Multidrug-Resistant Infections After Liver Transplantation, Etiology and Risk Factors: A Single-Center Experience

OBJECTIVES

Patients undergoing liver transplant are at an increased risk of morbidity and mortality due to the development of infections. We aimed to evaluate the risk factors affecting the incidence of infectious diseases after liver transplant and to present the epidemiological data.

MATERIALS AND METHODS

We investigated patients aged ≥18 years who underwent liver transplant between 2012 and 2020 at our center. We collected infections, causative microorganisms, and antibacterial resistance patterns seen during the first 6 months posttransplant. Risk factors affecting the development of infectious diseases were also analyzed and evaluated.

RESULTS

Of 112 patients included in our study, 76 (67.9%) were men, and the median age was 50 years (range, 20-66 years). Within month 1 and month 6 after transplant, at least 1 episode of infection occurred in 67 (59.8%) and 80 (71.4%) patients, respectively. Bacterial infections were the most common type (n = 78, 95.1%), followed by fungal (n = 2, 2.4%) and viral (n = 2, 2.4%) infections. The rate of multidrug resistance in bacterial infections was high (n = 38, 52.7%) and was also a risk factor for mortality in the first 6 months after transplant (P < .001). Pretransplant values of international normalized ratio, creatinine, bilirubin, and posttransplant intensive care unit stay, as well as the presence of encephalopathy, were shown to increase the risk of infection after transplant.

CONCLUSIONS

Multidrug-resistant bacterial infections are a significant risk factor for mortality in liver transplant patients. Many risk factors that contribute to the development of infections aftertransplant have been included in prognostic scoring systems of liver failure. Consequently, the severity of end-stage liver failure is directly related to the risk of posttransplant infections.

Are YouTube Videos Sufficient for Educational Purposes for Robotic Right Hemicolectomy Learning and Has Complete Mesocolic Excision Changed That?

BACKGROUND/AIMS

The aim of this study is to evaluate the efficiency for educational purposes by evaluating the videos published on YouTube channel, which is an open source video sharing platform, for robotic right hemicolectomy procedure.

MATERIALS AND METHODS

We searched YouTube website to choose video clips that included information about robotic right hemicolec- tomy for right colon cancer. All videos were analyzed according to the criteria like quality of videos, quality of teaching, and modified Laparoscopic Surgery Video Educational Guidelines.

RESULTS

There were 16 complete mesocolic excision and 56 noncomplete mesocolic excision videos in the study. According to the Likert scale, calculated complete mesocolic excision scores were analyzed better than the noncomplete mesocolic excision group and this difference was statistically significant (P < .0001). The teaching quality scores of complete mesocolic excision videos were higher than noncomplete mesocolic excision group and this result was statistically significant (P = .02). The videos were scored according to the modified Laparoscopic Surgery Video Educational Guideline, and the score difference was statistically significant between complete mesocolic excision and noncomplete mesocolic excision videos (P < .001). The video power index was higher (mean 5.52 ± 15.56 vs. mean 1.66 ± 3.41) in the complete mesocolic excision group, but there was no statistically significant difference between the 2 groups (P = .086).

CONCLUSIONS

Most of the robotic right hemicolectomy videos on the YouTube platform are insufficient in terms of educational capaci- ties. Complete mesocolic excision-containing videos are slightly superior in this respect to noncomplete mesocolic excision videos, as considering a new technique can make video presenters more attentive. In our opinion, if the images presented to the video platforms are to be used for educational purposes, they must undergo a certain evaluation and screening process.

Investigating Whether the Severity of SARS-CoV-2 Infection Is Higher in Liver Transplant Recipients: A Single-Center Experience

OBJECTIVES

Liver transplant recipients have been reported to be a high-risk population for severe disease from COVID-19 infection. In this crosssectional, single-center study, we investigated whether liver transplant increased the risk of death and severe disease in patients with SARS-CoV-2 infection.

MATERIALS AND METHODS

We collected data and serum anti-SARS-CoV-2 immunoglobulin M and immunoglobulin G results of 91 liver transplant recipients seen from September 2020 to March 2021. Liver transplant recipients were enrolled during presentation for scheduled routine follow-up visits. All patients who required serum anti-SARS-CoV-2 immunoglobulin M and immunoglobulin G tests completed a ques-tionnaire on clinical symptoms during the previous 6 months.

RESULTS

Among the 91 patients with SARS-CoV-2 immunoglobulin M and G results, 7 patients had a known history of symptomatic COVID-19 during the previous 6 months. Of the 84 participants who completed the questionnaire, 21 (25%) had positive anti-SARS-CoV-2 immunoglobulin M and G results. These 21 patients also received COVID-19 polymerase chain reaction tests, which were negative in all 21 patients. Overall, only 7 patients stated that they experienced flu-like upper respiratory tract infection symptoms or diarrhea.

CONCLUSIONS

We documented past SARS-CoV-2 infection in only 25% of our outpatient liver transplant recipients, and most were asymptomatic. We found no significant relationship between symptoms and seropositivity for SARS-CoV-2.

