Son dönem böbrek hastalarında gelişen sekonder hiperparatiroidizmin cerrahi tedavisi: Cerrahi yaklaşımlar ve olgu sunumları

Amaç: Son dönem böbrek hastalığı dünya çapında bir sağlık problemidir. Bu hastaların yaşam süreleri uzadıkça sekonder hiperparatiroidizm gibi ek patolojiler de gelişmektedir. Bu çalışmanın amacı sekonder hiperparatiroidizme cerrahi yaklaşımları gözden geçirmek ve kendi tecrübelerimizi sunmaktır. Hastalar ve Yöntemler: Bu retrospektif çalışmaya 2004 ve 2008 yılları arasında kronik böbrek hastalığı tanısıyla ameliyat edilen beş erkek hasta (ort. yaş 38.6) dahil edildi. Hasta bilgileri hastane kayıtlarından toplandı. Bulgular: Hastaların ortalama hemodiyaliz süresi 106.8 aydı. Bütün hastalar ameliyat öncesi dönemde ultrasonografi ve sintigrafi ile incelendi. Hastaların ameliyat öncesi ve sonrası dönemde ortalama serum PTH değeri 2097 ng/ ml ve 36.5 ng/dl, Ca 11.48 mg/dl ve 6.2 mg/dl, P 7.5 mg/dl ve 4.4 mg/dl, ALP 527 IU/L ve 89 IU/L idi. Bütün hastalara total paratiroidektomi ve sternokleidomastoid kasa ototransplantasyon yapılırken bir hastaya ek olarak sağ tiroidektomi yapıldı. Ameliyat sonrası dönemde tüm hastalar oral kalsiyum karbonat ve kalsitriol kullandılar. Hiçbir hastada ciddi komplikasyon görülmedi. Ortalama hastanede kalış süresi 4.6 gündü. Hastaların hepsinde serum PTH düzeyleri 300 ng/dl altında seyretti ve hiçbir hastada takipler esnasında nüks hiperparatiroidizm görülmedi. Sonuç: Sekonder hiperparatiroidizmin cerrahi tedavisi için birçok yöntem olsa da total paratiroidektomi ve ototransplantasyon düşük nüks ve komplikasyon oranları ile son dönem böbrek hastalarında gelişen sekonder hiperparatiroidizmin için en kabul edilen tedavi metotlarındandır.Objectives: End-stage renal disease is a worldwide public health problem. While the survival time of the patients extends, additional pathologies such as secondary hyperparathyroidism occurs. The aim of the study is to review the surgical approaches to secondary hyperparathyroidism and present our experiences. Patients and Methods: This retrospective study included five male patients (mean age 38.6 years) who were operated on for chronic renal failure between 2004 and 2008. The data of patients were collected from hospital records. Results: The mean duration of hemodialysis was 106.8 months. All patients had ultrasonography and scintigraphy preoperatively. The mean value of preoperative and postoperative serum PTH was 2097 ng/ml and 36.5 ng/dl, Ca 11.48 mg/dl and 6.2 mg/dl, P 7.5 mg/dl and 4.4 mg/dl, ALP 527 IU/L and 89 IU/L. Total parathyroidectomy and sternocleidomastoid muscle autotransplantation was performed in all patients and one patient had right thyroidectomy in addition. Postoperatively, all patients received oral calcium carbonate and calcitriol. No serious postoperative complications occurred in any of these cases. The duration of hospitalization was 4.6 days on the average. Serum PTH was kept constantly below 300 ng/L in all cases in follow-up and no recurrent hyperparathyroidism was detected. Conclusion: Although there are many types of surgery techniques in treatment of secondary hyperparathyroidism, total parathyroidectomy with autografting is the most accepted procedure with low recurrent and complication rate in end-stage renal disease patients

