An extremely rare cause of acute abdomen in pregnancy: ruptured pancreatic mucinous cystadenocarcinoma

Pancreatic cystadenocarcinoma is an extremely rare neoplasm in pregnancy. To our knowledge, there have been 2 published cases of pancreatic mucinous cystadenocarcinoma (PMC) during pregnancy in the literature; one of which was reported to have ruptured into the abdominal cavity. We present a second case of ruptured PMC resulting in acute abdomen in 36 weeks of pregnancy. Rupture of mucinous cystic neoplasms of pancreas including PMC should be remembered in acute abdomen during pregnancy.     

Asystole due to trigemino-cardiac reflex: A rare complication of trans-sphenoidal surgery for pituitary adenoma

The trigemino-cardiac reflex (TCR) is a well-known reflexive response in which bradycardia, hypotension, and gastric hypermotility are induced by stimulation of a peripheral or central portion of the trigeminal nerve. This reflex occurs during craniofacial surgery and other operations on or near the cerebellopontine angle, petrosal sinus, orbit and trigeminal ganglion. TCR is a well-known, although not well documented, phenomenon commonly observed during trans-sphenoidal surgery for resection of pituitary adenomas. We report a case in which asystole occurred during trans-sphenoidal surgery on a pituitary adenoma that was infiltrating the right cavernous sinus. When the anesthesiologist reported asystole, the team stopped manipulation and administered intravenous atropine. Intra-operative MRI showed a small tumour remnant in the right cavernous sinus. The operation was terminated but subsequent radiosurgery was planned for the residual tumor. Although TCR is rare and usually self-limiting, this case led us to change our treatment strategy. Surgeons who perform trans-sphenoidal surgery should be aware of this potential problem. Invasive pituitary adenomas should be removed gently and the risk of triggering TCR should be kept in mind.     

Effects of topiramate on neurophysiological and neuropsychological tests in migraine patients

Topiramate (TPM) is a antiepileptic drug that has multiple mechanisms of action. It is effective as a monotherapy for migraine prophylaxis. Unfortunately, TPM can frequently cause adverse effects, such as cognitive dysfunction. The present study examines the neuropsychological and neurophysiological effects of TPM in 35 consecutive migraine patients above 18 years of age. The TPM dose was started at 25 mg/day and increased by 25 mg/week, until reaching the maximum dose of 50 mg twice daily in the fourth week. Patients were evaluated for development of side effects of the medication and for its effectiveness on migraine. The Wechsler memory scale was used for neuropsychological evaluation and cognitive evoked potentials were used for neurophysiologic evaluations. Analyses of repeated measures show that visual analog scale pain values, as well as migraine attack frequency and headache duration, were decreased significantly during the study. The amplitudes and latencies of P300 did not change. The results of this study show that 100 mg TPM is effective in the prevention of migraine headache and in reducing severity of attacks. Patients’ cognitive complaints are frequent in the first month and decrease in the following month. Despite these complaints, only the attention section of the visual memory section of the Wechsler memory scale was affected – other sections were not affected. Also, P300 study did not reflect changes appropriate to these cognitive complaints.     

Serum uric acid and lipid levels while taking topiramate for migraine

Objective.— Topiramate (TPM) therapies for epilepsy or migraine are long-time therapies with unknown mechanisms and special side effects. TPM influences cholesterol (TC) and lipoprotein serum levels. In addition, TPM may cause uric acid (UA) stone formation.
Material and Methods.— Serum UA, TC, and triglyceride (TG) levels were measured in 53 migraine patients receiving TPM and in 44 age- and sex-matched controls. Compared with controls, patients on TPM showed significantly higher UA and nonsignificantly higher TC and TG values. We recorded pre- and posttreatment levels of UA, TC, and TG levels in 23 patients.
Results.— We found increased serum levels of UA with TPM use ( P  < .01). There was a significant and positive correlation between serum UA levels and male gender ( P  < .01).The changes in serum UA levels before and after TPM treatment differed significantly ( P  < .01).
Conclusion.— Our results suggest a need for monitoring serum UA levels in patients receiving TPM. We should perhaps prescribe a low-UA diet and advice to drink much more water in these patients.     

Abdominal wall mucocele: a late complication of colostomy closure

We present a case of incisional enteric mucocele formation 10 years following colostomy closure. The patient was admitted to the hospital with the symptoms of an abdominal wall mass lying on previously closed colostomy incision. Clinical presentation, diagnostic work up and pathology of the case were discussed. To our knowledge, this is the first abdominal wall mucocele after colostomy closure reported in the literature.     

