Should we consider Systemic Inflammatory Response Index (SIRI) as a new diagnostic marker for rectal cancer?

PURPOSE

The Systemic Inflammatory Response Index (SIRI), which depends on peripheral neutrophil, monocyte, and lymphocyte count, was found to be an effective prognostic indicator for various malignancies. In this study, we aimed to investigate the diagnostic value and the prognostic impact of SIRI on rectal cancer patients.

METHOD

The medical records of patients underwent sphincter-sparing rectal cancer surgery at general surgery between 2017 and 2022 were examined retrospectively. Patient demographics, operation types, neoadjuvant chemo/radiotherapies, pathological results, and complications were recorded. A total number of 99 patients who operated with diagnoses other than cancer were conducted as a control group. SIRI was calculated from preoperative peripheral blood samples' neutrophil, lymphocyte, and monocyte count. The optimal cut-off value for SIRI was found to be 1.38. The clinicopathological outcomes and Overall Survival (OS) were analyzed under two groups according to the SIRI values lower or higher than 1.38.

RESULTS

The number of eligible patients was 104. The median age of the entire cohort was 62 (31-89). The median follow-up time was 33 (1-62) months. The median SIRI value in the study group was significantly higher compared with the control group. The study group was examined under two groups: SIRI 1.38 and SIRI > 1.38. The male gender was significantly more frequent in the high SIRI group. The remaining patient demographics and operation types were similar between the groups. The pathological outcomes were similar between the two groups. Overall Survival rate was better in the low SIRI group than those higher. The higher group had significantly higher complication rates than the lower SIRI group (p: 0.004).

CONCLUSION

SIRI may be a valuable diagnostic marker in rectal cancer patients. Higher SIRI levels were also associated with poorer prognosis and increased complication rates. Still, further prospective studies with a larger number of patients are needed.

Melatonin in preservation solutions prevents ischemic injury in rat kidneys

Transplantation is lifesaving and the most effective treatment for end-stage organ failure. The transplantation success depends on the functional preservation of organs prior to transplantation. Currently, the University of Wisconsin (UW) and histidine-tryptophan-ketoglutarate (HTK) are the most commonly used preservation solutions. Despite intensive efforts, the functional preservation of solid organs prior to transplantation is limited to hours. In this study, we modified the UW solution containing components from both the UW and HTK solutions and analyzed their tissue-protective effect against ischemic injury. The composition of the UW solution was changed by reducing hydroxyethyl starch concentration and adding Histidine/Histidine-HCl which is the main component of HTK solution. Additionally, the preservation solutions were supplemented with melatonin and glucosamine. The protective effects of the preservation solutions were assessed by biochemical and microscopical analysis at 2, 10, 24, and 72 h after preserving the rat kidneys with static cold storage. Lactate dehydrogenase (LDH) activity in preservation solutions was measured at 2, 10, 24, and 72. It was not detectable at 2 h of preservation in all groups and 10 h of preservation in modified UW+melatonin (mUW-m) and modified UW+glucosamine (mUW-g) groups. At the 72nd hour, the lowest LDH activity (0.91 IU/g (0.63–1.17)) was measured in the mUW-m group. In comparison to the UW group, histopathological damage score was low in modified UW (mUW), mUW-m, and mUW-g groups at 10, 24, and 72 hours. The mUW-m solution at low temperature was an effective and suitable solution to protect renal tissue for up to 72 h.

The role of rectal redundancy in the pathophysiology of rectal prolapse: a pilot study

Purpose

Rectal prolapse is hypothesized to be caused due to weakness of the pelvic floor which is related to childbearing. However, half of the female patients with rectal prolapse were reported to be nulliparous and this hypothesis doesn't explain the prolapse in males. The aim of this study is to evaluate the role of rectal redundancy in rectal prolapse pathophysiology.

Methods

This study was conducted prospectively. Fourteen patients who underwent rectopexy were included in the study group. A total of 17 patients who underwent laparotomy for another reason and who have no symptoms regarding rectal prolapse were included in the control group. In order to measure the redundancy of the rectum, we have calculated the ratio of length of intraperitoneal rectum (R) to length of distance between promontorium and peritoneal reflection (PRx). The primary outcome of this study was to evaluate whether the R/PRx ratio is higher in patients with rectal prolapse compared to the control group.

Results

Comparing the anatomic features showed that the length of sigmoid colon and length of PRx were not significantly different between the two groups. However, the length of intraperitoneal rectum was significantly higher in the prolapse group. Furthermore, the median R/PRx ratio in the prolapse group was significantly higher than in the control group.