The role of oxidative stress parameters in the differential diagnosis of malignant and benign ascites

OBJECTIVE

Ascites is the pathological fluid accumulation in the peritoneal cavity and there are mainly two reasons for its etiology. These are malignant diseases such as hepatoma or pancreas cancer and benign diseases such as liver cirrhosis and heart failure. In this study, we investigated the diagnostic utility of arylesterase (ARES), paraoxonase (PON), stimulated paraoxonase (SPON), catalase (CAT) and myeloperoxidase (MPO) in the differential diagnosis of malignant and benign ascites.

PATIENTS AND METHODS

This study was conducted between February and September 2016. Patients with acute infection, those taking vitamin supplements and antioxidant medication, smoking, and drinking alcohol were excluded from the study.

RESULTS

The study population consisted of 60 patients: 36 had benign (60%) and 24 had malignant (40%) ascites. The mean age of the patients was 63.3 years. MPO levels (14.2 vs. 4.2; p=0.028) were found to be higher and PON (2.6 vs. 4.5; p<0.001), SPON (10.7 vs. 23.9; p<0.001), ARES (615.7 vs. 823.5, p<0.001) and CAT (13.3 vs. 36.8; p=0.044) were found to be lower in malignant patients compared to benign patients. There was a positive correlation between PON, SPON, and ARES levels, and a negative correlation between MPO levels and SPON, ARES, and CAT levels. MPO levels showed superior diagnostic performance compared to ARES and CAT levels (p<0.05) for predicting malignancy but showed no diagnostic superiority compared to PON and SPON levels (p>0.05).

CONCLUSIONS

PON, SPON, ARES, CAT, and MPO can be used with high sensitivity and specificity in the differential diagnosis of malignant and benign ascites.

Effect of Pretransplant Sarcopenia on Mortality in Liver Transplant Recipients

OBJECTIVES

Sarcopenia is an important metabolic disorder associated with end-stage liver disease and is an independent predictor of mortality in liver transplant candidates. We evaluated effects of pretransplant muscle mass, muscle quality, and visceral adipose tissue on mortality after liver transplant.

MATERIALS AND METHODS

For 2015-2020, we included 65 liver transplant recipients whose records contained pretransplant liver computed tomography images. We calculated skeletal muscle mass index (muscle tissue area in centimeters squared divided by height in meters squared), visceral-to-subcutaneous fat ratio (visceral adiposity indicator), and intramuscular adipose tissue content ratio (muscle quality indicator).

RESULTS

Median age was 55 years (IQR, 45-63 years), and 48 (73.8%) patients were men. During follow-up, 53 (81.5%) study group patients survived; mean survival time was 71.73 ± 3.81 months. The deceased patient group had a statistically higher pretransplant visceral-to-subcutaneous fat ratio than the survival group (P = .046). Survival was 100% for 1 positive indicator, 86.2% for 2 positive indicators, and 70.4% for 3 positive indicators (P = .096). Positive correlation was confirmed between pretransplant skeletal muscle mass index and age (P = .043) and pretransplant body mass index (weight in kilograms divided by height in meters squared) (P < .001). There was a moderate positive correlation between pretransplant intramuscular adipose tissue content ratio and age (R = 0.529, P ≤ .001) and a weak positive correlation with pretransplant body mass index (R = 0.361, P = .003). Furthermore, pretransplant visceral- tosubcutaneous fat ratio showed a weak positive correlation with age (R = 0.306, P = .013) and a weak negative correlation with the Model for End-Stage Liver Disease score (R = -0.301, P = .016).

CONCLUSIONS

Pretransplant sarcopenia is an important indicator to predict mortality and morbidity in posttransplant follow-up. Visceral-to-subcutaneous fat ratio is an important parameter to evaluate sarcopenia in liver transplant patients.

Biliary Complications in Living Liver Donors After Donor Hepatectomy: A Single-Center Experience

OBJECTIVES

The most frequent postoperative morbidity following living donor liver transplant is biliary complications, which can happen for both anatomical and procedural reasons.

MATERIALS AND METHODS

We conducted a retrospective analysis of 104 patients who were living liver donors undergoing hepatectomy from January 2011 to April 2022. We evaluated all perioperative finding such as age, sex, remnant liver volume, biliary anatomy, theduration of operation time and hospitalization, and blood loss.

RESULTS

Clavien-Dindo classification grade III complications were observed in 24% of all donors, with rate of biliary complications of 7.6% (n = 8). All biliary complications were typified as biliary leakage, and an endoscopic retrograde cholangiopancreatography procedure was performed for 5 patients. We analyzed the clinical and surgical features and discovered that the duration of hospitalization was longer in the biliary leakage group than the group without leakage (15.7 ± 5.8 days vs. 30.8 ± 9.3 days, respectively; P < .08). There was no significant statistical relationship between age, the duration of operation time, intraoperative blood loss, and remnant liver volume versus biliary leakage (P = .074, P = .217, P = .219, and P = .363, respectively).

CONCLUSIONS

Early detection and treatment of complications are ensured during the perioperative process by carefuldonor selection andaccurate identification of the patient atrisk for biliary complications.

