglobin level.RESULTS:Seventy-nine patients were included into the study. In nine of the patients POI developed, six had SSI, five had postoperative bleeding, and two had anastomosis leakage. In the univariate analysis; age <60 years (p= 0.02), presence of comorbidity (p= 0.007), using an open technique in the first surgery (p= 0.02), performing total colectomy in the first surgery (p= 0.048), performing hand-sewn anastomosis of LIC (p= 0.01), and postoperative blood transfusion (p= 0.04) were found to be risk factors for POI. Performing hand-sewn anastomosis of LIC (p= 0.03) and using an open technique in the first surgery (p= 0.03) were found to be independent variables for POI risk.CONCLUSION:Using an open technique in the first surgery and performing a hand-sewn anastomosis of LIC may increase POI.

The majority of groin hernias are treated according to the findings of the physical examination, but patients may also have occult hernias. With the use of laparoscopy, hernias that were not noticed during the initial examination or even in radiological images are increasingly being detected intraoperatively. Here, we present the case of a 62-year-old gentleman diagnosed with seven different types of occult and non-occult bilateral inguinal hernias that were treated with laparoscopic totally extraperitoneal herniorrhaphy. A major advantage of this method is that it allows the simultaneous diagnosis and treatment of occult and rare inguinal hernias.

OBJECTIVE To investigate the incidence of major low anterior resection syndrome (LARS), using the LARS score, in patients who underwent sphincter-preserving surgery for rectal cancer, and to explore the factors affecting major LARS development. METHOD The medical records were retrospectively reviewed of patients, who were operated for rectal cancer at a tertiary center between January 2009 and October 2017. The inclusion criteria were: The absence of other colorectal or proctologic diseases, the application of anterior resection (high anterior resection, low anterior resection, extremely low anterior resection), follow-up of more than one year after the primary surgery, and follow-up of more than one year after protective ileostomy closure, and the absence of an unreversed stoma, ongoing treatment with chemotherapy or radiotherapy, recurrence, and metastatic disease. LARS was diagnosed using the LARS score developed by Emmertsen and Laurberg. RESULTS For the study period, 81 patients met the inclusion criteria, including 45 (55.5%) men and 36 (44.4%) women, with a mean age of 60.1 years. Of the 81 patients, 56 (69.1%) underwent chemotherapy and 43 (53%) underwent radiotherapy. Major LARS was detected in 29.6% of the patients. Univariate analysis revealed that radiotherapy, lower tumor location and a short interval after ileostomy closure had an effect on LARS development, and multivariate analysis indicated that incidence of LARS was higher in middle and lower rectal cancer. CONCLUSIONS There appears to be no harm in creating a protective ileostomy for LARS development, with regard to anastomosis safety and the planning of the adjuvant therapy. Neither radiotherapy, nor type of surgery had an effect on major LARS. As was expected, a high rate of major LARS was reported in lower rectal tumors.

INTRODUCTION:Mushroom intoxication (MT) can lead to acute liver injury which may result in Mushroom intoxication-related liver failure (M-ALF) requiring liver transplantation (LT). In the present study, we want to share the experience of our institute regarding living-donor LT (LDLT) due to mushroom poisoning. AIM:The aim of this study is to identify the predictors of poor prognosis in patients with ALF secondary to mushroom intoxication requiring LDLT. MATERIALS AND METHODS:All patients with MT between 2008 and 2016 were evaluated. Demographics, symptoms, interval between symptoms and admission to our institute, laboratory data, model for end-stage liver disease (MELD)/pediatric end-stage liver disease (PELD) scores, clinical course, and outcomes of supportive therapy and LT were evaluated. There were two groups in the study: Group A = responsive to supportive therapy (n = 9) versus Group B = unresponsive to supportive therapy (n = 9). RESULTS:During the study, a total of 18 patients were admitted with M-ALF. Twelve (66.7%) of them were female, and the mean age was 39.9 ± 18.2 years. All of the nine patients in Group A fully recovered with supportive therapy. In Group B, one patient died during waiting period for LT and 8 patients received LDLT LDLT. Three of the eight patients who were transplanted died in the postoperative early period within postoperative 5 days. The patients in Group B had significantly higher MELD/PELD scores and encephalopathy rate than in Group A (P < 0.05). International normalized ratio (INR), bilirubin, ammonium levels, and platelet count were significantly different between groups (P < 0.05). The patients in Group B had significantly longer interval before admission to our institute (P < 0.05). CONCLUSION:The presence of encephalopathy, higher MELD/PELD, INR, bilirubin, ammonium levels, and lower platelet count was related to poor prognosis in MT. LDLT provides a good therapeutic option in patients with M-ALF. The time is a crucial factor in successful treatment of MT. Early admission to a tertiary referral center with expertise in LT results in a better prognosis and increased survival following M-ALF.