Conclusion

This study showed that intraperitoneal rectum in patients with rectal prolapse is significantly more redundant than in the normal population. This could be considered reasonable evidence for the role of rectal redundancy on rectal prolapse pathophysiology.

Low anterior resection syndrome (LARS) after sphincter-sparing rectal cancer surgery. Incidence and risk factors

BACKGROUNDS

Low anterior resection syndrome (LARS) was defined with symptoms such as frequency, incontinence, urgency, and constipation in patients who underwent Sphincter-Sparing Rectum Surgery (SSRC). In this study, LARS rates and risk factors of the patients who underwent SSRC were Investigated.

MATERIAL METHOD

The medical records of patients with SSRC at general surgery department were examined retrospectively. Clinical characteristics, neo/adjuvant chemo-radiotherapies, distal resection levels, open/laparoscopic procedures, postoperative complications, and pathological outcomes were recorded. LARS scoring system defined by Emmertsen and Laurberg was used to calculate LARS scores.

RESULTS

The number of eligible patients was 129. The rectal resection was performed by either low anterior resection (LAR) or very low anterior resection (VLAR). VLAR was used to specify that had anastomosis <5cm to the anal verge. The median follow-up time was 12 (1-30) months. LARS were detected in 60 (%47) patients. LARS rates were significantly higher in the patients underwent VLAR (n: 35 9% vs. 48%<0,001). In univariate analysis, the level of distal resection, open surgeries, neoadjuvant RT, and diversion with temporary stoma were significantly different in LARS group. However, in multivariate analysis, distal resection level was the only significant risk factor for LARS.

CONCLUSION

Low anterior resection syndrome (LARS) was frequently seen in patients who underwent sphincter-sparing rectum surgery (SSRS). It was detected that distal resection levels were the most important risk factor for the development of LARS. This result showed that LARS should not be disregarded in patients underwent SSRS.

KEY WORDS

Bowel Disfunction, Cancer, Incontinence, LARS, Rectum.

Recurrent Perianal Abscess in a Patient With Hermansky-Pudlak Syndrome Associated Granulomatous Colitis: A Case Report

Hermansky-Pudlak syndrome (HPS) is a rare genetic disease consisting of the triad of oculocutaneous albinism, bleeding diathesis, and pigmented reticuloendothelial cells. In HPS patients' granulomatous colitis could be an additional feature and perianal abscess could be seen in such patients. We report a patient with HPS-associated granulomatous colitis, refractory to medical treatment, and perianal involvement. Patients with HPS-associated granulomatous colitis and perianal involvement may require multiple surgical interventions and there is no consensus yet for treatment in such patients.

Gastric medullary carcinoma: clinicopathological features and prognosis-a single-center study

BACKGROUND

Gastric medullary carcinoma (GMC) is a distinct histologic subtype of gastric adenocarcinoma, which prominently associated with Epstein-Barr virus infection. This study aimed to evaluate the clinicopathological features and prognosis of patients with medullary carcinoma in one center.

METHODS

Data regarding patients with gastric cancer were retrospectively analyzed at Marmara University between 2014 and 2019. Demographics, pathological features, and overall survival of patients with GMC were evaluated. The primary outcome of this study was to compare the pathological features of GMC to non-GMC (NGMC). The secondary outcome was comparing overall survival between the two groups.

RESULTS

A total of 412 patients were enrolled in the study. Of 412 patients, 19 (5%) were diagnosed with medullary cancer. Compared to NGMC, no significant differences were observed in patient age, gender, tumor macroscopic pattern, size, lymphovascular invasion, pathological stage, location and size of the tumors, and the number of metastatic lymph nodes in GMC. However, perineural invasion and Borrmann ulcerated type rates were significantly higher among NGMC. Whereas the microsatellite instability (MSI) rate was significantly higher in the GMC (64% and 11%, respectively, p < 0.001). Multivariate analysis showed that the MSI status was the solely significantly different feature between the two groups.

CONCLUSION

This study showed that GMC was associated with MSI, which could explain the better prognosis of medullary carcinomas.

An experimental study on the pathophysiology of rectal prolapse

Objective: For decades, rectal prolapse has been hypothesized to be caused due to laxity or weakness of the pelvic floor muscles which is often sup- posed to be related to childbearing in females. However, 50% of females with rectal prolapse have been reported to be nulliparous and this hypothesis does not explain the incidence of rectal prolapse in males. The aim of this study was to evaluate the role of rectal redundancy in rectal prolapse patho- physiology.