COVID-19 infection frequency and clinical course in patients with liver transplantation: Results of a single transplant center in Türkiye

Objectives

In this paper, it was tried to determine the incidence of COVID-19, course of the disease, and mortality rate in liver transplant patients by evaluating all patients operated on in our center. In addition, the results of liver transplantation performed in our center during the pandemic period were also presented.

Material and Methods

All patients who had undergone liver transplantation in our liver transplant center were questioned about their history of COVID-19 either at their routine controls in the clinic or by phone interview.

Results

Our liver transplant unit had 195 registered liver transplantation patients (2002-2020), and 142 of these were still alive and under follow-up. During the pandemic period, 80 patients referred to our outpatient clinic for follow-up, and their records were evaluated retrospectively in January 2021. Among 142 liver transplant patients, a total of 18 (12.6%) COVID-19 patients were identified. While 13 of these patients were males, mean age of the patients at the time of interviews was 48.8 years (22-65 years). Nine of the patients had living donor liver transplant, and the rest had cadaveric liver transplant. The most common COVID-19 associated symptom in the patients was fever. During the pandemic period, 12 liver transplant operations were performed in our center. Nine of them were living donor liver transplantation and the remainder were cadaveric liver transplantations. Two of our patients got COVID-19 positive during this period. One of them who was transplanted after COVID treatment was followed-up in intesive care for a long time and was lost not related to COVID-19.

Conclusion

The incidence of COVID-19 is higher in liver transplant patients than in the general population. Nonetheless, mortality rates are low. During the pandemic period, liver transplantation can be continued by following general precautions.

Turkish HPB Surgery Association consensus report on hepatic cystic Echinococcosis (HCE)

OBJECTIVES

Cystic Echinococcosis (CE) is one of the important problems of the Eurasian region. We aimed to prepare a consensus report in order to update the treatment approaches of this disease. This study was conducted by Turkish HPB Surgery Association.

MATERIAL AND METHODS

This study was conducted with the modified Delphi model. For this purpose, we conducted a three-stage consensus-building approach.

RESULTS

Six topics, including diagnosis, medical treatment, percutaneous treatment, surgical treatment, management of complications and posttreatment follow-up and recurrences in HCE were discussed.

CONCLUSION

The expert panel made recommendations for every topic.

Primary anorectal malignant melanomas: retrospective analysis of 11 cases in a single center

Objectives

Anorectal malignant melanoma is a rare tumor with poor prognosis. In this study, it was aimed to present our surgical results by reviewing the literature retrospectively in 11 patients who underwent surgery for ARMM in our clinic.

Material and Methods

The patients who underwent surgery for anorectal malignant melanoma in Yuksek İhtisas Training and Research Hospital between 2007-2018 were included in the study.

Results

Four patients were males and seven were females. Mean age was 54.18. The tumor was in the rectum in 4 cases, in the anorectal region in 3 cases and in the anal canal in 4 cases. Wide local excision was performed in 3 cases and APR was performed in 8 cases. Four of the cases were stage I, 6 were stage II and 1 was stage III. Mean tumor size was 4.73 cm, and mean tumor depth was 13.6 mm. Mean number of metastatic lymph nodes was 10.37. Median survival was 12 months.

Conclusion

Anorectal malignant melanoma is a type of tumor diagnosed in late and advanced stages due to lack of specific findings. Although ARMM is rare, when rectal bleeding, pain, hemorrhoids and changes in bowel habits are observed, ARMM should be kept in mind.

The effect of carbon monoxide releasing molecule-2 (CORM-2) on healing of ischemic colon anastomosis in rats

Background/aim

Ischemia on the colon wall negatively affects healing of anastomosis. We were aimed to evaluate the effects of carbon monoxide releasing molecule-2 (CORM-2) on the healing of anastomosis in a rat model of the ischemic colon.

Materials and methods

In this prospective study a total of 60 rats were randomly divided into three groups as colon transection and end-to-end anastomosis (Group I), colon transection, and end-to-end anastomosis following the induction of ischemia (Group II), and colon transection and end-to-end anastomosis following the induction of ischemia and treated with daily intraperitoneal administration of CORM-2 (Group III). Each group was also divided into two equal subgroups as postoperative 3rd and 7th day. Postoperative healing of anastomoses was evaluated by anastomosis burst pressure (ABP), tissue biomarkers including hydroxyproline (HP), malondialdehyde (MDA), glutathione (GSH), and histopathological findings.

Results

In the ischemic group treated with CORM-2, lower MDA and higher HP levels were observed in comparison to the untreated ischemic group on the 3rd day. GSH and HP levels were higher and MDA levels was lower in the ischemic rats treated with CORM-2 than in the ischemic untreated rats on the 7th day. In the ischemic group treated with CORM-2, the mucosal epithelial score decreased and the neoangiogenesis score increased compared to the untreated rats on the 7th day.

Conclusion

In ischemic colon anastomosis, reduces cell destruction by suppressing the oxidative reaction, and strengthening the antioxidative mechanisms of the cells. It also increases collagen formation, epithelial development, and neoangiogenesis.

How can surgical continuity be maintained during the COVID-19 pandemic? A quality improvement study in the pre-vaccination period

Objective: During the COVID-19 pandemic, most of the elective surgeries had to be postponed. However, it is not possible to delay the surgical treat- ment of cancer patients for a long time. The aim of this study was to present how gastrointestinal system surgery operations are managed without delay and how employee safety is ensured , together with the results of the last five months. For this purpose, a preclinical and clinical screening system was created.

