Akademik Veri Yönetim Sistemi
TURKISH JOURNAL OF SURGERY, cilt.34, sa.Suppl.-1, ss.409-410, 2018 (ESCI)
Patient with Peutz-Jeghers Syndrome Presenting with Inoperable Periampullary Tumor
Muhammer Ergenç, Tevfik Kıvılcım Uprak, Şevket Cumhur Yeğen
Department of General Surgery, Marmara University School of Medicine, İstanbul, Turkey
Introduction: Peutz-Jeghers syndrome (PJS) is an autosomal dominant inherited genetic syndrome characterized by multiple hamartomatous polyps and mucocutaneous pigmentation in the gastrointestinal tract. In patients with Peutz-Jeghers syn- drome, the risk of gastrointestinal and non-gastrointestinal malignancies is increased.
Case: The patient, who had complaints of weight loss, nausea and vomiting for about 2 months was admitted to the emergency service and then referred to the general surgery unit for further examination and treatment. The patient’s physical examination revealed no evidence of defense-rebound in the abdomen, palpable mass lesions in the periumbilical region were present, and hyperpigmented areas were observed on the lips. The patient had undergone laparotomy about 25 years ago and had no knowl- edge about the reason. In laboratory tests; WBC was 14200, HGB was 10,6, Creatine was 1,51, Albumin was 3,6, and Bilirubin was N. A 10 cm mass at the head of the pancreas was detected in the tomography of the abdomen and the stomach was in a pitotic state. Upper gastrointestinal endoscopy showed polypoid appearance in the stomach fundus, pylorus could not be passed. The exploratory laparotomy was performed. At the head of the pancreas, all the retroperitoneal area filled with tumoral lesion was palpated. Implants on the gall bladder and hepatoduodenal ligaments were observed. Multiple invagination sites were observed in the small intestines and the polyps were palpated after being reduced. Multiple enterotomies were performed and polyps were excised. Gastrojejunostomy was performed on the patient due to duodenal obstruction secondary to lack of oral intake. The implants were biopsied and the operation was terminated. The patient who started the regimen on the postopera- tive 2nd day passed gas on the 3rd day. On the 4th day, the patient who started tolerating the regimen was discharged from the hospital. According to the patient`s pathology, the implants were reported to be compatible with mucinous adenocarcinoma and multiple hamartomatous small intestine polyps.
Conclusion: The patient was examined with the pre-diagnosis of gastric outlet obstruction and was detected a mass on the head of the pancreas. The patient was diagnosed with PJ syndrome with multiple PJS type polyps and characteristic pigmenta- tions on the lips. Pancreatic cancer has been reported in 11-36% of patients with Peutz-Jeghers syndrome. Patients and their relatives were informed about PJS family screening.
Mass in the Right Lower Quadrant; Retroperitoneal Localized Gastrointestinal Stromal Tumor
Muhammer Ergenç, Tevfik Kıvılcım Uprak, Şevket Cumhur Yeğen
Department of General Surgery, Marmara University School of Medicine, İstanbul, Turkey
Introduction: Gastrointestinal stromal tumors (GIST) develop from Cajal cells, which are pacemaker cells responsible for the adjustment of peristalsis in the digestive tract. The prevalence is 7-15 per million. GISTs can be seen in all gastrointestinal tract, in order of frequency; stomach (60%), jejenum and ileum (30%), duodenum (5%) and colorectal (5%). Small intestine GISs may present with a small nodule or a giant tumoral mass. Although the clinical symptoms and signs are generally nonspecific, they may cause gastrointestinal bleeding, intestinal obstruction, pelvic mass, acute pain like appendicitis, tumor rupture and acute abdomen.
Case: A 58-year-old woman was admitted to the general surgery outpatient unit with a complaint of abdominal pain. Physical examination was unremarkable. In the abdominal USG, a well-defined hypervascular solid lesion 19x19x21 mm in size, in theright lower quadrant of the abdomen was observed; its origin could not be detected. Abdominal computed tomography showed a 21x23 mm lesion in the right lower quadrant adjacent to the psoas muscle. Laparoscopic exploration was performed. Retroperi- toneal area was entered from the ileocecal region. Retroperitoneal area was opened and surrounding of the mass was cleaned and the lesion that was found to be ileum wall originated was resected via endostapler and the operation was terminated. The patient who was comfortable during the abdominal examination on the postop 1st day was started a diet and the patient was discharged. Pathology was reported as 3.5 cm in size, gastrointestinal stromal tumor, with spindle cell, in low risk group.
Conclusion: In patients presenting with a mass in the right lower quadrant, the ileal gist should be kept in mind. Laparoscopic mass excision can be performed safely.
Our Laparoscopic Splenectomy Experience in Patients with Idiopathic Thrombocytopenic Purpura (ITP) Diagnosis
Baha Tolga Demirbaş, Muhammer Ergenç, Ali Emre Atıcı, Şevket Cumhur Yeğen
Department of General Surgery, Marmara University Pendik Hospital, İstanbul, Turkey
Objective: ITP is an autoimmune etiology characterized by blood platelets below 100000/mm3. Its prevalence in the community is 4,000 per 100000. Patients who do not respond to steroid and intravenous immunoglobulin therapy have an indication of sple- nectomy. Laparoscopic splenectomy has been successfully performed in recent years with ITP patients with normal size spleen.
Material and Methods: A total of 23 ITP patients underwent laparoscopic splenectomy at Marmara University Pendik Train- ing and Research Hospital between May 2012 and January 2018. The data of these patients were analyzed retrospectively. Of the patients who underwent laparoscopic splenectomy, 12 of them were female and 11 of them were male. The median age of the patients was 33 years. The mean duration of hospitalization of the patients was 4.1 days. No mortality was observed in any patient. Intraoperative and postoperative bleeding were minimal. Therefore, blood transfusion was not required. Atelectasis developed in 1 patient as morbidity.
Results: Idiopathic thrombocytopenic purpura is a hematological disease characterized by autoimmune etiology, mucocutane- ous bleedings and low platelet counts. The cause of the disease is the formation of autoantibodies against platelets. Therefore, platelets are rapidly destroyed in the spleen and mucocutaneous and petechial hemorrhages occur as a result of thrombocyto- penia. Hemorrhage may give symptom in the form of menometrorrhagia in gingivas as hematuria or melena. The risk of intracra- nial hemorrhage is high when the platelet count falls below 10000/mm3. The first-line treatment of the disease is 1 mg/kg/day prednisone treatment. Relapses are quite common after 3 weeks of treatment. In this case, intravenous immunoglobulin treat- ment may be given. However, splenectomy is necessary if it does not respond to this treatment. Platelet counts rapidly increase to normal levels after splenectomy in 75-85% of the patients. However, complications such as surgical site infection, pancreatitis and hemorrhage can be seen in 15-20% of patients receiving steroid therapy, with immunosuppressive effect, for a long time before the surgery. Therefore, the application of minimally invasive surgery in patients with ITP suggests that good results can be obtained. In our series, the morbidity rate was 4%. No intraoperative bleeding occurred. We had no mortality.
Conclusion: Laparoscopic splenectomy can be performed safely in elective conditions in patients with ITP.