Might simple peripheral blood parameters be an early indicator in the prediction of severity and morbidity of cholecystitis?

Purpose

The aim of this study is to examine the effectiveness of the neutrophil-lymphocyte ratio (NLR) and CRP/albumin ratio (CAR) in evaluating disease severity and predicting clinical outcomes in patients diagnosed with acute cholecystitis (AC).

Methods

A total of 186 patients with AC were evaluated retrospectively. NLR, CAR, Mannheim Peritonitis Index (MPI), and P-POSSUM (Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity) scores were compared with AC severity grade.

Results

The rates of the grade 1 patients (group 1) and the grade 2-3 patients (group 2) were 57.5% (n = 107) and 42.5% (n = 79) according to the disease severity according to Tokyo Guidelines criteria (TG) 18/TG13, respectively. The morbidity rates determined in groups 1 and 2 were 26.7% (n = 28) and 51.9% (n = 41), respectively. No mortality was found in group 1, whereas the mortality rate in group 2 was 6.3% (n = 5). According to multivariate analysis, CAR (odds ratio [OR], 1.234; P < 0.001) and MPI (OR, 1.175; P = 0.001) were found to be associated with moderate-severe disease while CAR (OR, 1.109; P = 0.035) and P-POSSUM morbidity (OR, 1.063; P = 0.007) variables were found to be associated with the presence of morbidity.

Conclusion

We have demonstrated that CAR can be used in predicting severity of AC and that CAR is an alternative simple parameter of P-POSSUM morbidity score in prediction of morbidity in these cases. In addition to other assessment methods, these scores can provide valuable and complementary information in assessment of disease severity and prognosis in AC.

Impact of positive end-expiratory pressure with alveolar recruitment maneuver on respiratory and oxygenation parameters of patients during laparoscopic bariatric surgery

OBJECTIVE

Laparoscopic bariatric surgery is frequently associated with disturbances in respiratory mechanics. An alveolar recruitment maneuver (ARM) with positive end-expiratory pressure (PEEP) is a strategy to overcome such respiratory conditions. This study aimed to evaluate the effect of ARM+PEEP on intraoperative and postoperative respiratory and hemodynamic parameters of patients with laparoscopic bariatric surgery.

PATIENTS AND METHODS

Patients who underwent laparoscopic bariatric surgery between 2009 and 2016 were retrospectively evaluated. The study sample was divided into four groups based on PEEP values and the presence of ARM: Group PEEP 5 (5 cm H2O PEEP only), Group PEEP 5/RM (5 cm H2O PEEP plus ARM), Group PEEP 10 (10 cm H2O PEEP only), Group PEEP 10/RM (10 cm H2O PEEP plus ARM). Patients' demographic characteristics, ventilatory, respiratory, and oxygenation parameters were recorded. Oxygenation index (PaO2/FiO2) was the study's primary outcome.

RESULTS

There were 156, 158, 299, and 210 patients in Groups PEEP 5, PEEF 5/RM, PEEP 10, and PEEP 10/RM, respectively. Tidal volume, driving tidal volume/compliance, PaO2, PaO2/FiO2, and PaCO2 were significantly lower in Groups PEEP 5 and PEEP 5/RM, whereas SpO2 and FiO2 were significantly higher in Groups PEEP 5 and PEEP 5/RM (p<0.05). Patients in Group PEEP 5 had significantly higher end-tidal carbon dioxide (EtCO2) values than those of other groups (p<0.001). Patients in Group PEEP 5/RM had significantly higher SpO2 values than those in Group PEEP 5 (p<0.001). Rate of postoperative atelectasis was significantly higher in Group PEEP 5/RM compared to the other groups (p=0.011).

CONCLUSIONS

A PEEP level of at least 10 cm H2O with ARM improved intraoperative respiratory parameters and caused a significant reduction in postoperative atelectasis.

Spousal and living related kidney transplantation: our center experience

Background

Kidney transplantation is the most preferred type of renal displacement therapy for end stage renal disease (ESRD) patients. More patients developed ESRD. The most important source is the donations from unrelated spouses. In this study, we aimed to compare the transplantation data obtained from the spouses of the patients with the transplantation data obtained from other relatives.