Material and Methods: Data of the patients who presented to our outpatient clinic between April 1st 2020 and August 31st 2020 were retrospectively reviewed.

Results: During the last five months of the pandemic, a total of 387 patients were hospitalized and 309 of these patients underwent surgical procedures. 165 of the patients who underwent surgery were newly diagnosed malignancy patients. All patients who were hospitalized were subjected to a screening for COVID-19 during the preclinical, clinical and surgical period. In the preclinical period, five patients were found positive and were directed to COVID-19 treatment without hospitalization. In the clinical period, six patients were isolated by showing symptoms during the hospitalization period. Only one of these patients received surgical treatment. The remaining five patients underwent endoscopic and interventional procedures. In this process, COVID-19 positivity was detected in a total of five healthcare workers.

Conclusion: With this preclinical and clinical screening method, it is shown that a COVID-19 sterile environment can be provided by early detection of positive cases in both patients and healthcare workers. In this way, the possibility of surgical continuity was demonstrated.

The predictive power of C-reactive protein- lymphocyte ratio for in-hospital mortality after colorectal cancer surgery

BACKGROUND

The relation between immunity, inflammation, and tumor development and progression has been emphasized in colorectal cancer widely and the prognosis is linked to the inflammatory reaction of the host as well as the biological behavior of the tumor.

AIM

In this study, we aimed to find out the predictive power of C-reactive protein- lymphocyte ratio (CLR) for in-hospital mortality after colorectal surgery.

METHODS AND RESULTS

A series of 388 CRC patients were enrolled in the present retrospective study which was conducted in a tertiary state Hospital in Ankara, Turkey. In-hospital mortality was the main outcome to evaluate the predictive power of inflammatory markers, while the other outcomes that would be evaluated as separate variables were LOS in hospital and LOS in ICU. In this study, there were 260 males and 128 females, and the mean age was 60.9. The in-hospital mortality rate was 3.4% (n = 13) and age, APACHE II score and Charlson comorbidity index score were related to in-hospital mortality statistically. The mean LOS in the hospital was 13.9 days and LOS in ICU was 4.5 days. The CRP levels and the CLR levels were higher both in the preoperative and postoperative periods in the mortality (+) group and the difference was significant statistically (P = .008/ .002 and .004/ <.001, respectively). CLR in the postoperative period had the best predictive power with AUC: 0.876.

CONCLUSION

In conclusion, within the context of our study there appears to be a relationship between CLR, as measured on day 2 postoperatively, and in-hospital mortality. It is observed to be more effective than NLR, ALC, and CRP.

Surgical management of digestive system cancers during the coronavirus disease 2019 pandemic: review of general suggestions

Since December 2019, the world has been battling the COVID-19 pandemic, and health workers are at the forefront of the fight. Surgeons also fulfill their duty; however, elective cases had to be postponed in order to use resources appropriately in the fight against coronavirus. Although benign elective surgical procedures can be postponed to a distant time during this pandemic, surgical interventions for urgent and life-threatening situations are mandatory to perform but the main uncertainty among surgeons is about cancer patients. In this paper, we aimed to present a suggestion to the surgeon about how to manage digestive system cancers during pandemic in the light of the published articles and guidelines.

The attitude of Turkish general surgeons during the COVID-19 pandemic: Results of "general surgery COVID-19 pandemic attitude survey"

OBJECTIVES

The whole world is dealing with the COVID-19 pandemic, and healthcare professionals are the most affected group. The aim of this study was to evaluate the knowledge of general surgeons about COVID-19 and understand the attitude and current situation of our colleagues.

MATERIAL AND METHODS

This descriptive study comprised general surgeons working in different parts of Turkey. A survey with 23 questions was prepared to determine the demographic characteristics of the participants, workplace characteristics, change in daily work practices and their attitudes in the pandemic process.

RESULTS

A total of 332 forms were evaluated. Survey results show that the majority of surgeons have changed their daily surgical practices. Many surgeons take part in the treatment of COVID-19. While most benign cases are delayed, the managemet of malignant cases differs. There are also differences in the evaluation of patients preoperatively and the type of operation. Personal protective measures are followed. While the rate of infected surgeons is low, the majority of surgeons have concerns about infection.

CONCLUSION

Turkish surgeons have managed to get a quick reaction from the start of the pandemic. However, there are still differences in preoperative patient evaluation and operation selection and precautions during the operation. Surgeons also should be informed about the management of malignant patients.

Correction to: Does the preoperative platelet-tolymphocyte ratio and neutrophil-tolymphocyte ratio predict morbidity after gastrectomy for gastric cancer?

In the original publication of this article [1] there are two garbled codes in the second sentence, the fourth paragraph of the Background section. The correct sentence should be: Tumor growth leads to the increased production of inflammatory cytokines and growth factors (mainly IL-1, IL-3, IL-6, IL-11, IL-23, and TNF-), and this perpetual process ensures immortality. These promoting factors are also important for angiogenesis and hematopoiesis, which explains the increase in blood cell types in cancerous diseases. The original publication has been corrected.