Duodenum birinci kısım divertikülünden kaynaklanan nadir bir schwannom olgusu

Bu yazıda periferal sinir schwann hücrelerinden köken alan nadir bir duodenal schwannoma olgusu sunulmuştur. 57 yaşında bayan hasta anemi tetkiki sırasında ateş ve karın ağrısı şikayeti ile başvurdu. Fizik muayenesinde karın sağ üst kadranda hassasiyet tespit edildi. Laboratuar değerlerinde 15 300/l olan lökositoz haricinde anormallik yoktu. Tüm tümör belirteçleri normal değerlerdeydi. Ultrasonografide duodenuma yapışık hipoekoik kitle tespit edildi. Bilgisayarlı tomografi ve manyetik rezonans incelemede aynı lokalizasyonda 4x3 cm'lik kitle ve 8x11x12 cm'lik karaciğer sağ lobda abse bulundu. Hepatik abse drenajı ve duodenal divertikülektomi yapıldı. Histopatolojik incelemede şekil ve büyüklükte hafif derecede değişiklikler gösteren kesişen iğsi hücre kümeleri içeren tümöral kitle görüldü. İmmünohistokimyasal olarak tümör hücrelerinin S100 protein ile kuvvetli pozitiflik vermesi nedeni ile duodenal schwannoma tanısı kondu. Ameliyat sonrası dönemi sorunsuz geçen hasta 8. gün taburcu oldu.A case of duodenal schwannoma, a rare tumor arising from schwannian cells of peripheral nerves is presented. A 57-year-old woman was admitted with abdominal pain and fever during investigation of anemia. Physical examination revealed tenderness in the right side of the upper abdomen. Laboratory tests showed no abnormality except for leucocytosis of 15 300/l. All tumor markers were negative. Ultrasonography revealed a hypoechoic mass adjacent to the duodenum. Computed tomography and magnetic resonance imaging showed a 4x3 cm mass in the same region and an abscess with dimensions of 8x11x12 cm in the right lobe of liver. Hepatic abscess drainage and duodenal diverticulectomy was performed. Histopathological examination revealed a tumorous mass composed of interlacing bundles of spindle cells, showing mild variations in nuclear shape and size. Immunohistochemically tumor cells were positive for S100 protein, thus, schwannoma of the duodenum was diagnosed. The postoperative course was uneventful and the patient was discharged on the eighth day of operation

Midede sıradışı bir yabancı cisim: Yemek çatalı

18 yaşında erkek hasta acil servisimize çatal yutma şikayeti ile başvurdu. Çekilen karın grafisinde midede çatal olduğu görüldü. Hastanın laboratuvar bulguları normal değerlerdeydi. Hastanın midesindeki çatal cerrahi olarak çıkarıldı.An 18-year-old male patient applied to the emergency department with complaint of fork swallowing. Abdominal film of the patient showed meal fork in the stomach. Laboratory signs of the patient were normal. The fork in the stomach of the patient was removed surgically

The Effects of Different Insufflation Pressures on Liver Functions Assessed with LiMON on Patients Undergoing Laparoscopic Cholecystectomy

Purpose. Laparoscopic cholecystectomy has been accepted as an alternative to laparotomy, but there is still controversy regarding the effects of pneumoperitoneum on splanchnic and hepatic perfusion. We assessed the effects of different insufflation pressures on liver functions by using indocyanine green elimination tests (ICG-PDR). Methods. We analyzed 43 patients who were scheduled for laparoscopic cholecystectomy. The patients were randomly allocated to two groups. In Group I, the operation was performed using 10 mmHg pressure pneumoperitoneum. In Group II, 14 mmHg pressure pneumoperitoneum was used. The ICG-PDR measurements were made after induction (ICG-PDR 1) and after the end of the operation (ICG-PDR 2). Serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), and total bilirubin levels were all recorded preoperatively, 1 hour, and postoperative 24 hours after surgery. Results. The ICG-PDR 1 values for Groups I and II were as follows: 26.78 ± 4.2% per min versus 26.01 ± 2.4% per min (P > 0.05). ICG-PDR 2 values were found to be 25.63 ± 2.1% per min in Group I versus 19.06 ± 2.2% per min in Group II (P < 0.05). There was a statistically significant decrease between baseline and postoperative ICG-PDR values in Group II compared to Group I (P < 0.05). Statistically, there was an increase between baseline and postoperative 1st-hour serum AST and ALT level in Group II (P < 0.05) compared to Group I. No statistical differences were detected on postoperative 24st-hour serum AST and ALT levels and all the time bilirubin between groups (P > 0.05). Conclusion. In conclusion, the results show that 14 mmHg pressure pneumoperitoneum decreased the blood flow to the liver and increased postoperative 1st-hour serum AST and ALT levels. We think that 10 mmHg pressure pneumoperitoneum is superior to 14 mmHg pressure pneumoperitoneum in laparoscopic cholecystectomy