Methods

The data including 167 living kidney transplantations performed between January 2006 and December 2019 were retrospectively collected. The patients were divided into two groups; spousal donor group (n: 53) and living-related donor group (n: 114).

Results

There was no significant difference in delayed graft function in both groups. There were no patients with acute rejection proven by biopsy or considered biochemically in the spousal donor group. With regard to 3-year results in the living-related donor group the patient survival rate was 100%, while it was 98.2% in terms of graft survival.

Conclusions

In conclusion, similar patient and graft survival rates between spousal donor kidney transplantation and living-related kidney transplantation has made spousal donor kidney transplantation, with possible problems in terms of tissue compatibility, an acceptable alternative to donor supply.

Pregnancy after renal transplantation

OBJECTIVE

A well-functioning renal transplant usually reverses ESRD-related infertility and allows the reproductive function to improve. In this study, we wanted to emphasize that women who have renal transplantation can live healthy pregnancies with a careful follow-up.

BACKGROUND

204 patients underwent renal transplantation in our center and 84 of them were female. Five of our patients (one of them had two births) gave birth to a total of 6 pregnancies.

METHOD

All of these patients were evaluated according to the criteria by the organ transplant team and perinatologist before the pregnancy planning and during the pregnancy processes.

RESULTS

The mean age of the patients was 22.5 ± 4.5 (18-29) years. The creatinine level was below in 1.5 mg/dl in all patients in the pre-pregnancy period, and 1 + proteinuria was found in only two of them. Pregnancy periods varied between 31 weeks and 38 weeks. All births were performed by cesarean section and birth weight in babies ranged between 1650 and 3190 gram.

CONCLUSION

Pregnancy in the renal transplant recipient is high-risk and should be managed by a multidisciplinary team of high-risk obstetricians, perinatalogists and transplant nephrologists. It should be closely monitored in terms of complications during pregnancy (Tab. 5, Ref. 16).

Effects of abdominal and vaginal hysterectomy on anorectal functions along with quality of life of the patient

Objectives and background

Hysterectomy is the most commonly performed major gynecological operation for both benign and malign gynecologic conditions. After hysterectomy, although some investigators have declared an increased incidence of urinary and anorectal dysfunction, some others could not show any connection.

Methods

The voluntary patients were divided in two groups: abdominal hysterectomy (Group 1) and vaginal hysterectomy (Group 2). Anal manometry and all the other examinations of the patients were performed at the Department of General Surgery Endoscopy Unit of Ankara University, Faculty of Medicine.

Results

When the quality of life of the patients was assessed before the operation and on the 12^th post-operative month via the SF-36 form; it can be seen that body pain parameters of the patients in Group 1 had significantly improved and there is no statistical difference in other parameters. When the effect of hysterectomy on the quality of life of the patients was evaluated by the “Cleveland Clinic Global Quality of Life” form, the statistically significant improvement in the quality of life of the patients in Group 2 was observed.

Conclusion

If the type of operation (vaginal or abdominal) is performed due to benign causes, it does not affect the urinary and anorectal functions of the patients. Depending on the decrease of complaints of the patients, it has a positive effect on the quality of life.

The analysis of scoring systems predicting mortality in geriatric emergency abdominal surgery

BACKGROUND

Accurate measurement of surgical outcomes, proper evaluation of hospitals and surgeons regardless of case can be performed by mortality prediction models. The aim of this study was to analyze factors affecting mortality, present our clinical experience and patient profile and evaluate different scoring systems in use of these patients.

METHODS

A retrospective review of one hundred and twelve geriatric patients who underwent major abdominal emergency surgery between 2004 and 2008 was performed. APACHE II, ODIN, SAPS II expanded, P-POSSUM, Manheim peritonitis and Charlson comorbidity index, Goldman and ASA scores were calculated using patient data. Sensitivity, positive predictive value and Odd's ratio were calculated to predict the mortality for these scoring systems.