Intraoperative hemorrhage and increased spleen volume are risk factors for conversion to open surgery in patients undergoing elective robotic and laparoscopic splenectomy

Objectives

Minimal invasive surgery is one of the most popular treatment approaches which is safe and effective in experienced hands in different clinical practices. In the present study, we aimed to evaluate the risks factors for conversion to open splenectomy and the performance of indirect hilum dissection technique.

Material and Methods

A total of 56 patients who underwent laparoscopic or robotic splenectomy for isolated spleen diseases were included into the study. Patients were divided into two groups as robotic or laparoscopic splenectomy (Group 1; n= 48) and conversion to open surgery (Group 2; n= 8). Patients were retrospectively evaluated according to clinical, biochemical, hematological and microbiological parameters and morbidity.

Results

No statistically significant difference was found between the groups in terms of age, gender, body mass index (BMI), ASA score, co-morbid disease, operation time, hospital stay, follow-up period, accessory spleen, diagnosis, international normalized ratio (INR), red cell distribution width (RDW), platelet distribution width (PDW), platelet to lymphocyte ratio (PLR), neutrophil to lymphocyte ratio (NLR), reapplication, splenosis, surgical site infection, vascular thrombus and incisional hernia (p> 0.05). On the other hand, intraoperative splenic hilum hemorrhage and increased spleen size (p <0.05) were higher in the conversion to open surgery group. In logistic regression analysis, intraoperative splenic hilum hemorrhage (B= 4.127) (OR= 61.974) (95% CI= 3.913-981.454) (p= 0.003) and increased spleen volume (B= 3.114) (OR= 22.509) (95% CI= 1.818-278.714) (p= 0.015) were found as risk factors for conversion to open surgery.

Conclusion

Intraoperative hemorrhage from the splenic hilum and increased spleen volume (> 400 cm3) are risk factors for conversion to open splenectomy in patients undergoing elective robotic or laparoscopic splenectomy. Indirect splenic hilum dissection can decrease intraoperative hemorrhage and conversion to open surgery.

Does the preoperative platelet-to-lymphocyte ratio and neutrophil-to-lymphocyte ratio predict morbidity after gastrectomy for gastric cancer?

BACKGROUND

Gastric cancer is the 2nd most common cause of cancer-related deaths, and the morbidity rate after surgery is reported to be as high as 46%. The estimation of possible complications, morbidity, and mortality and the ability to specify patients at high risk have become substantial for an intimate follow-up and for proper management in the intensive care unit. This study aimed to determine the prognostic value of the preoperative platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) and their relations with clinical outcomes and complications after gastrectomy for gastric cancer.

METHODS

This single-center, retrospective cohort study evaluated the data of 292 patients who underwent gastrectomy with curative intent between January 2015 and June 2018 in a tertiary state hospital in Ankara, Turkey. A receiver operating characteristic curve was generated to evaluate the ability of laboratory values to predict clinically relevant postoperative complications. The area under the curve was computed to compare the predictive power of the NLR and PLR. Then, the cutoff points were selected as the stratifying values for the PLR and NLR.

RESULTS

The area under the curve values of the PLR (0.60, 95% CI 0.542-0.657) and NLR (0.556, 95% CI 0.497-0.614) were larger than those of the other preoperative laboratory values. For the PLR, the diagnostic sensitivity and specificity were 50.00 and 72.22%, respectively, whereas for the NLR, the diagnostic sensitivity and specificity were 37.50 and 80.16%, respectively. The PLR was related to morbidity, whereas the relation of the NLR with mortality was more prominent. This study demonstrated that the PLR and NLR may predict mortality and morbidity via the Clavien-Dindo classification in gastric cancer patients. The variable was grade ≥ 3 in the Clavien-Dindo classification, including complications requiring surgical or endoscopic interventions, life-threatening complications, and death. Both the PLR and NLR differed significantly according to Clavien-Dindo grade ≥ 3. In this analysis, the PLR was related to morbidity, while the NLR relation with mortality was more intense.

CONCLUSION

Based on the results of the study, the PLR and NLR could be used as independent predictive factors for mortality and morbidity in patients with gastric cancer.

Early laparoscopic cholecystectomy is associated with less risk of complications after the removal of common bile duct stones by endoscopic retrograde cholangiopancreatography

BACKGROUND/AIMS

Several studies recommend prompt laparoscopic cholecystectomy (LC) following endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis. However, histopathological alterations in the gallbladder during this time interval and the role played by ERCP in causing these changes have not been sufficiently elucidated. To compare early period LCs with delayed LCs following common bile duct stone extraction via ERCP with regard to operation time, hospitalization period, conversion to open cholecystectomy rate, morbidity, mortality, and histopathological alterations in the gallbladder wall.

MATERIALS AND METHODS

A total of 85 patients were retrospectively divided into three groups: early period LC group (48-72 h; n=30), moderate period LC group (72 h-6 weeks; n=25), and delayed period LC group (6-8 weeks; n=30).