Material and Methods: Nineteen female Sprague Dawley rats (250-300 g) at 16 weeks of age were obtained from the animal center. Rats were divided into two groups as rectal mobilization (study) group (n= 9) and sham-operated control (n= 10) group. In the study group, soft dissection was applied and rectum were mobilized up from the pelvic floor to create a redundant or hypermobilized rectum.The primary outcome was the rate of rectal pro- lapse after rectal mobilization.

Results: As compared to the sham-operated control group, in which none of the rats had rectal prolapse throughout the post-surgical period, rectal prolapse was observed in four of the rats in the rectal mobilization group (0% vs. 44%; p= 0.006). Being unable to increase the length of the rectums of the rats, but using only mobilization to create the redundancy, and the lack of data regarding any adhesions after surgery are the main limitations of this study.

Conclusion: This study showed the role of rectal redundancy on the rectal prolapse pathophysiology.

Prevention of biliary fistula after partial hepatectomy by transcystic biliary drainage: randomized clinical trial

I read the article ‘Prevention of biliary fistula after partial hepatectomy by transcystic biliary drainage: randomized clinical trial’ by C. Maulat et al. (1) with great interest.

I wanted to draw attention to certain details. The authors supposed that the use of transcystic drainage during hepatectomy to prevent postoperative biliary fistula is not recommended. However I think that this conclusion has some pitfalls which should be unadertaken to consideration.

Chemical Ablation for Treating Anal Fistulas without Surgical Intervention: Long-Term Results

Purposes. This study aimed to evaluate long-term outcomes after the application of a corrosive chemical agent for ablation of epithelial tissue as a non-surgical treatment of anal fistulas. Methods. Adult patients with symptomatic perianal fistula were prospectively included in the study. The fistula tract was irrigated with a 5% silver nitrate solution. The primary outcome measured in this study was the rate of clinical healing after long-term follow-up. Factors that may affect healing were also analysed. Results. A total of 186 patients with anal fistula were analysed. After irrigation with silver nitrate, 82 (44%) patients had complete clinical healing during a median follow-up time of 50 (7-64) months. Patients with intermittent discharge had a significantly higher rate of complete clinical healing than those with continuous discharge (P < .04). Fistulas without abscesses or secondary tracts had a significantly higher rate of complete clinical healing than the other types (P = .007). Conclusion. Chemical ablation of the epithelium of the anal fistula yields promising long-term outcomes in the management of anal fistulas without surgical intervention.

Could cholecystectomy be abandoned after removal of bile duct stones by endoscopic retrograde cholangio-pancreaticography?

BACKGROUND/OBJECTIVE

The current treatment for choledocholithiasis is endoscopic common bile duct clearance followed by cholecystectomy. However, few studies have investigated whether cholecystectomy is necessary after the endoscopic removal of bile duct stones. This study aimed to determine the rate of patients without symptoms during the follow-up period after endoscopic retrograde cholangiopancreaticography (ERCP).

MATERIALS AND METHODS

We retrospectively analyzed data from patients with choledocholithiasis who underwent ERCP from a single centre.The patients were invited to the hospital for evaluation of symptoms during the follow-up period after ERCP. The primary outcome of this study was to determine the rate of patients with symptoms during the follow-up period after ERCP.

RESULTS

A total of 286 patients with a median age of 57 (18-95) years old were included in the study. Of these, 195patients (68%) remained asymptomatic during the follow-up period of 18 months (1-70) after endoscopic sphincterotomy without cholecystectomy. A total of 75(50%) out of 151 patients who underwent cholecystectomy reported having symptoms after ERCP. In contrast, 119 (88%) out of 135 patients did not undergo cholecystectomy after the ERCP, remained asymptomatic during a median follow-up period of 43 months (11-70). The estimated 5-year asymptomatic rates of the patients after ERCP were 51% for the whole cohort (n = 286) according to Kaplan-Meier analysis.

CONCLUSION

Majority of patients with choledocholithiasis who did not undergo cholecystectomy after ERCP were asymptomatic during the follow-up period. Thus, cholecystectomy may be unnecessary after endoscopic sphincterotomy for bile duct stones within a midterm period.

A new technique of completely diverted tube ileostomy for the protection of colorectal anastomosis: a pilot study

AIM

This study was designed to evaluate a new technique for a completely diverting tube ileostomy achieved through temporary occlusion of the distal ileum using a flexible rubber strip.

METHODS

This prospective interventional study was conducted in one centre. Patients who underwent colorectal resections with a primary anastomosis and who were deemed as requiring a defunctioning stoma were included in the study. After completion of resection and anastomosis, the tube ileostomy was fashioned by inserting a reinforced (spiral) endotracheal tube with an inner diameter of 7.5 mm into the ileum. To provide complete faecal diversion, temporary occlusion of the distal ileum was performed using a flexible rubber strip. The primary outcome of this study was the incidence of complete diversion achieved using this method.