Objective. - This study was conducted to evaluate the effect of vaginal delivery and aging on anal sphincter anatomy and function. Method. - Asymptomatic thirty women were included in this prospective study. Group 1 included 10 women (age range: 18-50) who had never been pregnant. Group 2 included 10 women (age range: 18-50) who had vaginal delivery. Group 3 included 10 women over 50 who had vaginal delivery. Results. - There was no statistically significant difference between the three groups in terms of resting and squeeze pressures. It was found that sphincter thickness showed statistically significant difference between the group 1 and group 3, and also group 2 and group 3. There was not statistically significant difference between the group 1 and group 2 in terms of sphincter thickness. There was a positive correlation between the age and sphincter thickness in all groups. In terms of sphincter thickness and pressure findings there was a positive correlation between the squeeze pressure and external anal sphincter thickness only in group 3. Conclusion. - The vaginal delivery did not have a negative influence on the structure and function of the anal sphincter in asymptomatic women. However, it was found that anal sphincter thickness changed strongly in a positive manner with aging. (C) 2018 Elsevier Masson SAS. All rights reserved.

Objective: This study was conducted to present the preliminary results of seven patients treated with sphinctero-vagino-perineoplasty for secondary repair of obstetric anal sphincter injuries. Materials and Methods: This retrospective study was conducted on the records of seven patients who underwent secondary repair of obstetric anal sphincter injuries at the colorectal surgery unit of a tertiary care center between February 2015 and December 2017. Results: All patients with solid stool incontinence were fully recovered at postoperative month 3. The Wexner incontinence score was significantly improved (decreased from 14.12 [range: 8-20] to 2.28 [range: 1-4]). The complication rate was 85.7% (wound infection, abscess, hematoma, detachment). Conclusion: Combined repair of anal sphinchters, perineal body, superficial transverse perineal muscles, and bulbospongious muscles, which contribute to anal continence, may improve surgical outcomes in patients with obstetric anal sphincter injuries.

BACKGROUND:The identification of retropubic vasculature is not easy under the pressure of insufflated gas during totally extraperitoneal (TEP) inguinal hernioplasty. We aimed to present the usefulness of a maneuver that allows the clear identification of retropubic vasculature.METHODS:Vascular anatomy on the retropubic surface in 364 patients who underwent the TEP procedure from January 2005 to September 2015 was evaluated. In patients after July 2014, the pressure in the workspace was decreased from 14 to 8 mmHg before fixation of the mesh to clearly identify the veins. The results before and after July 2014 were compared.RESULTS:Demographic features were not significantly different between two periods. The number of hemipelvises in the first and second periods was 398 and 77, respectively. The rate of identification of venous corona mortis was 31% in the second period, whereas it was 1.0% in the first period (P = .000). The identification of thick (5.5% versus 10.3%; P = .123) and thin (22.8% versus 36.3%; P = .014) arterial structures and their sum were increased in the second period (28.4% versus 46.7%; P = .002). The rate of retropubic bleeding was zero in the second period, while it was 1.5% in the first period.CONCLUSIONS:During TEP hernioplasty, the pressure of insufflated gas more than 10 mmHg in the preperitoneal space hinders the correct identification of vessels on the retropubic surface. The proposed maneuver, to decrease the pressure in the workspace to 8 mmHg, can provide clear identification of all vessels, which decreases the potential risk of vascular injury.

