Eliminating first trimester combined testing: Consequences for early detection of significant fetal anomalies

OBJECTIVE

To determine whether implementation of cell-free DNA (cfDNA) testing for aneuploidy as a first-tier test and subsequent abolition of first trimester combined testing (FCT) affected the first trimester detection (<14 weeks) of certain fetal anomalies.

METHODS

We performed a geographical cohort study in two Fetal Medicine Units between 2011 and 2020, including 705 fetuses with prenatally detected severe brain, abdominal wall and congenital heart defects. Cases were divided into two groups: before (n = 396) and after (n = 309) cfDNA introduction. The primary outcome was the first trimester detection rate (<14 weeks) overall and for non-chromosomal anomalies solely.

RESULTS

Overall, gastroschisis, AVSD and HLHS were detected more often in the first trimester in the before group compared to the after group, respectively 54.5% versus 18.5% (p = 0.004), 45.9% versus 26.9% (p = 0.008) and 30% versus 3.4% (p = 0.005). After exclusion of chromosomal anomalies identifiable through cfDNA testing, the detection of AVSD remained higher in the before group (43.3% vs. 9.5%, p = 0.02), leading to a possible earlier gestation at termination. The termination of pregnancy (TOP) rate did not differ among the groups. In the after group, referrals for suspected anomalies following a dating scan between 11 and 14 weeks significantly increased from 17.4% to 29.1% (p < 0.001).

CONCLUSION

This study underscores the value of a scan dedicated to fetal anatomy in the first trimester as we observed a decline in the early detection of certain fetal anomalies (detectable in the first trimester) subsequent to the abolition of FCT.

Investigation of cardiopulmonary parameters, motor development and muscle strength in children with Down syndrome with and without congenital heart disease

BACKGROUND

Children with Down syndrome (DS) frequently have concomitant clinical problems. There are no studies in the literature evaluating gross motor development and handgrip strength in the presence of congenital heart disease (CHD), which is one of the most common comorbidities in population with DS. The aim of this study was to compare cardiopulmonary parameters, gross motor development and handgrip strength in children with DS with and without CHD.

METHODS

A total of 28 children with DS (14 with CHD and 14 without CHD) were evaluated. Demographic data and cardiopulmonary parameters were recorded. Gross motor development and handgrip strength were assessed.

RESULTS

Children with DS and CHD had lower GMFM-88 scores and right handgrip strength and higher Wang respiratory score than children with DS and no CHD (P < 0.05). GMFM-88 scores were moderately correlated with resting oxygen saturation (r = 0.46, P = 0.01) and right handgrip strength (r = 0.67, P < 0.001).

CONCLUSIONS

Peripheral muscle strength and oxygen saturation may be factors affecting gross motor development in children with DS. From this point of view, evaluating cardiopulmonary parameters, motor development and handgrip strength in children with DS and CHD is important to identify risks, provide early intervention and support development.

Comparison of transanal and transvaginal specimen extraction in laparoscopic colorectal surgery

AIM

This study aimed to compare the outcomes of transanal and transvaginal NOSES in patients undergoing laparoscopic colorectal surgery.

MATERIAL AND METHODS

This study included 45 patients who were scheduled for NOSES after undergoing laparoscopic colorectal resection in our clinic between January 2019 and March 2020. To ensure homogeneity between the groups, the data of 22 female patients were analyzed in this study. Patients were divided into two groups according to the specimen extraction technique used. Demographic data, preoperative and postoperative findings, as well as the pathology and sizes of the specimens were examined in both the groups.

RESULTS

The demographic characteristics and preoperative and early postoperative outcomes were similar in both the groups. The size of the lesion was larger in the transvaginal group than that in the transanal group [4.58 ± 1.28 and 2.71 ± 1.55, respectively (P = 0.039)]. Two complications associated with extraction were observed (%9.09). A patient who underwent transanal extraction developed transient anal incontinence, which spontaneously resolved, and a patient who underwent transvaginal extraction developed anastomotic leakage and rectovaginal fistula associated with anastomotic leakage; a colonic stent was inserted for the management of this condition following which the patient recovered.

CONCLUSION

Only the lesion size was statistically significantly different between the transanal and transvaginal routes. Further, avoiding secondary organ injury is essential; therefore, the transanal route is primarily preferred. However, if the diameter of the lesion is large and the patient is female, the transvaginal route can be a useful alternative.

KEY WORDS

Natural orifice specimen extraction surgery, Laparoscopic colorectal surgery, Minimally invasive surgery.