RESULTS

The overall mortality rate for our patients was found 33.9%. The factors affecting mortality in this study were found to be the duration of initial complaint, requirement of intensive care unit, requirement of mechanical ventilation and its duration, the presence of coexisting disease and peritonitis.

CONCLUSION

According to our study, in this particular group of patients, APACHE II scoring system is more valid and accurate in estimating the mortality risk when compared to other scoring systems.

[Four Hydatid Cysts in One Family: Is Family Screening Necessary?]

Hydatid cyst is a parasitic infection mostly caused by Echinococcus granulosus. As transmission occurs from infected dogs, it is endemic in animal husbandry regions. Here four patients within the same family are presented. The first patient is a 10 year-old girl admitted with nausea, vomiting, and fever. On her physical examination, there were decreased respiratory sounds in the right lung, rales, and hepatomegaly. In the radiological examination, cysts were seen in both her lung and liver. After the confirmation of the diagnosis with a serological examination, surgical resection was performed, and albendazole treatment was given. On family screening, cysts were detected in the liver and spleen in her asymptomatic 6-year-old brother; in the lung, liver, spleen, and right kidney in her 33-year-old mother who had repeating abdominal pain; and in the liver and left kidney in her 33-year-old asymptomatic father. Hydatid cyst infection was serologically confirmed in all patients, and they were given albendazole and were surgically treated. In this case report, four patients in the same family and diagnosed as having hydatid cysts were presented. It was emphasized that once a hydatid cyst was diagnosed, family screening became important, in endemic regions in particular.

Acute renal artery thrombosis after kidney transplantation

Early kidney transplant loss as a result of acute thrombosis of the renal artery remains a constant and devastating complication, with an incidence of 0.2-7.5%. While uncommon, arterial obstruction in the early postoperative period is a surgical emergency and must be ruled out if previously established diuresis ceases suddenly. Arterial thrombosis may occur as a result of injury to a diseased artery, problems with anastomoses, hypercoagulability or malpositioning of the allograft. In this study, we analyzed data on a group of 105 renal transplant recipients who presented with acute postoperative graft dysfunction between January 2006 and May 2012, to identify cases of acute renal artery thrombosis. We report on our experience of immediate re-transplantation following early kidney transplant thrombosis. Overall, two (1.9%) patients suffered early (within 48 hours of surgery) allograft renal artery thrombosis. In both patients, transplantation had not been complicated by atherosclerotic lesions or other thrombophilic states and postoperative diuresis had been successfully achieved, but diuresis ceased abruptly during the early postoperative period. Emergent duplex ultrasound scans were performed and acute renal artery thrombosis was detected in both patients. The patients were operated immediately and retransplantation procedures were conducted. We have reported our experience of immediate retransplantation following early primary graft dysfunction due to renal artery thrombosis. In conclusion, close monitoring of postoperative diuresis and, if necessary, immediate retransplantation in this situation can prove to be a successful treatment for preventing graft loss.

Initial experience with a new articulating energy device for laparoscopic liver resection

BACKGROUND

Although significant advances have been made in laparoscopic liver resection (LLR), most techniques still rely on multiple energy devices and staplers, which increase operative costs. The aim of this study was to report the initial results of a new multifunctional energy device for hepatic parenchymal transection.

METHODS

Fourteen patients who underwent LLR using this new device were compared to 20 patients who had LLR using current laparoscopic techniques (CL). Data were collected prospectively.

RESULTS

The groups were similar demographics and tumor type and size. Although the type of resection was similar between the groups, the parenchymal transection time was less in the Caiman group (32 ± 5 vs. 63 ± 4 min, respectively, p = 0.0001). The operative time was similar (194 ± 21 vs. 233 ± 16 min, respectively, p = 0.158). There was reduction of the number of advanced instrumentation used in the Caiman group, including the staplers. Estimated blood loss, size of surgical margin, and hospital stay were similar. There was no mortality, and morbidity was 7 % in the Caiman and 20 % in the CL group.

CONCLUSIONS

This initial study shows that the new device is safe and efficient for LLR. Its main advantage is shortening of hepatic parenchymal transection time. This has implications for increasing efficiency and cost saving in LLR.