Paratiroid karsinomu: Hiperparatiroidinin nadir bir nedeni

Paratiroid karsinomları primer hiperparatiroidinin nadir nedenleri arasında yer alır. Bu tümörler tüm primer hiperparatiroidilerin %0.4-1'inde görülür ve paratiroid bezininin diğer hastalıklarından ayrımı zordur. Daha once paratiroid adenoma tanısı ile opere olan 61 yaşında bayan hasta kliniğimize paratiroid karsinomu şüphesi ile başvurdu. Hastanın klinik muayenesinde tiroid glandın sağ tarafında kitle palpe edildi ve radyolojik incelemeler tanıyı destekledi. Hastaya tiroidektomi, paratiroidektomi, boyun diseksiyonu ve strap kas eksizyonu yapıldı ve patolojik incelemede paratiroid karsinomu tanısı kondu. Hasta oral kalsiyum ve kalsitriol tedavisi ile sorunsuz olarak taburcu edildi.Parathyroid carcinoma is one of the rare causes of primary hyperparathyroidism. These tumors account for 0.4-1% of all cases of primary hyperparathyroidism and it is difficult to distinguish from benign disorders of parathyroid glands. A 61-year-old female patient previously operated for parathyroid adenoma admitted to our clinic with parathyroid carcinoma suspicion. Clinical examination revealed a mass in the right half of the thyroid gland and radiological investigation supported the diagnosis. She underwent surgery and thyroidectomy, parathyroidectomy, neck dissection and strap muscle excision were performed. The pathological investigation revealed parathyroid carcinoma. The patient was discharged uneventful with oral calcitriol and calcium replacement

İntratorasik ekstra abdominal agresif fibromatozis

Fibröz doku kaynaklı tümörler toraksta ve mediastinumda nadir olarak görülmekte ve rapor edilmektedirler. Biz burada, agresif fibromatozisin, toraks içi dokulardan kaynaklanan nadir bir formunu bildirmek istedik. Otuz altı yaşında bayan hasta hastanemize sol göğüs ağrısı ve sıkışma hissi ile başvurdu. Çekilen PA grafi ve toraks bilgisayarlı tomografisinde, sol toraks alt kısmını üçte iki oranında dolduran dev kitle görüldü. Bunun üzerine hastaya sol yedinci interkostal aralıktan yapılan torakotomi ile geniş rezeksiyon uygulandı. Tümör patolojisi 20x15x15 cm çapında agresif fibromatozis olarak geldi. Hasta 15 aydır takip altında ve kontrollerinde yineleme görülmedi.Tumors of fibrous tissue origin (fibromatosis) in chest and mediastinum have been rarely reported in the literature. Herein, we report a rare case of aggressive fibromatosis presenting as an intrathoracic tumor. A 36-year-old woman admitted to our hospital due to a feeling of oppression and pain in the left chest. A chest X-ray, thorax computed tomography revealed a large mass filling two thirds of lower left thorax. Widely surgical resection of the tumor was performed thoracotomy via seventh intercostal space. The tumor was 20x15x15 mm in size and diagnosed pathologically as aggressive fibromatosis. The patient has been well without recurrence for 15 months after surgery