Combination of laparoscopic side-to-end colorectal anastomosis and vaginal nose (natural orifice specimen extraction) surgery for colorectal endometriosis: Technique and outcomes

Objective:

To investigate the effectiveness of combining side-to-end anastomosis and vaginal NOSE (Natural orifice specimen extraction) surgery in colorectal endometriosis.

Material and methods:

We included 11 patients treated with laparoscopic side-to-end colorectal anastomosis and vaginal NOSE surgery between January 2019 and May 2021. We questioned the visual analog score (VAS) for pain symptoms, the short form-36 (SF-36) for health survey questionnaire, The Female Sexual Function Index (FSFI), EHP-5 for endometriosis health profile, The Hospital Anxiety and Depression Scale (HADS), OAB-V8 for overactive bladder symptoms and Constipation Severity Instrument (CSI).

Results:

VAS, EHP-5, and SF-36 scores were better at postoperative third and sixth months than preoperative values ( p < 0.05). There were no statistically significant differences in terms of FSFI, OAB-V8, HADS, and the CSI.

Conclusions:

Laparoscopic side-to-end anastomosis with vaginal NOSE surgery is feasible, scarless, and could be offered to patients with deep symptomatic bowel endometriosis.

Comparison of stapled versus stapleless sleeve gastrectomy with natural orifice specimen extraction (NOSE)

Background

Sleeve gastrectomy is a stapler dependent bariatric procedure. A stapleless sleeve gastrectomy can be necessary for certain circumstances.

Aims

Here, we aimed to show whether laparoscopic stapleless sleeve gastrectomy with natural orifice specimen extraction (NOSE) can be an alternative procedure to stapled sleeve gastrectomy.

Patients and Methods

In the stapleless group (n = 6), no staplers were used and after vertical resection of the stomach by energy devices, the stomach remnant was closed by two rows of intracorporeal sutures. The resected specimen was removed through the mouth using an endoscopic snare. In the stapler group (n = 7), sleeve gastrectomy was carried out with linear stapler under the guidance of 36 Fr bougie. The specimens were extracted from the left upper quadrant trocar site.

Results

A total of 13 patients were compared (stapleless = 6 and stapled group = 7). All the sleeve gastrectomies were completed laparoscopically. The operative time was longer at 200 minutes (range 120-300) versus 120 minutes, (range 90-200) p = 0.07) and the amount of bleeding was higher at 100 ml (range 50-200) versus 30 ml (range 10-50) (p = 0.004) in the stapleless group. Leakage and gastrointestinal bleeding were seen in the stapleless group but no complications were found in the stapler group. No statistically significant difference was found between the metabolic outcomes of the two groups after the operation (p > 0.05). Decrease in BMI at similar rates was observed in 5 postoperative year (stapleless group: 35 kg/m² (range 31-39) versus stapled group: 36.5 kg/m² (range 31-39), p > 0.05).

Conclusion

Laparoscopic stapleless sleeve gastrectomy with natural orifice specimen extraction has longer procedure time, more blood loss and complications.

Success rate of natural orifice specimen extraction after laparoscopic colorectal resections

PURPOSE

To date, no data have been available to inform which cases are appropriate for natural orifice specimen extraction (NOSE) after laparoscopic colorectal resections (LCRRs). Our aim was to evaluate the success rate and the factors affecting the failure in patients who were scheduled for NOSE after LCRRs.

METHODS

Seventy-two consecutive cases that were intended for NOSE after LCRR were enrolled. The transanal route was always chosen as the first option, and when it failed, the transvaginal route was tried in female patients. If both failed, the specimen was judged as unsuitable for NOSE and removed through an abdominal wall incision. Demographic data, surgical indications, resection localization, implemented procedures, incision sites, specimen extraction methods, specimen sizes, and failures of NOSE were recorded.

RESULTS

A total of 349 colorectal resections (240 open and 109 laparoscopic) in a 3-year period were examined. The subset of 72 consecutive patients who met the criteria were analyzed. Five cases required a conversion to open surgery during resections. In the remaining 67 patients, NOSE after LCRR was successful in 49 cases (73.1%) but failed in 18 (26.9%). Specimens were extracted from transanal and transvaginal routes in 37 (75.5%) and 12 (24.5%) patients, respectively. The failure rate of NOSE after LCRR was higher in males, in colonic lesions, and in large-sized tumors. The mean sizes of transanal and transvaginal extracted specimens were 3.5 ± 3.1 and 5.4 ± 1.4 cm, respectively (p < 0.05). The mean size of the tumors in the failed cases was 6.5 ± 4.2 cm (p < 0.05).

CONCLUSIONS

Approximately 2/3 of the unselected LCRRs were suitable for NOSE. The success rate increased with female gender, small-sized tumors, and rectal resections.