A new risk stratification algorithm for the management of patients with adrenal incidentalomas

BACKGROUND

Although adrenal incidentalomas (AI) are detected in ≤5% of patients undergoing chest and abdominal computed tomography (CT), their management is challenging. The current guidelines include recommendations from the National Institutes of Health, the American Association of Endocrine Surgeons (AAES), and the American Association for Cancer Education (AACE). The aim of this study was to develop a new risk stratification model and compare its performance against the existing guidelines for managing AI.

METHODS

A risk stratification model was designed by assigning points for adrenal size (1, 2, or 3 points for tumors <4, 4-6, or >6 cm, respectively) and Hounsfield unit (HU) density on noncontrast CT (1, 2, or 3 points for HU <10, 10-20, or >20, respectively). This model was applied retrospectively to 157 patients with AI managed in an endocrine surgery clinic to assign a score to each tumor. The utility of this model versus the AAES/AACE guidelines was assessed.

RESULTS

Of the 157 patients, 54 (34%), had tumors <4 cm with HU <10 (a score of 2). One third of these were hormonally active on biochemical workup and underwent adrenalectomy. The remaining two thirds were nonsecretory lesions and have been followed conservatively with annual testing. In 103 patients (66%), the adrenal mass was >4 cm and/or had indeterminate features on noncontrast CT (HU >10, irregular borders, heterogeneity), and adrenalectomy was performed after hormonal evaluation was completed (10 were hormonally active on biochemical testing). Seven of these patients (7%) had adrenocortical cancer on final pathology with tumor size <4 cm in 0, 4-6 cm in 1, and >6 cm in 5 patients. Of the hormonally inactive patients, 32% had a score of 3, 38% 4, and 30% 5 or 6. The incidence of adrenocortical cancer in these subgroups was 0, 0, and 25%, respectively.

CONCLUSION

This study shows that an algorithm that utilizes the hormonal activity at the first decision step followed by a consolidated risk stratification, based on tumor size and HU density, has a potential to spare a substantial number of patients from unnecessary "diagnostic" surgery for AI.

Factors affecting the surgical approach and timing of bilateral adrenalectomy

BACKGROUND

Laparoscopic adrenalectomy has gained widespread acceptance. However, the optimal surgical approach to laparoscopic bilateral adrenalectomy has not been clearly defined. The aim of this study is to analyze the patient and intraoperative factors affecting the feasibility and outcome of different surgical approaches to define an algorithm for bilateral adrenalectomy.

METHODS

Between 2000 and 2013, all patients who underwent bilateral adrenalectomy at a single institution were selected for retrospective analysis. Patient factors, surgical approach, operative outcomes, and complications were analyzed.

RESULTS

From 2000 to 2013, 28 patients underwent bilateral adrenalectomy. Patient diagnoses included Cushing's disease (n = 19), pheochromocytoma (n = 7), and adrenal metastasis (n = 2). Of these 28 patients, successful laparoscopic adrenalectomy was performed in all but 2 patients. Twenty-three out of the 26 adrenalectomies were completed in a single stage, while three were performed as a staged approach due to deterioration in intraoperative respiratory status in two patients and patient body habitus in one. Of the adrenalectomies completed using the minimally invasive approach, a posterior retroperitoneal (PR) approach was performed in 17 patients and lateral transabdominal (LT) approach in 9 patients. Patients who underwent a LT approach had higher BMI, larger tumor size, and other concomitant intraabdominal pathology. Hospital stay for laparoscopic adrenalectomy was 3.5 days compared to 5 and 12 days for the two open cases. There were no 30-day hospital mortality and 5 patients had minor complications for the entire cohort.

CONCLUSIONS

A minimally invasive operation is feasible in 93% of patients undergoing bilateral adrenalectomy with 65% of adrenalectomies performed using the PR approach. Indications for the LT approach include morbid obesity, tumor size >6 cm, and other concomitant intraabdominal pathology. Single-stage adrenalectomies are feasible in most patients, with prolonged operative time causing respiratory instability being the main indication for a staged approach.

