Treatment Modalities and the Role of Endoscopy for Delayed Gastric Emptying After Whipple Operation: Analysis of 53 Patients

BACKGROUND

Delayed gastric emptying (DGE) is one of the most common complications after Whipple surgery. This situation delays postoperative oral food intake and prolongs hospitalization. Postoperative DGE often develops due to complications such as intra-abdominal abscess, collections, and anastomosis leaks, and these are called secondary DGE. The pathogenesis of primary DGE is still unknown, and there are insufficient data in the literature about the treatment. In this study, patients undergoing Whipple operation were examined separately as primary and secondary DGE. We discussed the causes and treatments of these patients, and also we aimed to present the therapeutic effect of endoscopy for primary DGE after the Whipple procedure.

METHODS

From March 2014 to March 2018, data of 262 patients who underwent the Whipple procedure were collected prospectively. We observed that postoperative DGE developed in 53 (21.7%) patients. We retrospectively divided the patients by etiology into 2 groups as primary and secondary and graded DGE according to the International Study Group of Pancreatic Surgery. We defined patients who did not have secondary causes such as intra-abdominal abscess as primary DGE. Appropriate interventional procedures were performed for patients with secondary causes. We performed endoscopic intervention with therapeutic intent for patients who had primary DGE.

RESULTS

The overall rate of DGE was 21.7% (n = 53) among 262 patients undergoing the Whipple procedure. It was observed that in 31 (58.5%) of these 53 patients, DGE was developed due to secondary causes. Interventional procedures were performed to these patients when necessary. A total of 22 (41.5%) patients developed primary DGE. Of these, 9 patients were grade A, 7 were grade B, and 6 were grade C. The mean duration of hospitalization for secondary DGE and primary DGE was 20.36 and 28.7 days, respectively. After endoscopic intervention with therapeutic intent to primary DGE patients, we observed that patients tolerated solid meal after 12 hours in grade B and after 26 hours in grade C patients.

CONCLUSION

Delayed gastric emptying, which is a common complication after Whipple operation and which deteriorates the quality of life and prolongs the duration of hospital stay, should be treated according to the cause. In secondary DGE, treatment modalities must be focused on intra-abdominal causes such as hematoma, collection, and abcess. We suggest that the primary DGE which is unresponsive to medical treatments could be treated endoscopically. After endoscopic intervention, patients with primary DGE can be started oral intake on the same day and discharged more quickly.

Comparison of Early Postoperative Outcomes after Total Gastrectomy and D2 Lymph Node Dissection with and without Splenectomy

Background

A famous prognostic ingredient for gastric cancer is the lymph node metastasis. Previously in the therapy of gastric cancer, splenectomy was considered as a definitive part of lymph node dissection. Currently, preservation of the spleen is the accepted approach during total gastrectomy and routine splenectomy is abandoned. The aim of this study was to estimate the impression of splenectomy for D2 lymph node dissection with total gastrectomy.

Methodology

Between February 1998 and January 2012, 1531 patients underwent gastric cancer surgery. Of these 257 patients, 205 patients underwent total gastrectomy with splenectomy, and the remaining 52 underwent a spleen-preserving total gastrectomy.

Results

No statistical difference between these two groups in terms of age, gender, comorbidity, stage and American Society of Anesthesiologists score, surgical complications were detected. A significant difference was not seen in these groups with regard to postoperative mortality too.

Conclusion

Early postoperative results were similar after TG ± splenectomy. Performing splenectomy did not increase the postoperative morbidity and mortality.

How to cite this article: Oter V, Dalgic T, Ozer I, Colakoglu K, Cayci M, Ulas M, Bostanci EB, Akoglu M. Comparison of Early Postoperative Outcomes after Total Gastrectomy and D2 Lymph Node Dissection with and without Splenectomy. Euroasian J Hepatogastroenterol, 2018;8(2):108-111.

Roles of adiponectin and leptin as diagnostic markers in pancreatic cancer

NTRODUCTION

Obesity is one of the most serious public health problem worldwide. Adipose tissue synthetize and secrete many growth factors and several cytokines known as adipokines. Studies demonstrated changes in the levels of these adipokines in many types of cancer associated with obesity. In this study, we aimed to evaluate the possible relationship between adiponectin and leptin levels with pancreas cancer and disease stage, representative of Turkish population.