AIM:Donor safety is the major concern in living-donor liver transplantation. Studies in literature related to donor hepatectomy (DH) have generally considered intra-abdominal complications. The aim of this study is to specifically evaluate pulmonary complications (PCs) after DH.MATERIALS AND METHODS:We evaluated retrospectively 1150 living donors who underwent to DH between January 2007 and July 2014. Patients with PCs, such as pneumonia, pleural effusion, pneumothorax, and respiratory insufficiency, were considered. A complication was considered only when it was clinically apparent and/or requiring interventions. Any special diagnostic tool was used to expose the clinically silent pathologies.RESULTS:A total of 986 right hepatectomies (RH) and 164 left hepatectomies (LH) (left lobectomy or left lateral segmentectomy) were performed in the study interval. There were 18 (1.6%) donors with PCs (15 males and 3 females). Mean age was 33.8 ± 9.3 years (18-51). Mean hospital stay was 23.8 ± 13.5 days (5-62). Presented PCs were pleural effusion (n = 5, 0.4%), pneumonia (n = 4, 0.3%), combinations (n = 2, 0.2%), pneumothorax (n = 2, 0.2%), and acute respiratory insufficiency (n = 5, 0.4%). Sixteen cases (1.7%) were seen after RH, whereas 2 cases (1.2%) were seen after LH (P = 1.000).CONCLUSION:The most common PCs after living donor hepatectomy were pleural effusion and acute respiratory insufficiency. There was no significant difference between RH and LH. It is possible to overcome those PCs with careful monitoring and timely and appropriate treatment.

Pancreaticoduodenectomy is considered the standard operation for periampullary tumors. Despite major advances in pancreatic surgery, pancreatic fistula is still an important cause of morbidity and mortality after pancreaticoduodenectomy. Meticulous surgical technique and proper reconstruction of the pancreas are essential to prevent pancreatic fistula. Pancreaticogastrostomy is a safe method for reconstruction of the pancreas after pancreaticoduodenectomy. Regardless of pancreatic texture or duct diameter, the reconstruction is performed by passing full-thickness sutures through both the anterior and posterior sides of the pancreas. In this study, we report 39 cases of reconstruction with pancreaticogastrostomy after pancreaticoduodenectomy without mortality or pancreatic fistula.

OBJECTIVES:Although the main factors responsible for donor deaths after living-donor liver transplant are liver failure and sepsis, the most common donor complications are associated with the biliary tract.MATERIALS AND METHODS:Between April 2006 and May 2012, five hundred ninety-three donors underwent living-donor hepatectomy procedures for living-donor liver transplants. The mean age of donors was 31.0 ± 9.9 years and the ratio of men to women was 341:252. Of all donors, 533 (89.9%) underwent a right lobe hepatectomy, 45 (7.6%) underwent a left lateral segmentectomy, and 15 (2.5%) underwent a left hepatectomy.RESULTS:Biliary complications were observed in 51 liver donors (8.6%). Based on the Clavien-Dindo classification, grade I and grade II complications were 3.2% and 0%, while grade IIIa and grade IIIb complications were observed in 3.5% and 1.85% of cases. Right lobe donor biliary complications occurred at the rate of 8.2% in 44 donors. Grade IV and grade V complications were not observed. Grade IIIa complications necessitating radiologic and endoscopic procedures were observed in 21 liver donors (3.5%). Bile leakage unresponsive to medical therapy was detected in 19 donors (3.2%). Nasobiliary catheters were placed in 3 of 19 donors and internal stents were placed in 1. Two sessions of balloon dilatation were performed in the 2 grade IIIb donors (0.33%). Biliary strictures observed in 2 right lobe donors and 1 left lobe donor was treated by hepaticojejunostomy an average of 14 months after surgery.CONCLUSIONS:Avoidance of intraoperative issues and early recognition of bile leakage are fundamental in preventing complications in living-donor liver transplant donors.