Tubularized incised plate for mid shaft and proximal hypospadias repair

PURPOSE: We report outcomes from tubularized incised plate repair of mid shaft and proximal hypospadias by a single surgeon. MATERIALS AND METHODS: Chart review of all patients undergoing mid shaft and proximal hypospadias was performed. Those with tubularized incised plate were divided into 2 groups for mid shaft and proximal repairs. Group 1 underwent single layer urethroplasty using chromic catgut suture, while group 2 underwent 2-layer polyglactin subepithelial closure. All patients had a dartos barrier flap, while spongioplasty was also done in group 2 when possible. RESULTS: A total of 30 patients underwent mid shaft repairs, while 35 had more proximal defects. Complication rates for mid shaft repairs did not differ between the 2 groups, and averaged 13%. However, complications in mid shaft vs proximal repairs (37%) were significantly different (p = 0.04). Overall complications (53% vs 25%) and incidence of fistulas (33% vs 10%) decreased in proximal repairs from group 1 to 2. CONCLUSIONS: Tubularized incised plate repair was applicable for all mid shaft hypospadias cases and for those more proximal cases when ventral curvature could be straightened without plate transection and the incised plate was grossly supple. Outcomes were improved using 2-layer subepithelial tubularization of the neourethra. Results of mid shaft vs proximal hypospadias repairs are significantly different and should be reported separately.     

Short-term effect of simvastatin treatment on inflammatory parameters in peritoneal dialysis patients

OBJECTIVE: Increased serum pro-inflammatory cytokine levels are associated with an increased mortality rate in end-stage renal disease (ESRD) patients. Statins decrease cardiovascular mortality and serum C-reactive protein (CRP) levels in hemodialysis patients. As the anti-inflammatory effect of statins has not previously been studied in peritoneal dialysis (PD) patients with a non-inflammatory status, we wanted to investigate the anti-inflammatory effect of simvastatin in these patients. MATERIAL AND METHODS: Forty-eight PD patients were randomly allocated to either simvastatin treatment (n=25) or placebo (n=23). Patients in the active-treatment group received simvastatin 20 mg/day for 1 month. At baseline and after 1 month of treatment, blood samples were drawn and high-sensitivity CRP, interleukin-6, tumor necrosis factor (TNF)-alpha and plasma lipid profiles were determined. These parameters were compared between the groups at baseline and at the end of the study period. RESULTS: Twenty-five subjects in the treatment group and 20 in the placebo group completed the study. Three patients in the placebo group were excluded from the study due to the occurrence of bacterial peritonitis during the study period. Clinical characteristics and baseline parameters were similar in both groups. Serum total and low-density lipoprotein cholesterol levels, and triglyceride and serum TNF-alpha levels decreased significantly compared to baseline in the treatment group; there were no corresponding differences in the placebo group. CONCLUSIONS: Simvastatin decreased the serum TNF-alpha level in PD patients with a non-inflammatory status. A decrease in the TNF-alpha level could be one of the possible mechanisms of the anti-atherogeneic effect of simvastatin. We suggest that different treatment strategies aimed at decreasing serum cytokine levels could be evaluated to decrease cardiovascular morbidity and mortality in the dialysis population.     

Uterine preservation and vaginal reconstruction in a patient with congenital vaginal agenesis presenting with cyclic menouria

Herein we report the case of a patient with primary amenorrhea and cyclic menouria. The patient was a 20-year-old woman with primary amenorrhea and inability to achieve sexual intercourse. Clinical examination revealed normally developed labia majora and minora, clitoris, and external urethral orifice, but no vaginal opening. A mature female pubic hair pattern was present, and axillary hair development was normal. Breasts were normally developed. Abdominopelvic magnetic resonance imaging demonstrated a remnant upper vagina and unicornuate uterus filled with fluid, and left-sided renal agenesis. Intraoperatively, a congenital vesicouterine fistulous tract was observed. The fistulous tract was completely resected. Vaginal reconstruction using a sigmoid colon pedicled flap was performed. The proximal part of the neovagina was connected to the remnant cervix, and a Foley catheter was left in the uterine cavity for 7 days to prevent obstruction. The patient has been menstruating regularly since the operation. Menouria might be an early sign of congenital vesicouterine fistula. Resection of the fistulous tract with uterine preservation might be considered in patients with vaginal agenesis.