Pituitary adenoma and concomitant Rathke’s cleft cyst

Summary Although pituitary adenomas and Rathke’s cleft cysts have a shared ancestry, they rarely occur simultaneously. Only 32 reports involving a pituitary adenoma and a concomitant Rathke’s cleft cyst were identified upon review of the literature. Most initial presenting complaints include hormonal symptoms, visual disturbances, and headache. Next to growth hormone, Prolactin was the most commonly hypersecreted pituitary hormone. Rathke’s cleft cysts show variable position, size, and signal intensity on magnetic resonance imaging (MRI). Here, we report a patient with a growth hormone- secreting pituitary adenoma associated with a Rathke’s cleft cyst. The mass contained two different signal intensities on MRI. The lesion was successfully removed assisted by intraoperative MRI, when the presence of both lesions was confirmed. When a non-enhancing cyst-like structure is demonstrated on imaging in a patient with a pituitary adenoma, the possibility of a coexisting Rathke’s cleft cyst should be considered.     

Novel flexible forceps for endoscopic transsphenoidal resection of pituitary tumors: technical report

The endoscope has become an essential tool for transsphenoidal pituitary surgeries because of the panoramic view and the ability to visualize structures beyond the direct line of vision. However, the regular dedicated instruments for these surgeries sometimes do not reach the areas visualized by an angled endoscope, and instrument maneuverability is limited. To overcome or minimize these problems, we constructed a new flexible tumor forceps that can be manipulated to change shape after placing into the surgical fields via the endonasal or sublabial route, to reach any desirable location for tumor dissection and excision. We applied this newly developed instrument in endonasal endoscopic resection complementing microsurgical procedure in 20 cases of pituitary tumors. The flexible forceps was able to access sites where regular dedicated instruments for transsphenoidal pituitary surgeries could not readily reach despite endoscopic visualization. No complication was observed in the present series, confirming the safety of the newly designed flexible forceps. Our newly developed flexible forceps improves the instrument maneuverability of endoscopic transsphenoidal resection of pituitary tumors, especially those located laterally at the cavernous sinuses or with frontal extension. The use of this instrument makes the best use of endoscopic panoramic visualization for tumor removal.     

内镜和显微镜下经鼻入路鞍区的解剖学对比研究

目的 研究对比神经内镜和手术显微镜经单鼻孔鼻内-蝶窦入路的解剖特点,为临床应用提供解剖学理论依据.方法 福尔马林浸泡固定的尸头10例,彩色乳胶灌注动脉系统.模拟经鼻内入路鞍区手术,先用显微镜,然后更换为内镜观察并测量相关解剖结构.结果 内镜相比显微镜:在蝶鞍水平区域,鞍旁术野同侧和对侧分别增加平均5.0 mm和6.5 mm的显露范围;前颅底区域,矢状位增加4.0 mm,横向同侧、对侧增加3.5 mm、4.0 mm;斜坡后颅底区域,都能显露对侧的斜坡旁颈内动脉隆起,而向两侧观察,内镜的显露范围平均同侧增加4.0 mm,对侧2.5 mm.结论 内镜可以提供一种全景的术野,从而扩展了经鼻入路显微手术的显露范围,尤其适用于简化和扩大经鼻内八路鞍区手术.     

Vascular studies in the preoperative evaluation of pituitary adenomas before transsphenoidal surgery

The transsphenoidal approach is being increasingly utilized in the surgical treatment of pituitary microadenoma. Even with high-resolution and dynamic computed tomography (CT) scanning, subtle vascular anatomic variants and other vascular anomalies involving the parasellar carotid arteries cannot always be clearly defined. Five cases are described in which evaluation by digital intravenous subtraction angiography or standard carotid arteriography provided useful preoperative information before transsphenoidal surgery. The implications of these findings are discussed.     

Surgical treatment of an abscess in a rathke's cleft cyst

An abscess in a Rathke's cleft cyst was surgically treated in a 39-year-old man. The patient presented with headaches, fever, and visual deficits. Transcranial decompression of the optic chiasm was carried out first. The abscess recurred, however, and drainage of the abscess and removal of its wall via the transsphenoidal route was carried out 4 weeks later. Visual evoked responses were useful in the successful management of this lesion. The patient regained normal pituitary function and visual function after the operation.     

