Postoperative pancreatic fistula after pancreaticoduodenectomy: if you lack knowledge of what to search for, you will be unable to locate what you desire

OBJECTIVE

Postoperative pancreatic fistula (POPF) is the most common and critical complication of pancreatoduodenectomy (PD). In this study, we aimed to define preoperative, perioperative, and postoperative conditions that may cause POPF and examine the predictive value of drain fluid amylase (DFA) values in showing the clinical severity of POPF.

PATIENTS AND METHODS

Between December 2018 and December 2019, 49 patients who underwent PD for malignant reasons by a single team were retrospectively analyzed. Patients with benign indications, vascular reconstruction, preoperative biliary drainage catheterization, resectable liver metastases, POPF that occurred after reoperation, and patients undergoing neoadjuvant oncological treatment were excluded from the study. The patients were divided into two groups developing (FP) and non-developing (FN) POPF.

RESULTS

There was no difference between the groups in terms of gender (p=0.781), age (p=0.219), American Society of Anesthesiologists (ASA) score (p=0.338), and comorbidity status (p=0.219). The mean body mass index (BMI) kg/m2 values of the patients in the FN and FP groups were 25.2±4.0 kg/m2 and 27.4±2.6 kg/m2, respectively (p=0.042). An increased BMI increases the risk of POPF. Preoperative prognostic nutritional index (PNI) score (p=0.588), preoperative total bilirubin level (p=0.707), pancreatic duct diameter (p=0.334), pancreatic texture (p=0.334), operation time (p=0.659) do not pose a risk for POPF. Increased perioperative bleeding amounted to a risk for POPF (123.8±46.7 ml, 244.7±66.3 ml in FN and FP groups, respectively, p=0.024). Drain fluid amylase (DFA) values (p<0.001, p=0.043, p=0.019, respectively) were found to be high in patients with POPF on postoperative days 1, 4, and 7.

CONCLUSIONS

Increased BMI and excess perioperative blood loss increase the risk of POPF. DFA level is an easily applicable method that provides early diagnosis for POPF.

The diagnostic role of preoperative blood tests in complicated appendicitis: A feasible approach to surgical decision

Background

An accurate diagnosis and timely surgical intervention have significant importance in noncomplicated appendicitis (NCA) and complicated appendicitis (CA). Therefore, any factor that helps in the prediction of CA also contributes to suitable treatment options.

Aim

This retrospective study aimed to identify any relationship between acute appendicitis (AA) and preoperative blood test levels and whether these parameters can differentiate between NCA and CA patients.

Patients and Methods

A database of 201 appendectomies and 100 control healthy patients was analyzed between 2019 and 2022. Patients were divided into three groups: NCA without peritonitis or phlegmonous appendicitis as group 1; CA with perforated, necrotizing appendicitis with peritonitis as group 2; and the healthy control group (CG) as group 3. White blood cell (WBC), platelet distribution width (PDW), mean platelet volume (MPV), red cell distribution width (RDW), creatine kinase (CK), and bilirubin levels were collected from the patients and compared statistically between the groups.

Results

Age, WBC, and PDW levels were set as predictive in the differential diagnosis of CA as a result of receiver operating characteristic (ROC) analysis. The multivariate analysis demonstrated that age (OR: 1.023; 95% CI: 1.000-1.045; P = 0.04), male sex (OR: 3.718; 95% CI: 1.501-9.213; P = 0.005), WBC levels (OR: 1.000; 95% CI: 1.000-1.000; P = 0.002), and PDW levels (OR: 2.129; 95% CI: 1.301-3.484; P = 0.003) were independently associated with CA.

Conclusion

Age, higher WBC count, and PDW levels are valuable in differentiating the diagnosis of CA from NCA, and this could be a feasible approach for surgical decisions.

Do Stoma Formation and Use of Vacuum Assisted Closure System Affect Mortality in Perineal Fournier's Gangrene?

OBJECTIVE

The aim of this study was to identify the effects of creation of stoma and the use of vacuum-assisted closure systems on postoperative mortality and hospital stay in patients with Fournier's gangrene involving anorectal region.

STUDY DESIGN

A retrospective study.

PLACE AND DURATION OF STUDY

Department of General Surgery, University of Health Sciences Tepecik Training and Research Hospital, Izmir, Turkey, from January 2010 to September 2021.

METHODOLOGY

A total of 66 patients with Fournier's gangrene with anorectal involvement were selected from hospital records and divided into two groups as alive and exitus. Differences between these two groups and the factors affecting mortality were analysed with the SPSS statistics software, version 25.0. The value of p<0.05 was considered statistically significant.

RESULTS

The mean age of the patients was 57.9±12.9 years, however, age was higher in exitus group (p=0.013). Debridement count was significantly raised in patients with vacuum assisted closure system (p<0.001). The use of vacuum-assisted closure system was associated with a longer hospital stay (p=0.042). Both stoma creation and the use of vacuum-assisted closure system were not found as risk factors for higher mortality.