Influence of repeated measurements on small bowel length

Purpose

Measurement of small bowel length (SBL) is a common procedure in gastrointestinal surgery. When required, repeated SBL measurements can be done during surgery. Our aim was to evaluate whether these repeated measurements differ in SBL results.

Methods

Small bowel length was measured during laparotomy in 28 patients between ligament of Treitz and caecum, using a standard measure, two times in each patient consecutively by two different surgeons from the anti-mesenteric border of the bowel.

Results

The median age was 33 (19–67) including 18 male. There were 16 healthy donors for living related liver transplantations. Second measurements, performed immediately after the first measurements, significantly shortened the measured SBLs in the same patients (580 ± 103 vs. 485 ± 78 cm, p < 0.001).

Conclusions

During surgery, repeated length measurements caused contractions in the small bowel and this resulted to a significant decrease in the SBL. This should be keep in mind to prevent mismeasurements.

Transgastric removal of a polycystic liver disease using mini-laparoscopic excision

Surgical treatment is often necessary for patients with symptomatic or complicated polycystic liver diseases (PLD). In this paper, we describe a 52-year-old female with symptomatic PLD that had resulted in the formation of liver cysts, the largest of which was 23 cm in diameter. The patient underwent mini-laparoscopic fenestration through 5-mm abdominal trocars. The walls of the cysts were unroofed using a harmonic scalpel. Four thickened rubber-like pieces of specimens (sizes ranged between 9 × 6 × 0.5 cm and 6 × 3 × 0.1 cm) were not suitable for extraction through the 5-mm trocars. A gastrotomy was performed, and the specimens were extracted through the stomach with the help of an endoscope. Transoral removal of the specimens was completed without any complications, and the gastrotomy was closed intracorporeally. The patient was permitted to take fluids on day one, and oral intake was gradually increased. She was discharged on day four and was asymptomatic after two months of follow-up. The combination of mini-laparoscopy and intraoperative endoscopic specimen extraction represented a minimally invasive surgical approach for the treatment of PLD. To the best of our knowledge, this was the first case report of the transoral extraction of a liver specimen.

Fibrin sealant use in pilonidal sinus: Systematic review

AIM: To review the current data about the success rates of fibrin sealant use in pilonidal disease.

METHODS: Fibrin sealant can be used for different purposes in pilonidal sinus treatment, such as filling in the sinus tracts, covering the open wound after excision and lay-open treatment, or obliterating the subcutaneous dead space before skin closure. We searched Pubmed, Google-Scholar, Ebsco-Host, clinicaltrials, and Cochrane databases and found nine studies eligible for analysis; these studies included a total of 217 patients (84% male, mean age 24.2 ± 7.8).

RESULTS: In cases where fibrin sealant was used to obliterate the subcutaneous dead space, there was no reduction in wound complication rates (9.8% vs 14.6%, P = 0.48). In cases where sealant was used to cover the laid-open area, the wound healing time and patient comfort were reported better than in previous studies (mean 17 d, 88% satisfaction). When fibrin sealant was used to fill the sinus tracts, the recurrence rate was around 20%, despite the highly selected grouping of patients.

CONCLUSION: Consequently, using fibrin sealant to decrease the risk of seroma formation was determined to be an ineffective course of action. It was not advisable to fill the sinus tracts with fibrin sealant because it was not superior to other cost-effective and minimally invasive treatments. New comparative studies can be conducted to confirm the results of sealant use in covering the laid-open area.

Retroperitoneal mass presenting as recurrent inguinal hernia: A case report

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A retroperitoneal tumor can present as a scrotal mass.

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An irreducible, hard but painless scrotal mass should warn the clinician.

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Slow growing pattern of the hard scrotal mass is important for the differential diagnosis.

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CT is diagnostic for the retroperitoneal tumor and its scrotal extension.

Introduction

Retroperitoneal masses presenting as an inguinal hernia are rare conditions.

Presentation of case

A 53 year old male admitted with the symptoms of weight loss, abdominal discomfort and left sided recurrent inguinal hernia. Physical examination demonstrated an abdominal mass in the left flank and an irreducible, painless scrotal mass. He had a history of left sided inguinal hernia surgery six years ago. Computed tomography revealed a large enhancing left sided retroperitoneal mass invading the colon, pancreas and kidney and it was going down towards the left scrotum. Unblock tumor resection including the neighboring organs (left kidney, left colon, distal pancreas with spleen) was performed. Scrotal extension of the tumor was also excised and the inguinal canal was repaired primarily. Histopathology of the mass was myxoid-liposarcoma. The patient has disease free, without hernia recurrence but poor in renal function after twenty months follow-up.

