Dual mesh repair for a large diaphragmatic hernia defect: An unusual case report

Introduction: Diaphragmatic hernia secondary to traumatic rupture is a rare entity which can occur after stab wound injuries or blunt abdominal traumas. We aimed to report successfully management of dual mesh repair for a large diaphragmatic defect. Case report: A 66-year-old male was admitted with a right sided diaphragmatic hernia which occurred ten years ago due to a traffic accident. He had abdominal pain with worsened breath. Chest X-ray showed an elevated right diaphragm. Further, thoraco-abdominal computerized tomography detected herniation a part of the liver, gallbladder, stomach, and omentum to the right hemi-thorax. It was decided to diaphragmatic hernia repair. After an extended right subcostal laparotomy, a giant right sided diaphragmatic defect measuring 25 × 15 cm was found in which the liver, gallbladder, stomach and omentum were herniated. The abdominal organs were reducted to their normal anatomic position and a dual mesh graft was laid to close the diaphragmatic defect. Patients’ postoperative course was uneventful. Discussion: Diaphragmatic hernia secondary to trauma is more common on the left side of the diaphragm (left/right = 3/1). A right sided diaphragmatic hernia including liver, stomach, gallbladder and omentum is extremely rare. The main treatment of diaphragmatic hernias is primary repair after reduction of the herniated organs to their anatomical position. However, in the existence of a large hernia defect where primary repair is not possible, a dual mesh should be considered. Conclusion: A dual mesh repair can be used successfully in extensive large diaphragmatic hernia defects when primary closure could not be achieved

Changing Trends in Gastric Cancer Surgery

Gastric cancer is one of the most common causes of cancer-related death. It requires multimodal treatment and surgery is the most effective treatment modality. Radical surgery includes total or subtotal gastrectomy with lymph node dissection. The extent of lymphadenectomy still remains controversial. Eastern surgeons have performed D2 or more extended lymphadenectomy while their Western colleagues have performed more limited lymph node dissection. However, the trend has been changing in favour of D2 lymph node dissection in both hemispheres. Currently, D2 is the recommended type of lymphadenectomy in experienced centres in the west. In Japan, D2 lymph node dissection is the standard surgical approach. More extensive lymphadenectomy than D2 has not been found to be associated with improved survival and generally is not performed. Bursectomy and splenectomy are additional controversial issues in surgical performance, and trends regarding them will be discussed. The performance of bursectomy is controversial and there is no clear evidence of its clinical benefit. However, a trend toward better survival in patients with serosal invasion has been reported. Routine splenectomy as a part of lymph node dissection has largely been abandoned, although splenectomy is recommended in selected cases. Minimally invasive surgery has gained wide popularity and indications for minimally invasive procedures have been expanding due to increasing experience and improving technology. Neoadjuvant therapy has been shown to have beneficial effects and seems necessary to provide a survival benefit. Diagnostic laparoscopy should be kept in mind prior to treatmen

Which Suture Material is Optimal for Pancreaticojejunostomy Anastomosis? An In Vitro Study

Background: Which suture material is optimal for pancreaticojejunostomy (PJ) anastomosis is a matter of debate with contradictory results. The aim of the present in vitro study was to determine the effects of pancreatic juice, bile, and their mixture on different suture materials in terms of breaking strength and disintegration. Material and Methods: Four suture materials, silk, polyglactin 910, polydioxanone, and polypropylene, were tested in pancreatic juice, bile, and their mixture. Determination of breaking strength and disintegration under electron microscope for each suture material was done on days 0, 3, 6, and 10. Results: The breaking strength of polyglactin 910 and silk was significantly higher than polypropylene and polydioxanone (p .05). No obvious disintegration has been observed under electron microscope in the architecture and appearance of suture materials after days of exposure to pancreatic juice, bile, and their mixture. Conclusions: None of the suture materials was disintegrated on exposure to pancreatic juice, bile, and their mixture. Polyglactin 910 has the highest breaking strength and significantly loses its strength throughout the experiment but still remains higher than other suture materials. Polypropylene, polydioxanone, and silk showed less variation across the incubation period