CONCLUSION

Stoma creation and the use of vacuum-assisted closure systems have no effect on mortality in patients of Fournier's gangrene with anorectal involvement. Urogenital involvement may be considered as a risk factors for mortality.

KEY WORDS

Fournier's gangrene, Vacuum-assisted closure system, Stoma, Anorectal region, Perineum, Mortality.

Evaluation of SARS-CoV-2 RT-PCR test results from a pandemic hospital according to demographic data

Objectives

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) leading to coronavirus disease 2019 (COVID-19) in China at the end of 2019 has resulted in a global pandemic. On 11 March 2020, the first case of COVID-19 was reported in Turkey. The aim of this study was to evaluate SARS-CoV-2 Real-Time Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) test results from the Medical Microbiology Laboratory of a pandemic hospital according to demographic data.

Study design

Retrospective cohort study.

Methods

SARS-CoV-2 RT-PCR test results of 413,013 samples from 194,062 patients were retrospectively analysed. Tests were carried out between 27 March and 31 December 2020 using two commercial kits. The patient's age and gender were recorded, in addition to the percentage of positive test results per month (i.e. monthly positivity). Pearson’s Chi-squared test was used to analyse statistical significance.

Results

Overall SARS-CoV-2 positivity in the pandemic hospital was 19.9%. Female gender and younger age (0–18 years) had a statistically significant higher positivity (P < 0.05). There was a statistically significant higher positivity in August and September.

Conclusions

Higher positivity among the younger population and females may be the leading cause of low COVID-19 mortality rates in Turkey as these population groups are less likely to die from the disease. Governments should disaggregate COVID-19 data by age and gender, and vaccine studies focussing on younger populations should be accelerated because this population group represents an important source of infection.

Effects of Membrane Adhesion Barriers on Wound Healing Reaction after Glaucoma Filtration Surgery: A Comparative Study with Interceed and Seprafilm

Purpose

To evaluate and compare the effectiveness of two adhesion barriers, Interceed and Seprafilm, on wound healing reaction after glaucoma filtration surgery.

Materials and Methods

Full-thickness filtration surgery was carried out on three groups, each containing four rabbits. Interceed and Seprafilm prepared in 3×4 mm dimensions was put on and around scleral opening in Groups 1 and 2, respectively. All groups received tobramycin and dexamethasone drops tid for 14 days. Intraocular pressure (IOP), anterior chamber depth, and bleb appearance were checked on the first, third, seventh, and 14th days. The rabbits were killed on the 14th day and the trabeculectomy area with overlying conjunctiva was excised. The samples were fixed with 10% formalin, buried in paraffin, and stained with hematoxylin and eosin. The surgical site and surrounding subconjunctival area were evaluated histopathologically for cell counts (fibroblast, lymphocyte, eosinophil, and macrophage), presence of edema and foreign body reaction, and potency of the fistula tract.

Results

Mean IOP at the first and third day examinations was significantly different between groups, but there was no statistically significant difference among the groups with respect to IOP, anterior chamber depth, or bleb appearance at the seventh and 14th days. The groups were similar with respect to number of fibroblasts, eosinophils, and neutrophils. Number of macrophages was significantly increased in Groups 1 and 2 and number of vessels was significantly decreased in Group 1.

Conclusions

Neither of these two adhesion-preventing substances seems to suppress wound healing reaction after glaucoma filtration surgery. However, a diminished wound healing reaction was expected with a decreased number of vessels, such as in Group 1. Increased number of macrophages in both groups may result in a decreased level of some inflammatory mediators.

Gastric duplication cyst in adult: Challenge for surgeons

Gastric duplication cysts (GDCs) are uncommon developmental anomalies found primarily in children, being rarely seen in adults. Duplications can occur anywhere in the intestinal tract from the mouth to the anus. Accurate diagnosis of cysts before resection is difficult even using the most advanced imaging techniques. In this report, we present and discuss a case of GDC in a 25-year-old man treated laparoscopically. Patient admitted to our department with complaints of epigastric pain and swelling. Magnetic resonance imaging performed for accurate characterisation showed a 4 cm × 4.5 cm cystic lesion, with heterogeneous signal intensity on T2-weighted images, located in the posterior wall of the stomach. Pre-operative differential diagnosis including gastrointestinal stromal tumour (GIST) was made according to radiological findings. Patient underwent surgery and cyst resected laparoscopically. Histopathological examination suggesting duplication cyst. GDC can easily be mistaken for a GIST, and the clinician as well as radiologist must maintain a high degree of suspicion.

