Ethyl Pyruvate; from Liver Preservation Solutions University of Wisconsin (UW) Increases the Effectiveness of the Solution

BACKGROUND

The most important factor affecting the success rate of liver transplants is the preservation of the normal histologic and biochemical properties of the cells in the tissue taken. The study aimed to identify the possible increase in efficacy of ethyl pyruvate, which has a hepatoprotective effect, on the University of Wisconsin (UW) solution.

METHODS

Rats were randomly selected and divided into 4 groups. After a laparotomy, the small intestines were removed from the abdomen and the portal pedicle was identified. Arterial and venous circulation of the liver was interrupted. After the portal vein was cannulated (and the distal of the portal pedicle was ligated, the liver was perfused with a solution. Perfusion solution was selected as Ringer Lactate in Group 1. In group 2, UW solution was chosen as the perfusion solution. In Group 3, the perfusion solution was chosen as the UW solution, but ethyl pyruvate at a dose of 40 mg/kg was administered intraperitoneally to the experimental animals 30 minutes before hepatectomy. In Group 4, as a perfusion solution, a UW solution with 40 mg/kg dose of ethyl pyruvate added to it was used.

RESULTS

With TUNEL and Caspase-3 staining, a significant decrease was found in the apoptosis rates of Groups 2, 3, and 4 at the 12th hour post hepatectomy when compared with Group 1. When the morphometric liver sinusoid/parenchyma ratios and vena centralis diameters of the groups were examined, it was found that all preservation solutions containing the UW solution were more protective than the RL solution.

CONCLUSIONS

Ethyl pyruvate is regarded as a promising agent that can increase the effect of the UW solution on organ preservation solutions. Because this study is the first in literature to apply ethyl pyruvate in preservation solutions, additional studies with larger series and different doses are needed.

Lateral lymph node involvement presents another challenge in rectum cancer in the age of neoadjuvant chemoradiotherapy + total mesorectal excision: an evaluation of survival outcomes

PURPOSE

In the last decades, total mesorectal excision (TME) and neoadjuvant chemoradiotherapy (nCRT) have produced an undeniable improvement in the treatment of rectal cancer. However, local recurrence is still an important problem, and the effect of lateral lymph node (LLN) involvement on local recurrence is a controversial issue. The aim of this study was to investigate the effects of LLN status on local recurrence and survival in rectal cancers treated with nCRT + TME.

METHODS

Clinical features, pre- and post-nCRT lateral pelvic region imaging, long-term local recurrence, and the survival outcomes of 114 patients who underwent nCRT + TME for rectal cancer were evaluated.

RESULTS

On MRI before nCRT, 20 (17.5%) patients had lateral lymph nodes (LLN+), and 94 (82.5%) patients had no lymph nodes in the lateral pelvic compartments (LLN-). Local recurrences at 1 year in LLN+ and LLN- patients were 3 (15.8%) and 2 (2.3%), respectively (p=0.039). Five-year local recurrence-free survival rates and the mean duration of recurrence-free survival in LLN+ and LLN- patients were 56.2%, 42.6 months, and 87.3% 66.9 months, respectively (p=0.001). Disease-free survival and overall survival were shorter in LLN+ patients, but the difference was not statistically significant (p=0.096 and p=0.46, respectively). In the multivariate analysis, LLN involvement was determined to be an independent risk factor for local recurrence-free survival (Hazard Ratio 4.54, p=0.003).

CONCLUSION

Lateral lymph node involvement causes local recurrence to remain high after nCRT + TME. LLN status should be considered in treatment planning. Further studies are needed to define precise criteria for LLN involvement and the effect of LLND on local recurrence and survival.

Results of positive proximal margin after resection for hilar cholangiocarcinoma: An analysis of 42 cases

BACKGROUND/AIMS

Hilar cholangiocarcinoma (HC) is a tumor that invades the confluence of the left and right hepatic bile ducts. Surgery is the definitive treatment but is also technically demanding. Here, we report our experience on 42 patients who underwent surgical resection for HC. The aim of the present study was to evaluate the margin status of resected specimens on frozen sections and the impact of R1 resection margin on survival.