Midenin glomus tümörü

Altmış dört yaşında erkek hasta masif üst gastrointestinal sistem kanaması ile acil servise başvurdu. Distal gastrektomi uygulanan hastada ameliyat sırasında antral bölge küçük kurvaturda submukozal yerleşimli, 2.4 cm çapında, iyi sınırlı bir kitle palpe edildi. Kitlenin histopatolojik incelemesinde, düzensiz dallanan, ince duvarlı damarların arasında yuvalanmalar, kordonlar ve tabakalar oluşturan berrak sitoplazmalı uniform tümör hücreleri görüldü. İmmünohistokimyasal olarak vimentin ve SMA ile pozitif; sitokeratin, CD34, sinaptofizin, kromogranin A, NSE, CD117 (C-kit) ve S-100 protein ile negatif sonuç elde edildi. Elektron mikroskopik olarak berrak sitoplazmalı, kaba kromatinli yuvarlak nukleusa sahip hücrelerinin damar yapıları etrafı nda gruplar oluşturdukları görüldü. Klinik bulgular, makroskopik görünüm, tümör paterni, immünohistokimyasal ve elektron mikroskopik bulgular glomus tümörü ile uyumlu bulundu.A sixty-four-year old male patient presented to the emergency room with massive upper gastrointestinal tract bleeding. During distal gastrectomy, a submucosal, well demarcated mass with a diameter of 2.4 cm was palpable in the antral region of the lesser curvature. Histopathological examination of the mass revealed uniform tumor cells with clear cytoplasms and round nuclei, forming nests, strands and sheets between dense, irregularly branching, thin-walled vessels. Immunohistochemistry was positive for vimentin and SMA and negative for cytokeratin, CD34, synaptophysin, chromogranin A, NSE, CD117 (C-kit) and S-100 protein. Electron microscopy demonstrated tumor cells with clear cytoplasms and round nuclei with coarsely dispersed chromatin, forming groups around vascular structures. Clinical findings, gross appearance, tumor pattern, immunohistochemical findings and electronmicroscopic findings were all consistent with a glomus tumo

Duodenal necrosis during nasogastric tube feeding: A case report

Akut solunum sıkıntısı sendromu tanısıyla yoğun bakım ünitesinde yatan 45 yaşlarndaki erkek hastada, nazogastrik tüp ile beslenme esnasında geli şen duodenal nekroz olgusu literatür eşliğinde sunuldu. Olaysız geçen birkaç günden sonra, abdominal distansiyon gelişti, laparotomi yapılıp, duodenal nekroz olduğu saptandı. Bağırsaklarda tı kanıklık veya mezenterik damar hasarı yoktu. Hastaya sedasyon sağlamak için verilen yüksek dozda fentanil, midazolam ve inotropik ajan olan dopamin infüzyonu, mukozal perfüzyonun hasarlanması ile gelişen nekrozda büyük katkı faktörü olarak suçlanabilir.A case of duodenal necrosis during nasogastric tube feeding in a 45-year-old male patient hospitalized in intensive care unit with a diagnosis of acute respiratory distress syndrome is reported with a review of literature. Abdominal distension developed after several days of uneventful nasogastric tube feeding. At laparotomy patchy necrosis of the duedonum was found without signs of bowel obstruction or impaired mesenteric perfusion. In this case, the large doses of fentanyl, midazolam and dopamine given for sedation, were suspected to be a major contributing factor to the development of the necrosis by impairing mucosal perfusion

A rare cause of intestinal obstruction due to an exophytic gastrointestinal stromal tumor of the small bowel

Introduction: Gastrointestinal stromal tumors constitute a distinct group of rare gastrointestinal tract tumors that originate from the interstitial cells of Cajal. These jejunoileal lesions are a rare cause of obstruction but can be associated with substantial morbidity. Case: A 59-year-old woman presented to the emergency department with abdominal pain and distention. Physical examination revealed tenderness and rebound in right lower quadrant. Computed tomography revealed a mass in lower right quadrant. A 9x9x4 cm exophytic ileal mass was observed at exploration. Preoperative diagnose was a small bowel tumor and then segmental resection and primary anastomosis were performed. Histopathological investigation revealed spindle cells that stained strongly for C-117, consistent with a diagnosis of a malign gastrointestinal stromal tumor. Conclusion: We conclude that exophytic small bowel gastrointestinal stromal tumors are rare lesions, which should be kept in mind by physicians among the diagnosis of small bowel obstructions in order to reduce substantial morbidity and mortality