Discussion

Large retroperitoneal tumors may grow towards the inguinal region and they can mimic an inguinal hernia. An irreducible, painless and hard scrotal mass should be considered from this perspective.

Comparison of Direct Trocar Entry and Veress Needle Entry in Laparoscopic Bariatric Surgery: Randomized Controlled Trial

BACKGROUND

We aimed to compare the direct trocar insertion (DTI) and Veress needle insertion (VNI) techniques in laparoscopic bariatric surgery.

MATERIALS AND METHODS

Eighty-one patients scheduled for bariatric surgery at Inonu University, Malatya, Turkey, were included in this study. In 39 patients, a bladed retractable nonoptical trocar was used for DTI, and VNI was performed in 42 patients. Intraoperative access-related parameters were compared. Data were analyzed with Student's t and chi-squared tests. A P value of <.05 was considered significant.

RESULTS

Both groups had comparable demographic profiles. Laparoscopic entry time was shorter in the DTI group (79.6 ± 94.6 versus 217.6 ± 111.0 seconds; P < .0001). Successful entry rates in the first attempt, CO2 consumptions, failed attempt rates, and overall intraoperative complication rates were similar. However, in the DTI group, 2 patients had mesenteric injuries, and 1 of them required conversion to open surgery due to the mesenteric hemorrhage.

CONCLUSIONS

DTI in obese patients significantly shortens the entry time, but there can be severe complications with DTI when a nonoptical bladed trocar is used blindly. Actually, neither method can be recommended for entry into the abdomen in this population based on our results. If the surgeon has to choose a nonoptical trocar in bariatric surgery, preference for the VNI technique instead of the DTI technique is safer.

Histopathologic Findings of Cholecystectomy Specimens in Patients Who Underwent Donor Hepatectomy for Living Donor Liver Transplantation

BACKGROUND

The aim of this study was to discuss the macroscopic and microscopic properties of gallbladder specimens obtained from living liver donors.

METHODS

The study retrospectively analyzed the clinical and histopathological data of 1088 donors who underwent living donor hepatectomy between March 2005 and September 2014 at Inonu University Faculty of Medicine, Liver Transplantation Center. Age, sex, macroscopic, and microscopic properties of the gallbladder (bladder length, diameter, content, and histopathological properties) were recorded by 2 researchers.

RESULTS

A total of 1009 donors aged 17 to 66 years (31.1 ± 9.5) met the inclusion criteria, whereas 79 donors were excluded due to missing data. In total, 587 donors were male (30.5 ± 9.1 years [16-63 years]) and 422 were female (31.8 ± 9.8 years [18-66 years]). Preoperative tests revealed Gilbert syndrome in 3 subjects, whereas other donors' biochemical tests were within normal ranges. The macroscopic examination of gallbladders revealed mean gallbladder wall thickness, length, and width of 1.82 ± 0.8 mm (1-10 mm), 72 ± 11.4 mm (40-120 mm), and 52.5 ± 14 mm (15-90 mm), respectively. The microscopic gallbladder examination showed that 740 donors had a normal gallbladder, 193 had chronic cholecystitis (1 donor had antral metaplasia and 1 had intestinal metaplasia), 40 had cholesterolosis (1 donor had both tubular adenoma and intestinal metaplasia), 15 had minimal chronic cholecystitis (1 donor had pyloric metaplasia), 14 had cholelithiasis, 2 had adenomyosis, 2 had muscular hypertrophy, 1 had papillary hyperplasia, 1 had microdiverticulitis, and 1 had mucosal lymphatic ectasia.

CONCLUSION

The results of this study reflect the actual gallbladder pathologies that can be detected in healthy people. Clearer conclusions can be reached about the epidemiological data on gallbladder as the number of living liver donors increases in the future.

Follow up of a family with asymptomatic compound long QT syndrome mutations

Long QT syndromes (LQTS) are a cause of syncope and sudden death and present as a long QT interval on the surface ECG. The mortality of the condition may be quite variable among affected individuals. Hundreds of mutations in more than ten genes are identified as responsible for almost all patients with LQTS. Compound mutations are reported in different series as 4.5 and 7.9% and are associated with poor outcome. Beta blockers are the mainstay of therapy. The use of intracardiac defibrillators (ICD) is widely considered in patients at high risk for sudden death. Herein, we report a case of LQTS with compound mutations of KCNQ1 and SCN5a. Although ICD implantation was advised due to high cardiac event risk, the patient followed with beta blocker treatment for 15 years without any syncope or palpitations.