Rhinological complications of sublabial transseptal transsphenoidal surgery for sellar and suprasellar lesions: prevention and management

Transseptal transsphenoidal surgery is the most widely accepted operative procedure for sellar and suprasellar lesions. About 35% out of fifty-four cases operated by this procedure at our centre had rhinological complications. Possible mechanism involved and their prevention and management is discussed herewith.     

The management of velopharyngeal insufficiency with Furlow double-opposing Z-plasty procedure

The aim of the study was an evaluation of Furlow’s method in correction of velopharyngeal insufficiency. A prospective study was conducted by a speech pathologist and a plastic surgeon. Rating of hypernasality and speech intelligibility were completed prior to and after surgical intervention. Nasometric measurements were also performed before and after surgical intervention. From May 2003 through September 2006, the first author performed 44 Furlow surgeries for the treatment of velopharyngeal insufficiency in patients with cleft palate. Patients with short, repaired cleft palates but with preserved normal function of pharyngeal sphincter qualified for the operation. The surgery was performed using double-opposing Z-plasty. The method was used in 24 males and 20 females aged from 6 to 25 years (mean age, 12 years). One patient (2%) developed wound dehiscence, and two further patients (4.5%) developed maceration of the wound margins, which delayed the healing process by only several days. Very good, good, or moderate results were obtained in 41 patients (91%). Poor outcome of treatment—excessive hypernasality or poor speech quality after the operation—was still present in four patients (9%). In our opinion, Furlow’s method is a very useful treatment method in patients with velopharyngeal insufficiency especially with sagittal orientation of levator veli palatini muscles.     

Surgical management of cystic lesions in the liver

Background: Liver cysts are common, occurring in up to 5% of the population. For many types of cysts, a variety of different treatment options exist and the preferred management is unclear. Methods: A Pubmed and Medline literature review using key words non‐parasitic hepatic cysts, polycystic liver disease, echinococcus, hydatid cysts parasitic cysts, Caroli's disease, cystadenoma; liver abscess, surgery, aspiration and treatment was undertaken and papers pertaining to the diagnosis and management of cystic lesions within the liver were retrieved. Results: Asymptomatic simple cysts in the liver require no treatment. Therapy for symptomatic cysts may incorporate aspiration with sclerotherapy or de‐roofing. At present, insufficient evidence exists to recommend one over the other. Polycystic liver disease presents a unique management problem because of high morbidity and mortality rates from intervention and high rates of recurrence. Careful patient counselling and assessment of symptom index is essential before embarking on any treatment. New medical treatments may ameliorate symptoms. Acquired cystic lesions in the liver require a thorough work‐up to fully characterize the abnormality and direct appropriate treatment. Hydatid cysts are best treated by chemotherapy followed by some form of surgical intervention (either aspiration and sclerotherapy or surgery). Liver abscesses can effectively be treated by aspiration or drainage. With improved antimicrobial efficacy, prolonged treatment with antibiotics may also be considered. Conclusion: All patients with cystic lesions in the liver require discussion at multi‐disciplinary meetings to confirm and the diagnosis and determine the most appropriate method of treatment.     

The role of the le fort I maxillotomy in the management of incompletely resected pituitary macroadenomas.

Objective: The options available for the treatment of a nonsecreting pituitary macroadenoma that has been incompletely resected include reoperation, fractionated radiation therapy, and radiosurgery. Reoperation in this setting may be hindered by the same obstacles that prevented a complete resection during the initial surgical procedure, and should prompt consideration of an alternate approach or exposure. Methods: Between January 1998 and December 2003, 10 consecutive patients were referred to the Department of Neurosurgery at the University of Texas Southwestern Medical Center for the evaluation of a nonsecreting pituitary macroadenoma that measured 3 cm or greater in diameter despite having undergone an attempt at a complete resection elsewhere. Each of these patients was reoperated using a Le Fort I maxillotomy to enhance the exposure provided by a traditional transsphenoidal approach. Results: A total or near total (> 95%) resection was achieved in each case. One patient required reoperation for the repositioning of a fat graft to treat a cerebrospinal fluid fistula and one patient experienced a worsening of anterior pituitary function postoperatively. Five patients noted improved vision and no patient experienced further visual loss. Three patients have required subsequent treatment of small foci of recurrent or progressing tumor with stereotactic radiation therapy. No patient has received fractionated radiation therapy. Conclusion: The added exposure provided by a Le Fort I maxillotomy facilitates the resection of pituitary macroadenomas that have been incompletely resected by a traditional transnasal, trans-sphenoidal approach.     