RESULTS

The operation time was significantly shorter, and the total number of complication rates and hospital readmission was significantly less frequent in the early period LC group (p<0.05). Ultrasound showed a significantly thicker gallbladder wall (>3 mm) in the moderate and late period LC groups than in the early period LC group (p<0.001). Culture growth was significantly higher, and fibrosis/collagen deposition in the gallbladder wall with injury to the mucosal epithelium was significantly more frequently detected by histopathological examination in the moderate and late period LC groups than in the early period LC group (p<0.05).

CONCLUSION

Early period LC following stone extraction by ERCP is associated with shorter operation time, fewer fibrotic changes in the gallbladder, and lower risk for the development of complications. Therefore, LC can be performed safely in the early period after ERCP.

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.

Effects of preoperative endoscopic pneumatic balloon dilatation on postoperative achalasia symptoms after Heller esophageal myotomy plus Dor fundoplication

BACKGROUND/AIMS

Currently, forceful endoscopic pneumatic balloon dilatation (PBD), laparoscopic Heller myotomy (LHM) with or without an anti-reflux procedure, and peroral endoscopic myotomy are the preferred treatment options for achalasia. The aim of the present study was to retrospectively compare postoperative outcomes after LHM plus Dor fundoplication (DF) between patients who underwent prior endoscopic balloon dilatation and those who did not.

MATERIALS AND METHODS

Sixty-five patients who underwent HM+DF between January 2008 and December 2016 were retrospectively analyzed. Of these, 45 had a history of endoscopic PBD. Pre- and postoperative achalasia symptoms, including weight loss, dysphagia, heartburn, and regurgitation, were evaluated using the Eckardt score.

RESULTS

Fifty (76.9%) patients underwent laparoscopic surgery and 15 (23.1%) underwent open surgery. When patients were compared according to the presence of preoperative endoscopic PBD, no significant difference were observed in terms of age, sex, preoperative lower esophageal sphincter pressure, operation time, hospitalization period, and follow-up period (p>0.05). The mean Eckardt score at the first postoperative year was significantly lower than the preoperative Eckardt score (4.51±1.8 vs. 0.52±0.7; p<0.001). In contrast, no significant difference was found between patients with and without previous PBD on the pre- and postoperative Eckardt scores (p=0.43).

CONCLUSION

HM+DF is an effective procedure in relieving achalasia symptoms as a first-line therapy as well as in individuals unresponsive to repeated endoscopic PBDs.

The Karaman score: A new diagnostic score for acute appendicitis

BACKGROUND

The Karaman score is a novel diagnostic scoring system consisting of 6 parameters. The aim of the present study was to assess the diagnostic performance of the Karaman score in comparison with the Alvarado score.

METHODS

A total of 200 patients who underwent an appendectomy were enrolled in the study (research registry number: 2290).

RESULTS

The cutoff threshold of the Karaman score in distinguishing acute appendicitis from negative appendectomy was ≥9 with 84.3% sensitivity, 64.7% specificity, 92.1% positive predictive value (PPV), and 45.8% negative predictive value (NPV). The cutoff threshold of the Alvarado score in distinguishing acute appendicitis from negative appendectomy was ≥8 with 72.9% sensitivity, 70.6% specificity, 92.4% PPV, and 34.8% NPV. In multivariate logistic regression analysis, an Alvarado ≥8 score (Odds ratio [OR]:6.644, 95% confidence interval [CI]: 2.854-15.466; p<0.001) and a Karaman ≥9 score (OR:10.374, 95% CI: 4.383-24.558; p<0.001) were each individually predictive in distinguishing acute appendicitis from negative appendectomy when correction was made according to age and gender. However, when both scores were evaluated together, the Alvarado score ≥8 lost its efficacy (OR:1.838, 95% CI: 0.517-6.530; p=0.347), whereas the Karaman score ≥9 retained its predictive power (OR:6.586, 95% CI: 1.893-22.917; p=0.003).

CONCLUSION

The Karaman score was more predictive than the Alvarado score in distinguishing acute appendicitis from a negative appendectomy.

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.

Is Serum Prostate-Specific Antigen a Reliable Prostate Cancer Marker in Liver Transplant Candidates

OBJECTIVES

In this study, we aimed to determine whether the prostate-specific antigen level is a reliable marker of prostate cancer in patients with hepatic insufficiency, based on evaluation of alterations in serum prostate-specific antigen levels after liver transplant in patients with hepatic insufficiency.

MATERIALS AND METHODS

Medical records of all patients who underwent liver transplant at our hospital between January 2003 and June 2017 were retrospectively reviewed. Male patients who were > 40 years old with available pre- and posttransplant serum total prostate-specific antigen levels were included in the study.

RESULTS

Our study included 36 male patients with a mean age of 54.6 ± 5.3 years (range, 45-73 y) at the time of liver transplant. The mean pretransplant serum total prostate-specific antigen level was 0.75 ± 0.77 ng/mL, which was significantly lower than the mean posttransplant level of 1.29 ± 1.57 ng/mL (P < .05). The pretransplant serum total prostate-specific antigen level was measured a mean of 4.9 ± 5.4 months before liver transplant versus a mean 27.6 ± 16.3 months after transplant. Prostate-specific antigen velocity was 0.2 ng/mL/year. Biochemical tests of liver function, including the mean serum levels of bilirubin, international normalized ratio, and albumin, were normal after liver transplant at 1.37 ± 2.33 mg/dL, 1.22 ± 0.36, and 4.16 ± 0.69 g/dL, respectively.