MATERIALS AND METHODS

The study was conducted between April 2012 - November 2013. Study included 46 patients - 46 control subjects, who had pancreatic carcinoma. Results between the patients and the control group and relationship between the disease stage and results were evaluated.

RESULTS

The comparison of preoperative adiponectin and leptin levels of the study group with the levels of the control group showed that there was no correlation with adiponectin and pancreas cancer. In contrast, leptin levels in the study group were significantly lower than in the control group. There was no correlation between the disease stage and adiponectin and leptin levels.

CONCLUSION

There was a significant correlation between low leptin levels and pancreatic cancer, while adiponectin had no correlation. Differential diagnosis of pancreas cancer can be made by evaluating low leptin levels with elevated tumor markers (Tab. 3, Ref. 17).

Management of Laparoscopic Cholecystectomy-Related Bile Duct Injuries: A Tertiary Center Experience

BACKGROUND

Laparoscopic cholecystectomy (LC)-related bile duct injuries remains a challenging issue with major implications for patient's outcome.

METHODS

Between January 2008 and December 2012, we retrospectively analyzed the management and treatment outcomes of 90 patients with bile duct injury following LC.

RESULTS

Forty-seven patients (52.2%) were treated surgically while the remaining 43 patients (47.8%) underwent non-surgical intervention. Injuries of Strasberg Type A and C were significantly more frequent in the non-surgical intervention group (P = 0.016, P = 0.044) whereas Type E2 was more frequent in the definitive surgery group (P < 0.001). The success rate of non-surgical intervention decreased as the waiting time increased whereas the success of definitive surgery was not time-dependent (P = 0.048). Initial jaundice (direct biluribin >1.3 gr/dL) significantly reduced the success rate of non-surgical interventions (P = 0.017). Presence of intraabdominal abscess significantly increased the complication rate after both definitive surgery and non-surgical interventions (P = 0.04, P = 0.023). Treatment success rates were similar in both surgery and non-surgical intervention groups according to the distribution of Strasberg injury types.

CONCLUSION

A multimodality approach is recommended in planning for patient-based treatment. Delayed referral reduces the success of nonsurgical interventions while it does not seem to significantly affect the success of surgical interventions when intraabdominal sepsis is under control.

A Retrospective Analysis of Factors Affecting Early Stoma Complications

Despite advances in surgical techniques and products for stoma care, stoma-related complications are still common. A retrospective analysis was performed of the medical records of 462 consecutive patients (295 [63.9%] female, 167 [36.1 %] male, mean age 55.5 ± 15.1 years, mean body mass index [BMI] 25.1 ± 5.2) who had undergone stoma creation at the Gastroenterological Surgery Clinic of Turkiye Yuksek İhtisas Teaching and Research Hospital between January 2008 and December 2012 to examine the incidence of early (ie, within 30 days after surgery) stoma complications and identify potential risk factors. Variables abstracted included gender, age, and BMI; existence of malignant disease; comorbidities (diabetes mellitus, hypertension, coronary artery disease, chronic respiratory disease); use of neoadjuvant chemoradiotherapy; permanent or temporary stoma; type of stoma (loop/end stoma); stoma localization; and the use of preoperative marking of the stoma site. Data were entered and analyzed using statistical software. Descriptive statistics, chi-squared, and Mann-Whitney U tests were used to describe and analyze all variables, and logistic regression analysis was used to determine independent risk factors for stoma complications. Ostomy-related complications developed in 131 patients (28.4%) Of these, superficial mucocutaneous separation was the most frequent complication (90 patients, 19.5%), followed by stoma retraction (15 patients, 3.2%). In univariate analysis, malignant disease (P = .025), creation of a colostomy (P = .002), and left lower quadrant stoma location (P <.001) were all significant indicators of stoma complication. Only stoma location was an independent risk factor for the development of a stoma complication (P = .044). The rate of stoma complications was not significantly different between patients who underwent nonemergent surgery (30% in patients preoperatively sited versus 28.4% not sited) and patients who underwent emergency surgery (27.1%). Early stoma complication rates were higher in patients with malignant diseases and with colostomies. The site of the stoma is an independent risk factor for the development of stoma complication. Preoperative marking for stoma creation should be considered to reduce the risk of stoma-related complications. Prospective, randomized controlled studies are needed to enhance understanding of the more prevalent risk factors.