The utility of F-18 fluorodeoxyglucose whole body PET imaging for determining malignancy in cystic lesions of the pancreas

Previous studies have suggested that whole body positron-emission tomography (PET) can distinguish between benign and malignant cysts of the pancreas. Patients were identified (n=68) who had undergone whole body PET imaging for a cystic lesion of the pancreas between Jan. 1997 and May 2005. Cross-sectional imaging studies were reviewed by a single blinded radiologist, and positive PET studies were reviewed by a blinded nuclear medicine physician. Operative resection was performed in 21 patients (31%), and 47 patients were managed with radiographic follow-up. F-18 Fluorodeoxyglucose (FDG)-avid lesions were identified in eight of the 68 patients (12%). Within the resected group of patients (n=21), four of the seven patients (57%) with either in situ or invasive malignancy (adenocarcinoma: 3 of 5, papillary mucinous carcinoma: 1 of 2) had positive PET imaging (mean SUV, 5.9; range 2.5-8.0), and 2 of the 14 patients (14%) with benign lesions had positive PET imaging (serous cystadenoma, n=1, SUV=3.3; pseudocyst n=1, SUV=2.7). All lesions proven to be malignant with increased FDG uptake had highly suspicious findings on cross-sectional imaging. Within the group of resected patients, the sensitivity of PET for identifying malignant pathology was 57%, and the specificity was 85%. The sensitivity and specificity of PET for malignancy in this study was lower than previously reported, and PET findings did not identify otherwise occult malignant cysts. We do not believe whole body FDG-PET to be essential in the evaluation of cystic lesions of the pancreas.     

Variable efficacy of bone remodeling biochemical markers in the management of patients with Paget’s disease of bone treated with tiludronate

The aim of this work was to evaluate the response of different biochemical bone markers to tiludronate administration in Paget’s disease of bone. Ten patients (five men and five women), 56–77 years old (67 ± 6.5), were treated for 3 months with tiludronate tablets (400 mg/day). Bone formation markers: alkaline phosphatase (AP), bone alkaline phosphatase (bAP), osteocalcin (BGP), and procollagen I carboxyterminal propeptide (PICP) in serum; and bone resorption markers: serum cross-linked carboxyterminal telopeptides of type I collagen (ICTP), urinary hydroxyproline/creatinine (Hyp/Cr), pyridinoline/Cr (Pyr/Cr), and alpha-1 collagen chain products degradation (CrossLaps) were assessed. Samples were taken before and at monthly intervals for 3 months after treatment began. The results of the present work show that serum AP and bAP are sensitive and reliable biochemical markers of bone formation in the follow-up of tiludronate in this disease. Serum PICP shows less sensitivity than serum AP, and serum BGP is not indicated as biochemical marker in these types of studies. Urinary hydroxyproline seems to be the most reliable biochemical marker of bone resorption. More studies should be performed with urinary Pyr and CrossLaps determinations. Serum ICTP is not adequate for the follow-up of tiludronate treatment in Paget’s disease of bone.     

The role of laparoscopy in the management of childhood intussusception

apd: 6 February 2001     

The implications of the presence of an aberrant right hepatic artery in patients undergoing a pancreaticoduodenectomy

Purpose  An aberrant right hepatic artery (ARHA) is a common anomaly and its implications for patients undergoing a pancreaticoduodenectomy (PD) have not yet been previously reported. We compared the outcomes following PD in patients with and without an ARHA. A novel classification of the anatomical course of ARHA, and surgical techniques for its identification and preservation are described herein. Methods  All patients undergoing PD between June 1, 2002, and May 31, 2007, were divided into two groups, one with ARHA and the other without. These groups were compared to identify differences in the intraoperative variables, the oncological clearance, the postoperative complications, and the survival. Results  A total of 135 patients underwent PD of which 28 (20.8%) patients were found to have either accessory or replaced right hepatic arteries (ARHA group). There were no significant differences in the intraoperative variables (blood loss and operative time) and the incidence of postoperative complications (pancreatic leak and delayed gastric emptying). Oncological clearance (nodal yield and resection margins) and survival were also similar in the two groups. Conclusions  The surgical and oncological outcomes of PD remain unaffected by the presence of ARHA provided that the anatomy is recognized and appropriately managed. Aberrant right hepatic artery can be classified into three types according to their anatomical relationship with the head of the pancreas. Presented in part at the 7th World Congress of International Hepato-Pancreatico-Biliary Association (IHPBA), September 2006, Edinburgh, UK.     