Toscana virus (TOSV) exposure is confirmed in blood donors from Central, North and South/Southeast Anatolia, Turkey

Toscana virus (TOSV), a sandfly fever virus serotype of medical and public health importance, is a major pathogen involved in aseptic meningtis occurring in Mediterranean countries and poses a threat to the residents as well as travellers. Limited data on TOSV activity are present from Turkey despite being located in the endemic zone. We aimed to identify TOSV exposure in 1115 healthy blood donors at the Hacettepe University Hospital Blood Bank in Ankara, Turkey, using commercial indirect fluorescence assays (IFAs) and virus neutralization test (VNT) for antibody detection and specificity confirmation. A total of 199 samples (17.8%) were positive for anti-TOSV that include IgG reactivity in 10.4%, IgM reactivity in 8.2% and IgM + IgG reactivity in 0.7% of the sera. Anti-TOSV specificity could be confirmed via VNT in 56% of the IgG- and 43.6% of the IgM-positive sera, making up a total of 58 samples (5.2%). Risk factors associated with TOSV IgG reactivity were male gender, residing in rural areas, frequent sighting of mosquitoes/sandflies and working outdoors. TOSV-specific antibody prevalence increased significantly with age. Evidence of exposure to other sandfly fever viruses was noted. These data reveal that mild or asymptomatic infections with TOSV are frequent in central and northern Anatolia. TOSV exposure has also been identified in residents of 9 provinces in southern/southeastern Anatolia for the first time.

Melatonin and nitric oxide

Melatonin is a product of the amino acid tryptophan in the pineal gland. Once synthesized, the specific mechanisms governing the release of melatonin from the pineal gland and its functions are largely unknown. Besides its regulatory role in circadian rhythms in mammals, because of its widespread subcellular distribution, melatonin contributes to the reduction of oxidative damage in both the lipid and the aqueous environments of the cell. This postulate is widely supported by the experimental observations showing that melatonin protects lipids in membranes, proteins in the cytosol, and DNA in the nucleus and mitochondria from free radical damage. Melatonin thus reduces the severity of disease conditions where free radicals are implicated. The direct free radical scavenging effects of melatonin are receptor independent. It has recently been shown that it has an ability to scavenge free radicals, including hydroxyl radicals, hydrogen peroxide, peroxyl radicals, singlet oxygen and nitric oxide (NO) and peroxynitrite anion. An excessive amount of NO, a free radical which is generated by the inducible form of NO synthase, is known to cause cytotoxic changes in cells. Hence, NO synthase is considered a pro-oxidative enzyme, and any factor that reduces its activity would be considered an antioxidant. Recent studies have shown that melatonin inhibits the activity of NO synthase, beside its NO and peroxynitrite scavenging activity. Thus, inhibition of NO production may be another means whereby melatonin reduces oxidative damage under conditions, such as ischemia-reperfusion, sepsis, etc, where NO seems to be important in terms of the resulting damage.

Zinc-induced alterations in contractile properties of rat diaphragm muscle in vitro

The effect of zinc ions on the isometric contraction of rat diaphragm muscles in the presence and in the absence of external calcium was studied. Using a transducer, the isometric force was measured as a function of supramaximal electrical stimulation, either directly or indirectly applied to the muscle. The following parameters were measured: peak twitch tension, PT, twitch contraction time, CT, relaxation half-time, RT-1/2, and peak rates of tension increase and decrease, +dP/dt and -dP/dt. The following zinc-induced alterations were observed: an increase of the PT; a decrease of the RT-1/2; an increase in the +dP/dt and -dP/dt. The CT was not changed significantly. Our results suggest that zinc ions have a positive inotropic effect on isolated diaphragm muscle. The increase in PT may be explained by a zinc-activated Ca2+ uptake by sarcoplasmic reticulum. This was followed by an increase in the rate of rise of tension development, which was secondary to increased -dP/dt. The mechanism(s) by which extracellular Ca2+ contributes to this action of zinc is not known.

Effects of honey containing grayanotoxin I on frog gastrocnemius muscle

The presence of grayanotoxins (GTX-I, GTX-II and GTX-III) in honey samples from the Mediterranean Sea and Black Sea regions of Turkey and the effect of honey containing GTX-I on the threshold stimulus voltage of frog gastrocnemius muscle were studied. We used 2 groups of gastrocnemius muscles isolated from curarized or noncurarized frogs. The threshold voltage was measured by external perfusion with a polygraphic system. Isolated muscle preparations were perfused separately with Clark-frog-Ringer's solution containing honey solutions from the Mediterranean Sea region (normal) or with honey solutions from the Black Sea region (GTX-I-containing, poisonous). There was no significant difference between the normal and poisonous honey groups data with the curarized preparations. But in the noncurarized preparations, the honey containing GTX-I significantly decreased the threshold voltage in comparison with normal honey. These findings suggest the effect of GTX-I on frog neuromuscular junctions is due to an increase in membrane permeability to sodium ions.