MATERIALS AND METHODS

A total of 42 patients with HC who underwent surgical resection in our clinic between January 2008 and January 2017 were included in the study. Patients' charts were evaluated retrospectively.

RESULTS

The 1-, 2-, and 4-year overall survival rates of the 42 patients were 76.2%, 40%, and 10.7%, respectively. The median survival rates of the patients with negative and positive proximal surgical margins were 22 (11.93-32.06) and 17 (14.43-19.56) months, respectively. There was no statistically significant difference between these two groups.

CONCLUSION

In HC, surgery achieving negative proximal surgical margin is often very difficult. Our results demonstrate that frozen sections are reliable for the assessment of the invasion status of the proximal and distal ductal surgical margins. Although complete resection is potentially curative, survival of the patients with HC is still poor. If there is no distant metastasis at the time of diagnosis, then extirpating surgery should be encouraged as survival of the patients with positive and negative margins is not significantly different.

Pancreatic stump closure using only stapler is associated with high postoperative fistula rate after minimal invasive surgery

BACKGROUND/AIMS

Postoperative pancreatic fistula (POPF) is the most common cause of morbidity and mortality after distal pancreatectomy (DP). The aim of the present study is to determine the risk factors that can lead to POPF.

MATERIALS AND METHODS

The study was conducted between January 2008 and December 2012. A total of 96 patients who underwent DP were retrospectively analyzed.

RESULTS

Overall, 24 patients (25%) underwent laparoscopic distal pancreatectomy (LDP) and 72 patients (75%) open surgery. The overall morbidity rate was 51% (49/96). POPF (32/96, 33.3%) was the most common postoperative complication. Grade B fistula (18/32, 56.2%) was the most common fistula type according to the International Study Group on Pancreatic Fistula definition. POPF rate was significantly higher in the minimally invasive surgery group (50%, p=0.046). POPF rate was 58.6% (17/29) in patients whose pancreatic stump closure was performed with only stapler, whereas POPF rate was 3.6% (1/28) in the group where the stump was closed with stapler plus oversewing sutures. Both minimally invasive surgery (OR: 0.286, 95% CI: 0.106-0.776, p=0.014) and intraoperative blood transfusion (OR: 4.210, 95% CI: 1.155-15.354, p=0.029) were detected as independent risk factors for POPF in multi-variety analysis.

CONCLUSION

LDP is associated with a higher risk of POPF when stump closure is performed with only staplers. Intraoperative blood transfusion is another risk factor for POPF. On the other hand, oversewing sutures to the stapler line reduces the risk of POPF.

Mixed Adeno-Neuroendocrine Carcinoma; Case Series of Ten Patients with Review of the Literature

Aims:

Mixed adeno-neuroendocrine carcinoma is a rare entity, diagnosed with immunohistochemical studies. Literature mainly includes case reports and series which are very few. In our study, we aimed to report a case series from a tertiary hospital with demographics of the patients, detailed tumor and clinical findings and follow-up plus survival conditions.

Methods:

Pathology database was explored for patients with the pathological diagnosis of ‘mixed adeno-neuroendocrine carcinoma’ and patients were identified retrospectively and evaluated in means of demographics, histopathological examination, tumor properties.

Results:

Ten patients had been diagnosed with mixed adeno-neuroendocrine carcinoma in our center, diagnosed at a mean age of 64.7. Stomach was found to be the most common localization. Five patients (50%) were diagnosed as grade 3. Following surgery, median follow-up was 15 months with a median survival time of 20.6 months.

Conclusion:

This case series may contribute to the literature on the pathological and clinical aspects of the mixed adenoneuroendocrine carcinoma of the gastrointestinal system.

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 treatment.