An analysis of whether surgeon-performed neck ultrasound can be used as the main localizing study in primary hyperparathyroidism

BACKGROUND

Tc-99 sestamibi (MIBI) scan is the imaging study most frequently used in primary hyperparathyroidism (PHP). Transcutaneous cervical ultrasonography (US) is the other modality used for preoperative localization. The aim of this study was to determine whether surgeon-performed neck US can be used as the primary localizing study in PHP.

METHODS

This was a prospective study of 1,000 consecutive patients with first-time, sporadic PHP who underwent parathyroidectomy at a tertiary academic center. All patients had surgeon-performed neck US and MIBI before bilateral neck exploration.

RESULTS

The findings at exploration were 72% single adenoma, 15% double adenoma, and 13% hyperplasia. When US suggested single-gland disease (n = 842), MIBI was concordant in 82.5%, discordant and false in 8%, negative in 7%, and discordant but correct in 2.5%. When US suggested multigland disease (n = 68), MIBI was concordant in 47%, discordant and false in 41%, and negative in 12%. When US was negative (n = 90), MIBI was positive and correct in 43%, negative in 31%, and positive but false in 26%. Surgeon-performed neck US identified unrecognized thyroid nodules in 326 patients (33%), which led to fine-needle aspiration biopsy in 161 (49%) patients and thyroid surgery in 103 (32%) patients, with a final diagnosis of thyroid cancer in 24 (7%) patients.

CONCLUSION

Our results show that MIBI provides additional useful information in only a minority of patients with a positive US in PHP. Nevertheless, MIBI benefits about half of patients with a negative US. Because one-third of this patient population has unrecognized thyroid nodules as well, we propose that the most cost-effective algorithm would be to do US first and reserve MIBI for US-negative cases.

Post-kidney transplantation external iliac artery stenosis due to vascular clamp: report of a case

We report a case of right external iliac artery stenosis after kidney transplantation surgery caused by vascular clamp application injury. The patient presented with claudication of the ipsilateral lower limb and the lesion was diagnosed angiographically. The patient was treated with endovascular stent placement.

Clinical scenarios associated with local recurrence after laparoscopic radiofrequency thermal ablation of colorectal liver metastases

BACKGROUND

Over the last decade, radiofrequency thermal ablation (RFA) has been incorporated into the treatment algorithm of patients with unresectable colorectal liver metastases (CLM). For this population, the local recurrence (LR) rate is a key parameter used to assess the success of RFA. LR is defined as development of new tumor abutting and/or in 1 cm of an ablation zone. The aim of this study is to correlate LR with other hepatic or extrahepatic recurrence and patient survival.

METHODS

Between 2000 and 2011, 252 patients with CLM underwent laparoscopic RFA of 883 lesions. These patients were followed under a prospective protocol with quarterly liver computed tomography and blood work, including carcinoembryonic antigen levels quarterly for the first 2 years and then biannually. Clinical scenarios associated with LR were identified and categorized as being "isolated LR," "LR associated with new liver disease," or "LR associated with systemic disease." Demographic, clinical, and survival data were assessed using analysis of variance, Chi-square test, and univariate and multivariate Kaplan-Meier analysis.

RESULTS

One hundred eighteen patients (47%) developed LR after their initial laparoscopic RFA. These were 85 men (72%) and 33 women (28%), with a mean age of 70 ± 8 years. For this cohort, the mean of number of lesions was 3.1 ± 0.2 cm (range, 1-11) and dominant tumor size 2.9 ± 0.1 cm (range, 0.7-6.5) at the time of initial RFA. The LR rate per lesion was 29%. Of the patients who developed treatment failure at the RFA site, this was an isolated LR in 31 (26%) patients, associated with new liver disease in 51 (43%) and systemic metastases in 36 patients (31%). When patients with different clinical scenarios associated with LR were compared, no clinical predictors were identified to differentiate these subgroups. At a median follow up of 30 months (range, 3-113), the Kaplan-Meier median overall survival (OS) for patients with and without LR were 28 vs 31 months, respectively (P = .103). The OS for patients whose LR was isolated, associated with new liver and systemic recurrences was 39, 26, and 22 months, respectively (P = .009).