Risk Factors for Development of Biliary Complications after Surgery for Solitary Liver Hydatid Cyst

Biliary leakage (BL) is the most common cause of postoperative morbidity after conservative liver hydatid cyst surgery. The objective of this study was to determine incidence of BL and related risk factors in patients with solitary liver hydatid cyst who underwent conservative surgery. A total of 186 patients were included in this study. Age, gender, cyst recurrence, diameter, and localization, World Health Organization Informal Working Group on Echinococcosis (WHO-IWGE) classification, cavity management techniques, cyst content, and alkaline phosphatase (ALP) levels were evaluated with univariate and multivariate analyses. Of these patients 104 were female and 82 were male. The mean age was 43.5 ± 14.7 years. Postoperative BL was detected in 36 (19.4%) patients. Cyst diameter (P = 0.019), cyst localization (P = 0.007), WHO-IWGE classification (P = 0.017), and ALP level (P = 0.001) were the most significant risk factors for BL. Independent risk factors for BL were perihilar localization, large cyst diameter, high ALP level, and advanced age according to WHO-IWGE classification.

Risk Factors for Development of Biliary Complications after Surgery for Solitary Liver Hydatid Cyst

Biliary leakage (BL) is the most common cause of postoperative morbidity after conservative liver hydatid cyst surgery. The objective of this study was to determine incidence of BL and related risk factors in patients with solitary liver hydatid cyst who underwent conservative surgery. A total of 186 patients were included in this study. Age, gender, cyst recurrence, diameter, and localization, World Health Organization Informal Working Group on Echinococcosis (WHO-IWGE) classification, cavity management techniques, cyst content, and alkaline phosphatase (ALP) levels were evaluated with univariate and multivariate analyses. Of these patients 104 were female and 82 were male. The mean age was 43.5 ± 14.7 years. Postoperative BL was detected in 36 (19.4%) patients. Cyst diameter (P = 0.019), cyst localization (P = 0.007), WHO-IWGE classification (P = 0.017), and ALP level (P = 0.001) were the most significant risk factors for BL. Independent risk factors for BL were perihilar localization, large cyst diameter, high ALP level, and advanced age according to WHO-IWGE classification.

Effects of carbon dioxide pneumoperitoneum on postoperative adhesion formation and oxidative stress in a rat cecal abrasion model

INTRODUCTION

It is claimed that CO2 pneumoperitoneum (CP) is less adhesiogenic than laparotomy. Our aim in this study was to investigate the local oxidative stress responses and related adhesion formation resulting from exposure to CP.

METHODS

Forty-five rats were randomised into six groups. Group 1 underwent laparotomy only; in group 2, 6 mmHg CP was performed for 60 min; in group 3, the same procedure was carried out using 12 mmHg CP; in group 4, laparotomy and cecal-peritoneal abrasion were performed; in group 5, 6 mmHg CP was performed for 60 min, followed by laparotomy and cecal-peritoneal abrasion; in group 6, the same procedure was carried out using 12 mmHg CP. Groups 1, 2 and 3 were sacrificed immediately and used only for biochemical examination. The other groups were sacrificed on the 14th postoperative day.

RESULTS

The total adhesion scores, thickness, quantity, extent and type of adhesions decreased steadily in groups 4, 5 and 6 (p < 0.05). The median values for neutrophil and monocyte infiltration, and for capillary and fibroblast proliferation decreased steadily in groups 4, 5 and 6 (p < 0.05). CAT, SOD and GSHPx levels decreased significantly in line with increasing pressure in groups 1, 2 and 3. SOD and GSHPx levels were similar in groups 4, 5 and 6, while CAT levels decreased with increasing pressure in groups 4, 5 and 6.