Hiatal Hernia, Lower Esophageal Sphincter Incompetence, and Effectiveness of Nissen Fundoplication in the Spectrum of Gastroesophageal Reflux Disease

Background and Aims  Gastroesophageal reflux disease (GERD) is a spectrum of disease that includes nonerosive reflux disease (NERD), erosive reflux disease (ERD), and Barrett’s esophagus (BE). Treatment outcomes for patients with different stages have differed in many studies. In particular, acid suppressant medication therapy is reported to be less effective for treating patients with NERD and Barrett’s esophagus. The aims of this study were to investigate (1) the role of mechanical factors including hiatal hernia and lower esophageal sphincter (LES) competence in the spectrum of GERD and (2) outcomes of Nissen fundoplication. Methods  From the records of patients who had undergone laparoscopic Nissen fundoplication after an abnormal pH study, we identified 50 symptomatic consecutive patients with each of the GERD stages: (1) NERD, (2) mild ERD, defined as esophagitis that was healed with acid suppression therapy, (3) severe ERD, defined as esophagitis that persisted despite medical therapy, and (4) BE. Exclusion criteria were normal distal esophageal acid exposure, esophageal pH monitoring performed elsewhere, antireflux surgery less than 1 year previously or previous fundoplication, and a named esophageal motility disorder or distal esophageal low amplitude hypomotility. Patients who could not be contacted for the study were also excluded. All patients completed a detailed preoperative questionnaire; underwent preoperative upper gastrointestinal endoscopy, stationary manometry, and distal esophageal pH monitoring; and were interviewed at least 1 year after operation. Results  One hundred sixty patients meeting the entry criteria were studied. The mean follow-up period was 36.7 months. The only significant preoperative symptom difference was that patients with BE had more moderately severe or severe dysphagia compared to patients with NERD. Patients with severe ERD or BE had a significantly higher prevalence of hiatal hernia, lower LES pressures, and more esophageal acid exposure. Hiatal hernia and hypotensive LES were present in most patients with severe ERD or BE but in only a minority of patients with NERD or mild ERD. Surgical therapy resulted in similarly excellent symptom outcomes for patients in all GERD categories. Conclusions  Compared to mild ERD and NERD, severe ERD and BE are associated with significantly greater loss of the mechanical antireflux barrier as reflected in the presence of hiatal hernia and LES measurements. Restoration of the antireflux barrier and hernia reduction by laparoscopic Nissen fundoplication provides similarly excellent symptom control in all patients.     

Studies on the role of calcium phosphate in the process of calcium oxalate crystal formation

Crystals of calcium phosphate (CaP) added to solutions with a composition corresponding to that at different levels of the collecting duct (CD) and with different pH were rapidly dissolved at pH 5.0, 5.25 and 5.5. Only minor or no dissolution was observed at higher pH levels. Despite this effect, CaP crystals induced nucleation or heterogeneous crystallization of CaOx up to a pH of 6.1, whereas CaP was the type of crystalline material that precipitated at higher pH. Accordingly, small crystal volumes were recorded at pH 5.5 and great volumes at pH 6.7 4 h after the addition of CaP crystals to the solutions. Dialyzed urine appeared to counteract the dissolution of CaP and to reduce the rate of secondary crystallization. The CaP induced crystallization of CaOx was confirmed by a reduction of ¹⁴C-labeled oxalate in solution. The AP_CaOx required for a nucleation or heterogeneous crystallization of CaOx in the presence of CaP was around 1.5 × 10⁻⁸ (mol/l)². For CaP crystal formation on CaP, an AP_CaP (^aCa²⁺ × ^aPO₄ ³⁻) of approximately 50 × 10⁻¹⁴ (mol/l)² appeared to be necessary. The CaOx crystals formed were microscopically found in association with the CaP crystalline material and were most frequently of CaOx dihydrate type. Step-wise crystallization experiments comprising supersaturation with CaP (Step A), supersaturation with CaOx (Step B) and subsequently acidification (Step C) showed that CaOx crystal formation occurred when CaP crystals were dissolved and thereby served as a source of calcium. The ensuing formation of CaOx crystals is most likely the result from high local levels of supersaturation with CaOx caused by the increased concentration of calcium. These experimental studies give support to the hypothesis that crystallization of CaOx at lower nephron levels or in caliceal urine might be induced by dissolution of CaP formed at nephron levels above the CD, and that a low pH is prerequisite for the precipitation of CaOx. The observations accordingly provide additional evidence for the important role of calcium phosphate in the crystallization of calcium oxalate, that might occur both at the surface of Randall’s plaques and intratubularly at the papillary tip. Parts of these studies were presented at the Scanning Microscopy Meeting 1996, at the International Symposium on Urolithiasis, Dallas 1996 and at the Eurolithiasis meeting in Istanbul 1998.     