Surgical Outcomes of Solid Pseudopapillary Neoplasm of the Pancreas: A Single Institution's Experience of 16 Cases

INTRODUCTION

Solid-pseudopapillary tumor (SPT) of the pancreas is a rare tumor, generally characterized by a well-encapsulated mass. The aim of the current study was to analyse the clinicopathological characteristics and treatment outcomes of patients with SPT. In this study, we report our clinical experience with 16 cases of SPTs.

METHODS

Sixteen patients who underwent surgery for pathologically confirmed SPT were included. Data of the patients were reviewed from the prospectively recorded database. Patients' demographics, laboratory values, clinical presentation, radiological imaging findings, surgical treatment, perioperative complications, pathological features, post-operative course, and long-term survival were collected and analyzed. Statistical analyses were performed using the computer program Statistical Package for Social Sciences (SPSS) 16.0 for Windows.

RESULTS

The tumors ranged from 2 to 11 cm in diameter and were located in the head in ten patients (62.5%), the neck in two patients (12.5%), and the body or tail in four patients (25%). All patients were women whose ages ranged from 21 to 79 years (mean age was 41.62 ± 15.08). Patients had resection margins free of tumor resections and there were no preoperative or postoperative mortalities. There was no recurrence or metastasis after the surgical resection. All patients were alive at a mean follow-up of 49.06 ± 29.53 months (range 6 to 99).

CONCLUSION

SPT is a rare pancreatic neoplasm with a low malignant potential, and is common in young women. If SPT is diagnosed before surgery, complete surgical resection, generally enucleation is the most effective therapy for SPT.

Unresectable pancreatic adenocarcinoma with complete clinical response following chemoradiotherapy

Locally advanced or metastatic disease is present in 2/3s of patients with pancreatic cancer. Pancreatic cancer patients are assessed as resectable, potentially resectable (borderline) and unresectable according to pre-operative examinations. The chance for operability may be enhanced by using adjuvant-neoadjuvant systemic chemotherapy, radiotherapy or both. The rates of R0 resection may be increased by means of treatment delivered this way. This case report presents a pancreatic adenocarcinoma case that was assessed to be resectable but was identified to be unresectable during surgical exploration, thus received adjuvant chemoradiotherapy. The patient was then re-evaluated, identified as resectable and received pancreaticoduodenectomy.

A new approach to gastrointestinal fistula closure: endoloop and clips technique using double endoscope

Several endoscopic techniques have been described for closure of gastrointestinal fistulas. Herein, we describe a case of iatrogenic gastric fistula successfully treated with a new approach by simultaneous insertion of two endoscopes and using the endoloop and endoclips technique.

Short-term outcomes after surgery for colorectal cancer in Turkish patients aged 70 and above

BACKGROUND/AIMS

We aimed to evaluate the impact of age on short-term surgical outcomes and to investigate the risk factors for postoperative mortality in 660 Turkish colorectal cancer patients.

METHODS

Between January 2002 and January 2007, 660 consecutive patients who were operated for colorectal cancer at our institution were enrolled in this study. The patients were divided into two groups as: a younger group (<70 years) and an older group (≥70 years). Patient data were recorded prospectively with the use of specially designed forms. Variables and short-term patient results were compared.

RESULTS

American Society of Anesthesiologists (ASA) scores were significantly higher and albumin levels were lower in the older group compared with the younger group (p<0.05). Morbidity and mortality rates were 16.8% (83/494) and 2.6% (13/494) in the younger group and 22.9% (38/166) and 3.0% (5/166) in the older group, respectively. These differences in rates were not statistically significant. ASA score (ASA 4) and non-resective procedures were found to be independent risk factors for mortality.

CONCLUSIONS

Age should not be regarded as a reason for limited surgery. Elderly patients should undergo the same standard surgical approach as younger patients. The patient's general state of health is more effective on postoperative mortality.