CONCLUSION

It was found that CP is associated with less adhesion formation than laparotomy in the presence of similar antioxidant levels. The reduced adhesion formation is probably caused by a decreased inflammatory response.

The rationality of resectional surgery and palliative interventions in the management of patients with gallbladder cancer

The aim of the present study was to evaluate in a retrospective manner, the survival period and survival rate according to stages and groups after R0, R1, R2 resections and palliative interventions. Between 2003 and 2012, 67 patients diagnosed with gallbladder carcinoma were retrospectively analyzed. Patient demographics, the survival period, and survival rate according to stages and groups after R0, R1, R2 resections and palliative interventions were retrospectively analyzed. Sixty-seven patients were diagnosed with gallbladder carcinoma. Thirty-eight patients (56.7%) were female and 29 patients (43.3%) were male. The median survival period was significantly longer in stage II and III diseases than in stage IV disease (P < 0.001). The R0, R1, and R2 resection rates in patients who underwent surgery with curative intent were 67.7, 19.4, and 12.9 per cent, respectively. The R0 resection rate according to the tumor stages was 100 per cent for stage I, 87.5 per cent for stage II, 66.7 per cent for stage III, and 42.8 per cent for stage IV disease. The median follow-up period was six months (eight days to 36 months). During this follow-up period, 53 patients (79.1%) died. In conclusion, R0 resection rate decreases when tumor stage increases. The highest survival rates after R0 resection are achieved in patients with stage I, II, and III diseases. Radical surgery has no benefit over palliative surgery for stage IV disease in terms of survival.

The Rationality of Resectional Surgery and Palliative Interventions in the Management of Patients with Gallbladder Cancer

The aim of the present study was to evaluate in a retrospective manner, the survival period and survival rate according to stages and groups after R0, R1, R2 resections and palliative interventions. Between 2003 and 2012, 67 patients diagnosed with gallbladder carcinoma were retrospectively analyzed. Patient demographics, the survival period, and survival rate according to stages and groups after R0, R1, R2 resections and palliative interventions were retrospectively analyzed. Sixty-seven patients were diagnosed with gallbladder carcinoma. Thirty-eight patients (56.7%) were female and 29 patients (43.3%) were male. The median survival period was significantly longer in stage II and III diseases than in stage IV disease ( P < 0.001). The R0, R1, and R2 resection rates in patients who underwent surgery with curative intent were 67.7, 19.4, and 12.9 per cent, respectively. The R0 resection rate according to the tumor stages was 100 per cent for stage I, 87.5 per cent for stage II, 66.7 per cent for stage III, and 42.8 per cent for stage IV disease. The median follow-up period was six months (eight days to 36 months). During this follow-up period, 53 patients (79.1%) died. In conclusion, R0 resection rate decreases when tumor stage increases. The highest survival rates after R0 resection are achieved in patients with stage I, II, and III diseases. Radical surgery has no benefit over palliative surgery for stage IV disease in terms of survival.

The analysis of clinico-pathologic characteristics in patients who underwent surgery due to stricturing and non-perineal fistulizing forms of Crohn's disease: a retrospective cohort study

BACKGROUND

The diagnosis of Crohn's disease is based mainly on the patient's history and clinical examination and supported by serologic, radiologic, endoscopic, and histologic findings.

AIMS

The main purpose of the present study was to evaluate in a retrospective manner the clinico-pathological characteristics of patients who underwent surgery due to stricturing or non perineal fistulizing Crohn's disease.

MATERIAL AND METHODS

Between January 2007 and June 2012, 75 patients who were operated on for stricturing and non-perineal fistulizing forms of Crohn's disease were analyzed according to their clinico-pathological characteristics.

RESULTS

The L3 localization (Montreal Classification) was detected significantly more often in the non-perineal fistulizing group than in the stricturing group (P < 0.03). Wound infection (18 patient, 24%) was the most commonly observed postoperative complication, followed by postoperative ileus (5 patients, 6.7%) and intraabdominal abscess (4 patients, 5.2%). The distribution of postoperative complications according to the two groups was not significantly different (P = 0.772). Submucosal fibrosis, ulcers and transmural inflammation were the three most common histopathological signs in resected specimens from both groups. Pseudopolyps, microabscess, granuloma, mononuclear inflammation and deep fissures were significantly far more frequent in the non perineal fistulizing group when compared to the stricturing group (P < 0.05). On the other hand, superficial ulcers were significantly more frequent in the stricturing group (P = 0.007).