CONCLUSIONS

Serum prostate-specific antigen levels may decrease in patients with hepatic insufficiency/cirrhosis; therefore, a low serum prostate-specific antigen level may not be a reliable marker for excluding prostate cancer in such patients. Transplant surgeons and clinicians must be aware of this so that all male transplant candidates > 40 years old are evaluated via digital rectal examination, regardless of the serum prostate-specific antigen level.

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.

Symptomatic hepatic metastasis of insulinoma 15 years after pancreatic resection

Malignant insulinomas are infrequent endocrine tumors with miscellaneous clinical courses. In this report, we present a rare case of insulinoma that recurred with solitary hepatic metastasis 15 years after the initial resection of the primary tumor from the pancreas. A 20-year-old woman first presented with the symptoms of hypoglycemia in 1996. The diagnosis of pancreatic insulinoma was confirmed by laboratory findings, and the initial surgery had been performed involving complete enucleation of the pancreatic mass. Histopathologically, the tumor was diagnosed as a benign adenoma. After 15 years, the patient experienced symptoms of hypoglycemia again, and laboratory findings and abdominal computed tomography identified a lesion in the liver. Intraoperative ultrasound did not show any lesion in the pancreas, and wedge resection was performed for the hepatic lesion. Postoperative blood glucose levels returned to normal. Histopathologic examination confirmed the diagnosis of liver metastasis of a neuroendocrine tumor. This is the longest interval between primary tumor and the metastasis reported in the literature, for insulinoma. Thus, it should be remembered that long-term follow-up is mandatory for the patients with insulinoma even after resection of the primary tumor. Resection is recommended when a metastatic lesion is observed.

Intra-pancreatic Accessory Spleen Mimicking Pancreatic Neuroendocrine Tumor on 68-Ga-Dotatate PET/CT

Neuroendocrine tumors (NETs) are rare tumors, but the incidence is increasing with new diagnostics. A 37-year-old man was admitted to our hospital for an incidental 17-mm nodule in the tail of the pancreas. PET/CT shows indeterminate mass in the pancreatic tail with enhanced uptake of 68-Ga-dotatate. NET was suspected and laparoscopic distal pancreatectomy was performed. Pathologic examination revealed an accessory spleen with a heterotopic location. To the best of our knowledge, this is the first intrapancreatic accessory spleen (IPAS) case in which the positive 68-Ga-dotatate uptake reported in the literature. Our case showed that IPAS is one of the reasons of false positive involvement of 68-Ga-dotatate PET/CT. When PET/CT shows an indeterminate mass in the pancreatic tail with enhanced uptake of 68-Ga-dotatate, surgeons should keep IPAS in their mind for differential diagnosis to avoid false treatment.

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.

Laparoscopic sleeve gastrectomy on a morbidly obese patient with situs inversus totalis: A case study and systematic review of the literature

INTRODUCTION

Situs inversus totalis (SIT) is a condition where the internal organs or organ systems are located contra-laterally to the norm, forming a mirror image. Laparoscopic sleeve gastrectomy (LSG) is an effective bariatric procedure that has become more common over the last two decades. We report on a morbidly obese patient with SIT who underwent a successful LSG.

CASE REPORT

A 54-year-old female morbidly obese patient (136k; 167cm; body mass index (BMI): 48kg/m²) was admitted for bariatric surgery. She had congenital SIT, a history of open cholecystectomy and, despite implementing the suggestions of the dietitian and endocrinologist, she had failed to lose weight. A standard LSG was performed successfully using the French method. The patient's postoperative course was uneventful and she was discharged on the 5th postoperative day. She is now in the 4th month with a weight loss of 30kg.

DISCUSSION

SIT is a rare congenital condition, occurring in 1/10,000 to 1/50,000 live births. Organ function is generally normal, although it may sometimes be accompanied by respiratory or cardiovascular anomalies. Although undertaking LSG on morbidly obese patients with SIT may seem a daunting proposition at first, experienced laparoscopic surgeons can manage this operation with success.

CONCLUSION

Although SIT is a rare congenital condition, LSG can be performed safely and effectively.

Postperfusion Syndrome in Cadaveric Liver Transplantations: A Retrospective Study

OBJECTIVE

To evaluate the factors that affects the postperfusion syndrome in cadaveric liver transplantations and the effect of the postperfusion syndrome on discharge from the hospital.

METHODS

Patients who underwent cadaveric liver transplantations between 2007 and 2013 were scanned retrospectively. Intraoperative anaesthesia records, intensive care unit follow-up forms and discharge reports were examined from patient files. Overall, 43 patients having complete data were included in the study. The postperfusion syndrome is defined as asystoli or a decrease in mean arterial pressure of more than 30%, which occurred in the first 5 min of reperfusion and continued for 1 min. Patients were divided into two groups: those who had the postperfusion syndrome and those who did not.