RESULTS

Fifty consecutive patients underwent a diverted tube ileostomy using the technique described above. Defaecation before removal of the strip did not occur in any of the patients inferring that complete diversion was observed in all patients (100%). The tube was removed at postoperative week 3. After tube removal, the resulting enterocutaneous fistulas closed spontaneously in a median of 6 (2-30) days.

CONCLUSION

The diverting tube ileostomy technique using an easily removable rubber strip to defunction the colorectal anastomosis is a safe and effective method that precludes the need to fashion a stoma.

Does hyperthermic preconditioning affect the rate of surgical site infection rate and inflammatory reaction in colorectal cancer patients? A prospective randomized clinical trial

OBJECTIVE

Hyperthermic preconditioning has been shown to protect against different insults in experimental studies. However, clinical studies assessing its effects remain limited. The aim of this study was to investigate the effects of hyperthermic preconditioning on the rate of surgical site infection and inflammatory reaction in patients undergoing elective colorectal cancer surgery.

MATERIAL AND METHODS

Patients with colorectal cancer, scheduled to undergo elective surgery were enrolled in this prospective randomized study. Patients were randomly assigned to either the hyperthermic preconditioning group or control group. Postoperative superficial and deep surgical site infection were recorded. Blood samples were collected from all the patients in the hyperthermic preconditioning group prior to the application of hyperthermia 12 h before surgery, immediately prior to surgery, and 4 h and 24 h postoperatively. For the control group, blood samples were obtained within the same periods without the application of hyperthermia. Levels of interleukin-1, IL-6, and tumor necrosis factor-α were measured from blood samples.

RESULTS

Twenty patients were randomized to the hyperthermic preconditioning group and 21 to the control group. No significant difference was found in deep or superficial surgical site infection between the groups. No significant difference in the tumor necrosis factor-α, interleukin-1, and IL-6 levels was found in serum samples collected before hyperthermia, during the operation, and postoperatively.

CONCLUSION

This study showed that hyperthermic preconditioning has no effect on the surgical site infection and cytokine response in patients undergoing elective surgical intervention for colorectal cancer.

Prospective study of sexual dysfunction after proctectomy for rectal cancer

BACKGROUND

Although rectal cancer is a common malignancy and has an improved cure rate in response to oncological treatment, research on rectal-cancer survivors' sexual function remains limited.

OBJECTIVE

The aim of this prospective study is to assess sexual dysfunction after rectal cancer surgery.

PATIENTS AND METHODS

Patients undergoing curative rectal cancer surgery were included in the study. Sexual function before and 6 months after the operation was measured using the validated questionnaires. Primary outcome was to determine the rates of Sexual dysfunction after rectal cancer surgery. Furthermore, the factors which can have an impact on sexual function after radical treatment have been assessed.

RESULTS

A total of 187 patients [117 (63%) men and 70 (37%) women] with rectal cancer who underwent radical resection were included in the study. Sexual function has significantly decreased after surgery. Among male patients, sexual dysfunction increased from the baseline 4% (n = 5) up to 41% (n = 48) after the operation. Among female patients, sexual dysfunction increased from the baseline 53% (n = 37) up to 77% (n = 54) after the operation. A significant lower rate of laparoscopic surgery has been found in both males and females who reported sexual dysfunction after surgery. The patients who have locally advanced disease and those who received postoperative chemotherapy or radiotherapy have higher rates of sexual dysfunction.

CONCLUSION

This study, showed that sexual dysfunction is common in patients with rectal cancer after radical treatment. However, patients who underwent laparoscopic surgery have lower rates of sexual dysfunction than those who underwent open surgery.

Simultaneous resection for colorectal cancer with synchronous liver metastases is a safe procedure: Outcomes at a single center in Turkey