Spontaneous hepaticoduodenal fistula functioning like a bilioenteric anastomosis following bile duct injury: case report

Bile duct injury is a serious complication of laparoscopic cholecystectomy. We report a case of spontaneous hepaticoduodenal fistula following bile duct injury. Initially, Roux-en-Y hepaticojejunostomy had been planned for the patient, but as the patient did not show any symptoms or findings of biliary obstruction, we preferred a non-operative management. The fistula allowed adequate biliary drainage, and the patient has been followed regularly by the outpatient clinic with good clinical results for approximately five years.

Development of two cancers in the same patient after ileorectal and ileal pouch anal anastomosis for familial adenomatous polyposis

OBJECTIVE

To report a case of a patient with familial adenomatous polyposis.

CLINICAL PRESENTATION AND INTERVENTION

A 36-year-old male patient who suffered from rectal bleeding was treated with colectomy and ileorectal anastomosis for familial adenomatous polyposis (FAP) in 1974. After 19 years, in situ adenocarcinoma was detected in the rectal stump. Completion proctectomy, mucosectomy, and hand-sewn ileal pouch anal anastomosis with protective ileostomy were performed. In 2002, a metachronous cancer was detected at the anastomosis and abdominoperineal resection of the pouch and end ileostomy were performed. Later on, the perineum was excised locally because of cancer recurrence.

CONCLUSION

This case shows that lifetime surveillance of the FAP patients after surgery is crucial.

The relationship between prognostic factors of breast cancer and thyroid disorders in Turkish women

BACKGROUND

Breast carcinoma is a frequent disease that affects the female population. As for other malignant diseases, several studies have been carried out in an attempt to identify its etiology, yet the etiological agent has not been clearly defined. The etiological relationship between thyroid disease and breast cancer is still being investigated. However, most of the studies in this field are conflicting and discussions on this relationship still continue.

PATIENTS AND METHOD

Our prospective open study was conducted on 136 consecutive patients operated for breast carcinoma. As a control group, 68 individuals with normal breast examination, who did not have any known malignancy and/or thyroid disease, living in the same geographical region and with matching socio-cultural and economical status, were included in the study. We aimed to identify the occurrence and frequency of thyroid pathologies in both groups to compare the clinical and the laboratory features of thyroid disease and breast carcinoma in an attempt to contribute to the studies investigating the relationship between these two entities.

RESULTS

We found thyroid pathology in 77.9% of breast cancer patients while this was 47.1% in the control group. Breast cancer patients had higher levels of free-T3 and more frequent diffuse and nodular enlargement of thyroid gland in ultrasonography when compared to the control group. Furthermore, in the presence of thyroid disease, breast cancer patients had statistically significant increases in the number of metastatic lymph nodes, vascular invasion, and tumor size.

CONCLUSION

In conclusion, the frequency of thyroid pathology is higher in breast cancer patients compared to controls indicating a relationship between breast carcinoma and thyroid pathology. Our study shows that the presence of thyroid pathology in breast cancer patients can be influential on the spread of cancer and adversely affect its prognosis. We thought further studies are needed to confirm these findings and to explain the reason for co-occurrence of breast cancer and thyroid disease and furthermore to investigate the prognosis and survival of breast cancer patients in the presence of thyroid pathology.

Coronary sinus retroperfusion during acute experimental coronary artery occlusion

BACKGROUND

This study was planned to show the effect of retroperfusion and cardiopulmonary bypass on myocardial hemodynamic recovery.

METHODS

Eighteen dogs entered this study. After, left anterior descending artery (LAD) was dissected and occluded, the animals were divided into three equal groups; Group I: retrograde coronary sinus perfusion, group II: cardiopulmonary bypass and retrograde coronary sinus perfusion, Group III: control group, left anterior descending artery occlusion only.

RESULTS

In Group III, deterioration of the hemodynamic values progressed parallel with the degree of ischemic damage but in Group I, hemodynamic parameters were better because of the retrograde coronary sinus perfusion and minimally affected by the reperfusion. In Group II, at the end of the cardiopulmonary bypass minimal myocardial damage was observed.

CONCLUSIONS

There is no statistical difference between Group I and II if we examine the data that was taken after reperfusion although myocardial performance was better in Group II.