RESULTS

The number of patients who had the postperfusion syndrome was 25 of 43 (58.1%). The MELD score of patients without the postperfusion syndrome was calculated as 16.9±3.2 and that of patients with the postperfusion syndrome was 19.7±3.6. A statistically significant relationship was detected between the postperfusion syndrome occurrence and a high MELD score (p=0.013). The diastolic blood pressure just before reperfusion was statistically lower in the group with the postperfusion syndrome than in the other group (p=0.023, 50±8 vs. 58±11). According to the logistic regression analysis, the MELD score and the decrease in diastolic blood pressure before reperfusion were defined as independent predictive factors.

CONCLUSION

According to the study, the ratio for having the postperfusion syndrome was found to be 58.1%. The independent predictor factors affecting the postperfusion syndrome were detected as the MELD score and the decrease in diastolic blood pressure before reperfusion. The postperfusion syndrome during orthotropic liver transplantation is an important issue for anaesthesiologists. The awareness of the related factors with the postperfusion syndrome may help in the development of various preventive strategies.

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.

An unusual cause of recurrent pancreatitis: A gastric duplication cyst with an accessory pancreatic lobe

Congenital anomalies of pancreas and its ductal drainage are uncommon but in general surgically correctable causes of recurrent pancreatitis. A gastric duplication cyst communicated with an accessory pancreatic lobe is an extremely rare cause of recurrent pancreatitis, but an early and accurate diagnosis of this anomaly is important because suitable surgical treatment may lead to a satisfactory outcome. Herein, we presented multidetector computed tomography and magnetic resonance imaging findings of a gastric duplication cyst communicating with an accessory pancreatic lobe via an aberrant duct in a 29-year-old woman with recurrent acute pancreatitis and also reviewed other similar cases reported in the literature.

Assessment of surgical resectability of pancreatic adenocarcinomas with multidetector computed tomography: what are the possibilities and problems?

BACKGROUND/AIMS

To investigate the accuracy of multidetector computed tomography (MDCT) in preoperatively determining the surgical resectability of pancreatic adenocarcinomas.

MATERIALS AND METHODS

Multidetector computed tomography, surgery, and pathological results of 274 patients with pancreatic adenocarcinoma were evaluated retrospectively. MDCT findings were compared with surgical and pathological findings to determine the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of MDCT in determining surgical resectability.

RESULTS

A total of 124 of 274 (56%) patients (83 males, mean age: 60 years) underwent laparoscopy and/or laparotomy. The sensitivity, specificity, PPV, NPV, and accuracy of MDCT in determining the surgical resectability of pancreatic adenocarcinomas were 100%, 72%, 78%, 100%, and 86%, respectively. Liver metastases in 9 cases, peritoneal metastases in 3 cases, and vascular invasion in 5 cases, which were determined during surgery, were not reported by MDCT. On re-review of the MDCT images of these 17 patients, no metastatic lesions could be seen in 9 patients with liver metastases and in 2 of 3 patients with peritoneal metastases. In 1 patient, a peritoneal implant of a diameter of 8 mm was missed on MDCT. There was no vascular invasion according to Lu criteria on the MDCT images in the 5 cases that had vascular invasion in the surgical exploration.

CONCLUSION

The accuracy of MDCT is high in the preoperative determination of surgical resectability of pancreatic adenocarcinomas, but the detection of small liver and peritoneal metastases and accurate determination of vascular invasion are still major problems. Surgeons should be aware of the limitations of preoperative MDCT.

Effect of intraoperative PEEP application on colonic anastomoses healing: An experimental animal study

PURPOSE

This study aimed to assess the effect of intraoperative PEEP intervention on the healing of colonic anastomoses in rabbits.

MATERIALS AND METHODS

Thirty-two New Zealand type male rabbits were divided into two groups of sixteen animals each. Following ventilation with tracheostomy, colonic resection and anastomosis were performed in both groups. While 10 cm H2O PEEP level was applied in Group I (PEEP), Group II (ZEEP) was ventilated without PEEP throughout the surgery. Half of the both PEEP and ZEEP group animals were killed on the third postoperative day, while the remaining half on the seventh. Anastomotic bursting pressures, the tissue concentrations in hydroxyproline, and histological assessments were performed. Besides, intraoperative oxygen saturation and postoperative arterial blood gas parameters were also compared.

RESULTS

On the first postoperative day, both arterial oxygen tension (PO2) and oxygen saturation (SO2) in the PEEP group were significantly higher than in the ZEEP group. On the seventh postoperative day, the bursting pressures of the anastomoses were significantly higher in the PEEP group, however the hydroxyproline content was significantly lower in the PEEP group than that in the ZEEP group. At day 7, PEEP group was significantly associated with increased neoangiogenesis compared with the ZEEP group.

CONCLUSION

The anastomotic healing process is positively influenced by the intraoperative PEEP application.

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.

Repair of an extensive iatrogenic tracheal rupture with a pleural patch and a vascular graft

Here we describe a 48-year-old woman who suffered a 7-cm rupture in the lower trachea after intubation with a double-lumen tube. We repaired the rupture with a new technique using a pleural patch reinforced by a ringed vascular graft. This technique appears to be appropriate for use in patients who have large tracheal ruptures to avoid tracheal stenosis.