The optimal surgical strategy for treating colorectal cancer with synchronous liver metastases is subject to debate. The current study sought to evaluate the outcomes of simultaneous colorectal cancer and liver metastases resection in a single center. Prospectively collected data on all patients with synchronous colorectal liver metastases who underwent simultaneous resection with curative intent were analyzed retrospectively. Patient outcomes were compared depending on the primary tumor location and type of liver resection (major or minor). Between January 2005 and August 2016, 108 patients underwent simultaneous resection of primary colorectal cancer and liver metastases. The tumor was localized to the right side of the colon in 24 patients (22%), to the left side in 40 (37%), and to the rectum in 44 (41%). Perioperative mortality occurred in 3 patients (3%). Postoperative complications were noted in 32 patients (30%), and most of these complications (75%) were grade 1 to 3 according to the Clavien-Dindo classification. Neither perioperative mortality nor the rate of postoperative complications after simultaneous resection differed among patients with cancer of the right side of the colon, those with cancer of the left side of the colon, and those with rectal cancer (4%, 2.5%, and 2%, respectively, p = 0.89) and (17%, 33%, and 34%, respectively; p = 0.29)]. The 5-year overall survival of the entire sample was 54% and the 3-year overall survival was 67 %. In conclusion, simultaneous resection for primary colorectal cancer and liver metastases is a safe procedure and can be performed without excess morbidity in carefully selected patients regardless of the location of the primary tumor and type of hepatectomy.

Neutrophil-lymphocyte ratio and mean platelet volume can be a predictor for severity of acute appendicitis

BACKGROUND

Early diagnosis of perforation in acute appendicitis (AA) allows surgeons to select the most appropriate treatment. The aim of the present study was to determine whether preoperative neutrophil-lymphocyte ratio (NLR) and mean platelet volume (MPV) could predict perforation in AA.

METHODS

Data collected from 413 consecutive patients with AA and 100 healthy controls were analyzed retrospectively. Patients were categorized as having had phlegmonous appendicitis, appendicitis with localized peritonitis, or appendicitis with perforation and/or gangrene. MPV and NLR values were compared among the control group and the 3 groups of patients with AA.

RESULTS

Means values of MPV were 9.3±8 fL for the patient group and 8.5±0.9 fL for the healthy control group (p=0.0005). Mean values of MPV by patient subgroup were 8.8±5.8 for phlegmonous appendicitis, 8.9±5.8 for localized peritonitis, and 12.8±9.7 for appendicitis with perforation and/or gangrene (p=0.005). Cut-off value of MPV was set at 8.92 to differentiate AA with perforation and/or gangrene from other types of AA. Mean NLRs of patients with phlegmonous appendicitis, appendicitis with localized peritonitis, and appendicitis with perforation and/or gangrene were 8.3±5.6, 9.1±6.2, and 10.6±6.4, respectively; p=0.023. The cut-off value for NLR was set at 7.95 to differentiate AA with perforation and/or gangrene from other types of AA.

CONCLUSION

Both NLR and MPV can be useful in predicting severity of AA.

Laparoscopic resection for colorectal diseases: short-term outcomes of a single center

OBJECTIVE

Even though, laparoscopy is not accepted as the current gold standard in colorectal surgery, it can be performed as safely as open surgery. It is also widely accepted that the technique has many advantages. In this study, we evaluated the results of 33 patients with laparoscopic colorectal resection.

MATERIAL AND METHODS

Thirty-three patients who underwent laparoscopic colon surgery between January 2013 and September 2014 in the General Surgery Clinic at Marmara University Hospital were included in the study. Patients were evaluated in terms of their demographic and tumor histopathologic characteristics, type of surgery and early postoperative complications.

RESULTS

Laparoscopic colorectal resection was performed for 33 patients who had malignant or benign lesions. The median age was 60 (35-70), and 18 (55%) were male patients. The majority of the patients (90%) were diagnosed with colorectal adenocarcinoma. Half of the patients were T3 and 67% had N0 stage. The median number of retrieved lymph nodes was 17 (4-28). Negative surgical margins were obtained in all patients. The postoperative hospital stay was 5 (4-16) days. Postoperative early complications were observed in only 5 patients. The majority of complications were treated without the need for surgery. No mortality was recorded in this series of patients.

CONCLUSION

This study showed that laparoscopic colorectal surgery could be performed safely based on its low complication rate, short length of hospital stay, providing sufficient surgical resection and lymph node dissection.

A Simple Method to Evaluate Whether Pancreas Texture Can Be Used to Predict Pancreatic Fistula Risk After Pancreatoduodenectomy

INTRODUCTION

Soft pancreas is one of the most important risk factor for postoperative pancreatic fistula after pancreatoduodenectomy. The aim of this study is to investigate whether pancreatic attenuation index utilized to assess the pancreatic texture with computed tomography can be used to predict the risk of developing a clinically relevant postoperative pancreatic fistula after pancreatoduodenectomy.

METHODS

We reviewed 76 consecutive patients undergoing pancreatoduodenectomy between 2012 and 2014. The pancreatic attenuation index is found by dividing the pancreas density by the spleen density achieved with non-enhanced computed tomography. The independent predictors of clinically relevant postoperative pancreatic fistula were investigated.