AIM:To study the transcolonic extraction of the proximally resected colonic specimens by colonoscopic assistance at laparoscopic colonic surgery.METHODS:The diagnoses of our patients were Crohn's disease, carcinoid of appendix and adenocarcinoma of cecum. We preferred laparoscopic total mesocolic resections. Colon and terminal ileum were divided with endoscopic staplers. A colonoscope was placed per anal and moved proximally in the colon till to reach the colonic closed end under the laparoscopic guidance. The stump of the colon was opened with laparoscopic scissors. A snare of colonoscope was released and the intraperitoneal complete free colonic specimen was grasped. Specimen was moved in to the colon with the help of the laparoscopic graspers and pulled gently through the large bowel and extracted through the anus. The open end of the colon was closed again and the ileal limb and the colon were anastomosed intracorporeally with a 60-mm laparoscopic stapler. The common enterotomy orifice was closed in two layers with a running intracorporeal suture.RESULTS:There were three patients with laparoscopic right-sided colonic resections and their specimens were intended to remove through the remnant colon by colonoscopy but the procedure failed in one patient (adenocarcinoma) due to a bulky mass and the specimen extraction was converted to transvaginal route. All the patients had prior abdominal surgeries and had related adhesions. The operating times were 210, 300 and 500 min. The lengths of the specimens were 13, 17 and 27 cm. In our cases, there were no superficial or deep surgical site infections or any other complications. The patients were discharged uneventfully within 4-5 d and they were asymptomatic after a mean 7.6 mo follow-up (ranged 4-12). As far as we know, there were only 12 cases reported yet on transcolonic extraction of the proximal colonic specimens by colonoscopic assistance after laparoscopic resections. With our cases, success rate of the overall experience in the literature was 80% (12/15) in selected cases.CONCLUSION:Transcolonic specimen extraction for right-sided colonic resection is feasible in selected patients. Both natural orifice surgery and intracorporeal anastomosis avoids mini-laparotomy for specimen extraction or anastomosis.

BACKGROUND Donor selection criteria are being continuously modified to expand the potential donor pool in living donor liver transplantation (LDLT). This retrospective study reports our center's experience in utilizing extended criteria donors for LDLT. MATERIAL AND METHODS The charts of 342 LDLT donors who underwent right hepatectomy between September 2007 and December 2010 were reviewed. Donors who were older than 55 years, and/or with BMI >30, and/or with a remnant liver volume of <30% were defined as extended criteria donors. The surgical complications in the extended criteria donors and non-extended criteria donors were compared. RESULTS There were 61 extended criteria donors (21 male, 40 female; mean age 41 years) and 281 non-extended criteria donors (189 male, 92 female; mean age 31 Years). Surgical morbidities were observed in 70 (20.4%) of donors. The number of patients with complications according to Clavien's system were: Grade I, 30 (43%); Grade II, 11 (16%); Grade IIIa, 12 (17%); Grade IIIb, 16 (23%); and Grade IV, 1 (1%). Postoperative complications were observed in 17 (28%) of 61 extended criteria donors, and 53 (19%) of 281 non-extended donors (p>0.05). However, only the Grade IIIb complication rate in donors with extended criteria was significantly higher than in non-extended criteria donors (p=0.04). Complications developed in 3 of 7 donors aged >55 years and with BMI >30. There was no donor mortality. CONCLUSIONS Although there was no statistical difference between the 2 groups' postoperative complication rates, Grade IIIb complications were statistically significantly higher in the extended group. Having more than 1 extended criteria may increase the donor's postoperative complications in LDLT. Thus, the elimination of the donors should be considered in the presence of more than 1 extended criteria.