CONCLUSION

This study shows that, although the presence of LR does not negatively impact on survival, the pattern of recurrent disease does. LR after RFA for CLM is most often associated with new liver and systemic recurrences, reflecting the aggressive biology of cancer in patients channeled to this treatment modality.

A comparison of laparoscopic radiofrequency ablation versus systemic therapy alone in the treatment of breast cancer metastasis to the liver

OBJECTIVES

There is controversy about the roles of locoregional therapies in patients with liver metastases from breast cancer (LMBC). The aim of this study was to analyse survival after laparoscopic radiofrequency ablation (RFA) of LMBC and to compare this with survival in patients receiving systemic therapy (ST) alone.

METHODS

During 1996-2011, 24 patients who had failed to respond or had shown an incomplete response to ST underwent laparoscopic RFA for LMBC. Outcomes in these patients were compared with those in 32 patients with LMBC matched by tumour size and number, but treated with ST alone. Clinical parameters and overall survival were compared using t-tests, chi-squared tests and Kaplan-Meier analysis.

RESULTS

The groups were similar in hormone receptor status and chemotherapy exposure. In the laparoscopic RFA and ST groups, respectively, the mean ± standard deviation size of the dominant liver tumour and the number of tumours per patient were 3.7 ± 0.4 cm and 2.4 ± 0.4 cm, and 2.6 ± 0.4 tumours and 3.3 ± 0.4 tumours, respectively. These differences were not significant. At a median follow-up of 20 months in the laparoscopic RFA group, 42% of patients were found to have developed local liver recurrence, 63% had developed new liver disease and 38% had developed extrahepatic disease. Overall survival after the diagnosis of liver metastasis was 47 months in the laparoscopic RFA group and 9 months in the ST-only group (P = 0.0001). Five-year survival after the diagnosis of liver metastasis was 29% in the RFA group and 0% in the ST-only group.

CONCLUSIONS

This is the first study to compare outcomes in RFA and ST, respectively, in LMBC. The results show that survival after laparoscopic RFA plus ST is better than that after ST alone.

The effect of polypropylene mesh on ilioinguinal nerve in open mesh repair of groin hernia

OBJECTIVES

Repair of groin hernia is one of the most common operations performed by general surgeons, and mesh repair methods have gained wide acceptance. Chronic pain is the most serious long-term complication that can occur after repair of groin hernia. The development of chronic pain after herniorraphy has been attributed to several mechanisms, including damage to sensory nerves and mesh inguinodynia.

MATERIAL AND METHODS

Twenty-four rabbits underwent bilateral inguinal dissection and synthetic polypropylene mesh laid on one side. Bilateral inguinal dissection was performed again after 3 months, and samples of nerve tissue were taken from both sides for histological examination.

RESULTS

Light microscopic examination of the sections of control group peripheral nerves were in normal appearance, but the nerve fascicles in experimental group operated with mesh showed axonal dilation and mild-to-severe loss of myelinated axons. Examination of semi-thin and ultra-thin sections in control group peripheral nerve fascicles showed normal morphology. Ultrastructural nerve morphology in experimental group operated with mesh exhibited endoneurinal edema with thickening of both endoneurium and perineurium, causing separation of nerve fibers. Myelin sheaths of fibers showed an ondulation toward the axoplasm and the endoneurium. Separation of myelin layers from each other as a prominent feature of myelin degeneration in nerve fibers was also observed. Axoplasms exhibited edema and crystallization.

CONCLUSIONS

The light microscopic and ultrastructural changes seen in peripheral nerves in experimental group operated with mesh suggested that mechanical compression of peripheral nerves is associated with myelin degeneration, endoneurinal and perineurial edema, fibrosis, axonal loss, and edema that may cause peripheral neuropathy. Chronic groin pain after hernia repair can be possibly caused by the entrapment of peripheral nerves in the scar tissue formed by the mesh.