RESULTS

Clinically relevant postoperative pancreatic fistula occurred in 13 patients (17.1%). The group of patients with postoperative pancreatic fistula is compared with the group of patients without postoperative pancreatic fistula in terms of age, gender, body mass index, the American Society of Anesthesiologists (ASA) score, smoking, alcohol consumption, medical comorbidities, preoperative biliary drainage, type of anastomosis, and pancreatic duct size and pancreatic attenuation index. Univariate analyses have shown a significant difference in relation to chronic obstructive pulmonary disease and pancreatic attenuation index. The multivariate analyses showed that only pancreatic attenuation index was associated with a high postoperative pancreatic fistula rate (P = 0.012).

CONCLUSION

A preoperative non-contrast computed tomography scan evaluating pancreatic attenuation index could help to predict the occurrence of clinically significant postoperative pancreatic fistula after pancreatoduodenectomy.

HER-2 incidence in gastric cancer, its association with prognosis and clinicopathological parameters

OBJECTIVE

Human epidermal growth factor-2 (HER-2) overexpression has prognostic value in breast cancer. However, the significance of HER-2 positivity in gastric cancer is controversial. In this study, we investigated the frequency of overexpression of HER-2 and its relationship with clinicopathological findings and impact on survival in gastric cancer.

MATERIAL AND METHODS

Gastric cancer patients, operated in Marmara University Faculty of Medicine, Pendik Training and Research Hospital, General Surgery Department, between January 2012-December 2013 were enrolled in this study. Medical records were retrospectively evaluated. Tissue samples were stained by immunohistochemistry (IHC) method, and were followed by fluorescence in situ hybridization (FISH) in those with positive results. HER-2 expression rates and its association with other histopathological features and survival have been analyzed.

RESULTS

135 patients were enrolled in the study, with 88 (65%) male and 47 (35%) female patients. The median age was 61 (29-84) years. Only 11 patients (8%) were positive for HER-2. HER-2 positive patients were similar to negative patients in terms of age, gender, tumor size, tumor location, tumor T stage, lymph node metastasis, histological type, differentiation, lymphovascular invasion, perinodal, perineural invasion and stage. No significant difference was detected on 1 and 2-year overall and disease-free survival rates between receptor positive and negative groups.

CONCLUSION

Consistent with the literature data, HER-2 positivity rate in this study was approximately 8%, but this positivity has not been found to be associated with either clinical and pathological parameters or overall and disease-free survival.

Radiofrequency ablation of benign symptomatic thyroid nodules: prospective safety and efficacy study

BACKGROUND

Radiofrequency ablation (RFA) is a relatively novel procedure in the management of benign nodular goiter. This study was conducted to evaluate the safety and efficacy of ultrasound (US)-guided percutaneous RFA for benign symptomatic thyroid nodules as an alternative to surgery.

METHODS

The study involved patients for whom a fine needle aspiration biopsy had proved a diagnosis of benign nodular goiter and had nodule-related symptoms such as dysphagia, cosmetic problems, sensation of foreign body in the neck, hyperthyroidism due to autonomous nodules or fear of malignancy. Percutaneous RFA was performed as an outpatient procedure under local anesthesia. The primary outcome was an evaluation of the changes in symptom scores (0-10) for pain, dysphagia and foreign body sensation at the 1st, 3rd, and 6th months after the RFA procedure. Secondary outcomes were assessing volume changes in nodules, complication rates, and changes in thyroid function status.

RESULTS

A total of 33 patients (24% female, 76% male) and a total of 65 nodules were included into the study. More than one nodule was treated in 63.6% of the patients. We found a statistically significant improvement from baseline to values at the 1st, 3rd, and 6th months, respectively, as follows: pain scores (2.9 ± 2.7, 2.3 ± 2.01, 1.8 ± 1.7, and 1.5 ± 1.2, p 0.005), dysphagia scores (3.9 ± 2.7, 2.6 ± 1.9; 1.7 ± 1.6, and 1.1 ± 0.3, p 0.032), and foreign body sensation scores 3.6 ± 3, 2.5 ± 2.2; 1.6 ± 1.5, and 1.1 ± 0.4, p 0.002).The mean pre-treatment nodule volume was 7.3 ± 8.3 mL. There was a statistically significant size reduction in the nodules at the 1st, 3rd, and 6th months after RFA (3.5 ± 3.8, 2.7 ± 3.4, and 1.2 ± 1.7 mL, p 0.002). The volume reduction was found to be 74% at 6th months following the RFA (p 0.005). 8 patients had autonomously functioning nodules in the pre-treatment period, 50% (n: 4) became euthyroid at the 6th month after RFA. There were no complaints other than pain (12%).