The use of the Taylor spatial frame in adolescent Blount’s disease: is fibular osteotomy necessary?

Background  The standard treatment of adolescent Blount disease includes proximal tibial osteotomy and osteotomy of the fibula. Some believe that the fibula should also be fixed to prevent migration and subluxation. The purpose of the current study was to examine the results of treatment of patients with adolescent tibia vara treated by tibial osteotomy and Taylor spatial frame (TSF) without fibular osteotomy. Methods  Correction of deformities was performed on eight patients (ten tibias) with adolescent Blount disease using TSF. The fibula was not osteotomized in any patient and was not fixed in the last five patients. Results  All patients had precise anatomical correction of deformities and no problems related to the fibula occurred during or after correction. Conclusion  Based on our experience we believe that placement of the origin at the level of the proximal tibial fibular joint in conjunction with external fixation eliminates the need for fibular osteotomy and the potential morbidity of this procedure in patients with mild to moderate tibia vara.     

The Effects of Endothelin Receptor Blockade by Bosentan on the Healing of a Bowel Anastomosis in an Experimental Crohn’s Disease Model

Objective  It was previously described that endothelins may contribute to the pathogenesis of Crohn’s disease. In this study, it was aimed to investigate the effects of endothelin receptor blockade by bosentan on the healing of a bowel anastomosis in an experimental Crohn’s disease model. Material and Methods  Twenty-eight Sprague–Dawley rats were divided into four groups. Groups I and II were used as sham-operated and control groups, respectively. Bowel inflammation induced by intrajejunal injection of iodoacetamide in groups III and IV. Rats in group IV were treated with oral preparation of bosentan 60 mg/kg/day. Three days after induction of the inflammation, partial resection of test loop and anastomosis was performed. Re-laparotomy was performed, anastomosis bursting pressures and peritonitis scores were measured, and tissue samples were obtained for the measurements of tissue hydroxylproline level and mucosal damage index 4 days later. Results  The mean mucosal damage index and peritonitis score of group IV were significantly lower, and the mean tissue hydroxyproline level and anastomotic bursting pressure of group IV were significantly higher than those of group III. Conclusion  The blockade of endothelin receptors by bosentan decreases the severity of iodoacetamide induced intestinal inflammation, increases the wound healing in the inflamed intestinal tissue, and decreases the severity of peritonitis. This study was supported by The Coordination Committee of Scientific Researches and Projects of Fırat University.     

The critical view of safety in laparoscopic cholecystectomy is optimized by exposing the inner layer of the subserosal layer

During laparoscopic cholecystectomy (LC), misidentification of the cystic duct, which causes major bile duct injuries, can result from wrong or incomplete dissection of Calot’s triangle. Therefore, the critical view of safety has been accepted as a safe method for gaining a sufficient view of Calot’s triangle before transecting the cystic duct. However, even in cases without aberrant anatomy of the bile duct, bile duct injury can occur by a wrong approach to a critical view of safety. Additionally, in cases of badly inflamed gallbladders, it is often hard to achieve a critical view of safety, because Calot’s triangle is often solid and cannot be expanded. In our standardized procedure, which is based on exposing the inner layer of the subserosal layer (the ss-i layer), the critical view of safety can be safely achieved. We have safely performed LC, using our standardized procedure, for many cases with cholecystitis with highly inflamed gallbladders. In this article, focusing especially on prevention of bile duct injuries, we present our standardized procedure to achieve the critical view of safety along with histological findings.