Pancreatic schwannoma: A rare case and a brief literature review

Introduction: Pancreatic schwannoma (PS) is an extremly rare benign tumor. Less than 50 cases of pancreatic schwannoma have been described in the English literature over the past thirty years. Presentation of case report: A 63-year-old female underwent left modified radical mastectomy 2 years ago due to breast cancer. During her routine check-up, a 65 × 63 × 55 mm measured calcified, well-demarcated, cystic-mass having septations and calcifications that localized to the pancreatic head was detected by abdominal computerized tomography. She was asymptomatic and her tumor markers were in normal ranges. A standard Whipple procedure was performed, and the histo-pathological diagnosis of the resected specimen was reported as ancient schwannoma with clear surgical margins. Patient’s postoperative course was eventful. She had a biliary leakage after surgery which was managed conservatively. She is under follow-up. Discussion: Pancreatic schwannoma also known as neurilemoma or neuroma is a slowly growing, encapsulated, mostly benign tumor with smooth well-delineated margins that originates from myelin producing schwann cells located on the nerve sheath of the peripheral epineurium of either the sympathetic or parasympathetic autonomic fibers. PS’s are extremly rare. The head of pancreas being involved in the vast majority of cases (40%), followed by its body (20%). Management of pancreatic schwannomas remains largely controversial. Both enucleation and radical surgical resections have revealed great therapeutic efficiency. with a well prognosis without recurrences. Conclusion: Although rare, PS’s should be considered in the differential diagnosis of the other solid or cystic masses of the pancreas

A Retrospective Analysis of Factors Affecting Early Stoma Complications

Despite advances in surgical techniques and products for stoma care, stoma-related complications are still common. A retrospective analysis was performed of the medical records of 462 consecutive patients (295 [63.9%] female, 167 [36.1 %] male, mean age 55.5 +/- 15.1 years, mean body mass index [BMI] 25.1 +/- 5.2) who had undergone stoma creation at the Gastroenterological Surgery Clinic of Turkiye Yuksek Ihtisas Teaching and Research Hospital between January 2008 and December 2012 to examine the incidence of early (ie, within 30 days after surgery) stoma complications and identify potential risk factors. Variables abstracted included gender, age, and BMI; existence of malignant disease; comorbidities (diabetes mellitus, hypertension, coronary artery disease, chronic respiratory disease); use of neoadjuvant chemoradiotherapy; permanent or temporary stoma; type of stoma (loop/end stoma); stoma localization; and the use of preoperative marking of the stoma site. Data were entered and analyzed using statistical software. Descriptive statistics, chi-squared, and Mann-Whitney U tests were used to describe and analyze all variables, and logistic regression analysis was used to determine independent risk factors for stoma complications. Ostomy-related complications developed in 131 patients (28.4%) Of these, superficial mucocutaneous separation was the most frequent complication (90 patients, 19.5%), followed by stoma retraction (15 patients, 3.2%). In univariate analysis, malignant disease (P = .025), creation of a colostomy (P = .002), and left lower quadrant stoma location (P <. 001) were all significant indicators of stoma complication. Only stoma location was an independent risk factor for the development of a stoma complication (P = .044). The rate of stoma complications was not significantly different between patients who underwent nonemergent surgery (30% in patients preoperatively sited versus 28.4% not sited) and patients who underwent emergency surgery (27.1%). Early stoma complication rates were higher in patients with malignant diseases and with colostomies. The site of the stoma is an independent risk factor for the development of stoma complication. Preoperative marking for stoma creation should be considered to reduce the risk of stoma-related complications. Prospective, randomized controlled studies are needed to enhance understanding of the more prevalent risk factors

The Rationality of Resectional Surgery and Palliative Interventions in the Management of Patients with Gallbladder Cancer

The aim of the present study was to evaluate in a retrospective manner, the survival period and survival rate according to stages and groups after R0, R1, R2 resections and palliative interventions. Between 2003 and 2012, 67 patients diagnosed with gallbladder carcinoma were retrospectively analyzed. Patient demographics, the survival period, and survival rate according to stages and groups after R0, R1, R2 resections and palliative interventions were retrospectively analyzed. Sixty-seven patients were diagnosed with gallbladder carcinoma. Thirty-eight patients (56.7%) were female and 29 patients (43.3%) were male. The median survival period was significantly longer in stage II and III diseases than in stage IV disease (P < 0.001). The R0, R1, and R2 resection rates in patients who underwent surgery with curative intent were 67.7, 19.4, and 12.9 per cent, respectively. The R0 resection rate according to the tumor stages was 100 per cent for stage I, 87.5 per cent for stage II, 66.7 per cent for stage III, and 42.8 per cent for stage IV disease. The median follow-up period was six months (eight days to 36 months). During this follow-up period, 53 patients (79.1%) died. In conclusion, R0 resection rate decreases when tumor stage increases. The highest survival rates after R0 resection are achieved in patients with stage I, II, and III diseases. Radical surgery has no benefit over palliative surgery for stage IV disease in terms of survival