CONCLUSION

RFA can be an alternative treatment modality in the management of benign symptomatic thyroid nodules. The results showed that it is a safe and effective procedure.

Spontaneous rupture of extraluminal jejunal gastrointestinal stromal tumor causing acute abdomen and hemoperitoneum

Tumor perforation is accepted as an important prognostic factor along with tumor size and mitotic index in gastrointestinal stromal tumors (GIST). The prognosis is worse in patients with tumor perforation or rupture. A few case reports of small bowel GIST presenting with rupture have been published in the medical literature. We report an unusual case of a 7.5 cm GIST of the jejunum that presented with spontaneous rupture. A previously healthy 46-year-old male patient presented with sudden abdominal pain. Physical examination revealed overt peritonitis, and computed tomography showed a heterogeneous solid mass measuring approximately 6 cm × 5.5 cm arising from the jejunum and massive fluid in the peritoneum. The mass was diagnosed as a GIST originating from the gastrointestinal tract. Emergency laparotomy was performed and intraoperative findings showed massive hemoperitoneum and an outgrowing mass at the jejunum, 50 cm distal to the Treitz ligament. The tumor had ruptured near the wall of the small intestine and it was actively bleeding. Surgical resection of the tumor was performed and the patient was discharged home uneventfully on the third postoperative day. The immunohistochemical characteristics of the tumor revealed it to be a GIST.

Endoscopic snare excision of adenoma of the papilla of Vater without prophylactic pancreatic-duct stent

CONTEXT

The endoscopic excision of adenomas of the papilla of Vater has gained increased popularity in the recent years. Temporary pancreatic drainage has been advised to accompany snare papillectomy in order to prevent ductal obstruction and serious pancreatitis.

OBJECTIVES

We evaluated treatment outcome of patients who had undergone endoscopic papillectomy without pancreatic drainage.

METHODS

Three consecutive adult patients with adenomas of the papilla of Vater presented with jaundice and pain were treated by endoscopic snare excision between October 2013 and February 2014 in a single center. ERCP procedures revealed papillary tumors and endoscopic biopsy specimens revealed tubular adenoma the papilla of Vater. Adenomas were treated by snare papillectomy method and a biliary stent was inserted as a prophylactic procedure immediately after excision of the adenoma in each case. In addition to physical examination, laboratory tests were repeated in the follow-up period after papillectomy in order to document if there is any complication particularly pancreatitis.

RESULTS

None of the patients experienced an immediate complication, including pancreatitis after papillectomy. Also neither patient experienced abnormal fluctuations of laboratory tests during the follow-up. Histopathologic evaluation of the resection specimens revealed a tubular adenoma with low grade dysplasia in the first two patients and a tubular adenoma with high-grade dysplasia in the third one. Endoscopy and pathologic evaluation revealed no recurrent/residual disease during the follow-up period of these patients.

CONCLUSION

Endoscopic snare resection of adenoma of the major papilla of the duodenum is a safe and minimal invasive alternative to surgical therapy. Biliary stent is sufficient to prevent biliary ductal patency and pancreatic stenting might not be necessary to prevent pancreatitis.

Impact of body mass index on number of lymph nodes retrieved in gastric cancer patients

BACKGROUND/AIMS

The aim of this study was to assess the influence of obesity on the number of the dissected lymph nodes in patients who underwent gastrectomy for gastric adenocarcinoma.

METHODOLOGY

Thirty eight Patients with gastric adenocarcinoma who underwent curative gastrectomy at one center between April 2012 and December 2012 were eligible for the study. According to their body mass index (BMI) values before surgery patients with BMI > 24.9 kg/m2 were defined as obese. Patients with BMI ≤ 24.9 kg/m2 were defined as normal group. The number of retrieved lymph nodes and metastatic lymph nodes were obtained from pathology reports.

RESULTS

Among 38 patients there were 17 (45%) patients had BMI ≤ 24.9 kg/m2 (normal group), while 21 (%55) patients had BMI > 24.9 kg/m2 (obese group). The median number of retrieved lymph nodes in obese patients who underwent total gastrectomy was significantly higher compared to the normal patients underwent the same procedure.

CONCLUSION

In this study we showed that the obesity affects the outcomes of surgery in gastric cancer. Furthermore, the total number of retrieved lymph nodes in obese patients who underwent total gastrectomy was higher than that in non-obese patients.

High rate of sexual dysfunction following surgery for rectal cancer

Purpose

Although rectal cancer is a very common malignancy and has an improved cure rate in response to oncological treatment, research on rectal-cancer survivors' sexual function remains limited. Sexual dysfunction (SD) after rectal cancer treatment was measured, and possible predisposing factors that may have an impact on the development of this disorder were identified.

Methods

Patients undergoing curative rectal cancer surgery from January 2012 to September 2013 were surveyed using questionnaires. The female sexual function index or the International Index of Erectile Function was recorded. A multiple logistic regression was used to test associations of clinical factors with outcomes.

Results

Fifty-six men (56%) and 28 women (44%) who completed the questionnaire were included in the study. A total of 76 patients of the 86 patients (90.5%) with the diagnosis of rectal cancer who were included in this study reported different levels of SD after radical surgery. A total of 64 patients (76%) from the whole cohort reported moderate to severe SD after treatment of rectal cancer. Gender (P = 0.011) was independently associated with SD. Female patients reported significantly higher rates of moderate to severe SD than male patients. Patients were rarely treated for dysfunction.

Conclusion

Sexual problems after surgery for rectal cancer are common, but patients are rarely treated for SD. Female patients reported higher rates of SD than males. These results point out the importance of sexual (dys)function in survivors of rectal cancer. More attention should be drawn to this topic for clinical and research purposes.

Intestinal obstruction due to congenital mesenteric band in an adult patient

We report the case of a 30-year-old male patient who was admitted to the Emergency Department with symptoms and signs of intestinal obstruction. There was no history of abdominal surgery or trauma. Abdomen was distended. Abdominal plain X-ray showed intestinal loops with air-fluid levels in the middle area of the abdomen. Computed tomography showed small bowel dilatation and free fluid in the abdomen. A laparotomy was subsequently performed and the intraoperative findings revealed a band extending from the root of the mesentery to the antimesenteric wall of the jejunum. The band was resected; the postoperative course was uneventful. Congenital bands are extremely rare and usually observed in childhood. This case, therefore, represents an unusual surgical problem in an older individual in whom the diagnosis was clinically unexpected.

Locally advanced pseudopapillary neoplasm of the pancreas in a male patient: a case report

CONTEXT

Solid pseudopapillary tumor of the pancreas is a rare neoplasm, predominantly observed in young women and with greatest incidence in the second and third decade. Although large at the time of diagnosis, it has clinically good behavior. The occurrence of infiltrating varieties of solid pseudopapillary tumors is very rare.

CASE REPORT

We report the case of a 48-year-old man with a giant mass in the pancreas, incidentally discovered during an abdominal ultrasonography. The mass was later investigated using multidetector computed tomography and magnetic resonance imaging. The lobulated lesion had cystic-necrotic appearances which lead the radiologists to suggest the possibility of either a gastrointestinal stromal tumor or a pancreatic cancer. The patient was operated. Operative signs showed that the tumor invaded the splenic hilum and mesentery of transverse colon. En-block resection of pancreas, spleen and transverse colon was performed as the mass was thought to be a locally advanced pancreas tumor. Pathological diagnosis reported a solid pseudopapillary tumor.

CONCLUSION

Although solid pseudopapillary tumor is considered a rare tumor, with a very rare rate of locally infiltrating variety, and rarely presents in males, it must be kept in mind while making the differential diagnosis of cystic pancreatic lesions to begin appropriate clinical management.

Prognostic impact of the metastatic lymph node ratio on survival in rectal cancer

Purpose

Lymph-node metastasis is the most important predictor of survival in stage III rectal cancer. The number of metastatic lymph nodes may vary depending on the level of specimen dissection and the total number of lymph nodes harvested. The aim of this study was to evaluate whether the lymph node ratio (LNR) is a prognostic parameter for patients with rectal cancer.

Methods

A retrospective review of a database of rectal cancer patients was performed to determine the effect of the LNR on the disease-free survival (DFS) and the overall survival. Of the total 228 patients with rectal cancer, 55 patients with stage III cancer were eligible for analysis. Survival curves were estimated using the Kaplan-Meier method. Cox regression analyses, after adjustments for potential confounders, were used to evaluate the relationship between the LNR and survival.

Results

According to the cutoff point 0.15 (15%), the 2-year DFS was 95.2% among patients with a LNR < 0.15 compared with 67.6% for those with LNR ≥ 0.15 (P = 0.02). In stratified and multivariate analyses adjusted for age, gender, histology and tumor status, a higher LNR was independently associated with worse DFS.

Conclusion

This study showed the prognostic significance of ratio-based staging for rectal cancer and may help in developing better staging systems. LNR 0.15 (15%) was shown to be a cutoff point for determining survival and prognosis in rectal cancer cases.