CONCLUSION

No specific clinical feature was found to differentiate patients with the stricturing form of Crohn's disease from the fistulizing form. However, histopathological analysis of the resected specimens revealed significant differences in some parameters between the two disease forms.

Giant hemangiomas: effects of size and type of surgical procedure on postoperative outcome

BACKGROUND/AIMS

Controversies still exist regarding the management of giant hemangiomas. The purpose of this study was to evaluate in a retrospective manner the effects of size and type of surgical procedures on early postoperative results.

METHODOLOGY

Between January 2000 and January 2011, a total of 82 patients underwent surgery. Patients were divided into 2 groups; according to size (Group 1 >10cm and Group 2 ≤10cm) and the selected operative procedure.

RESULTS

When the patients were compared according to size of the lesions, the operation time was significantly longer (p=0.01) and the amount of blood loss was significantly higher (p=0.04) in hemangiomas >10cm. If the patients were compared according to type of the surgical procedure, hepatic resection was more frequently preferred in bilobar and left lobe localized lesions, whereas enucleation was significantly more chosen in lesions localized to the right lobe (p=0.01).

CONCLUSIONS

Size of the hemangioma did not alter selection of the surgical procedure in this series. Larger hemangiomas are associated with longer operation time and more blood loss. Surgical results after enucleation and resection are similar. Although enucleation seems preferable, it is not an easy procedure, and may result in severe bleeding.

Diagnostic value of preoperative serum carcinoembryonic antigen and carbohydrate antigen 19-9 in colorectal cancer

BACKGROUND

Since the first introduction of tumour markers, their usefulness for diagnosis has been a challenging question. The aim of the present prospective study was to investigate, in colorectal cancer patients, the relationship between preoperative tumour marker concentrations and various clinical variables.

METHODS

The study prospectively enrolled 131 consecutive patients with a confirmed diagnosis of colorectal carcinoma and 131 age- and sex-matched control subjects with no malignancy. The relationships of the tumour markers carcinoembryonic antigen (cea) and carbohydrate antigen (ca) 19-9 with disease stage, tumour differentiation (grade), mucus production, liver function tests, T stage, N stage, M stage were investigated.

RESULTS

Serum concentrations of cea were significantly higher in the patient group than in the control group (p = 0.001); they were also significantly higher in stage iii (p = 0.018) and iv disease (p = 0.001) than in stage i. Serum concentrations of cea were significantly elevated in the presence of spread to lymph nodes (p = 0.005) in the patient group. Levels of both tumour markers were significantly elevated in the presence of distant metastasis in the patient group (p = 0.005 for cea; p = 0.004 for ca 19-9).

CONCLUSIONS

Preoperative levels of cea and ca 19-9 might provide an estimate of lymph node invasion and distant metastasis in colorectal cancer patients.

Multiple synchronous anorectal malignant melanoma coexisting with adenocarcinoma of the sigmoid colon

Primary anorectal malignant melanoma is an exceptionally rare neoplasm associated with poor prognosis. Anorectal malignant melanoma has been very rarely described with coexisting primary tumors of the colorectum. A 56-year-old female patient was admitted with a history of rectal bleeding. She had experienced increasing constipation and a sense of obstruction in the rectum for 6 months. Flexible rectosigmoidoscopy showed a large, pedinculated polypoid lesion extending from the anal canal to the rectum. She underwent a transanal local excision and was diagnosed with a melanoma of the anorectum with positive margins. Therefore, a formal abdominoperineal resection was performed. In addition to multiple synchronous anorectal malignant melanoma, we incidentally found another primary tumor in the proximal surgical margin of the resected specimen. Histopathologically, the lesion was an intramucosal adenocarcinoma of the sigmoid colon. Postoperatively, the patient received adjuvant chemotherapy of six cycles duration. At present, the patient has completed 18 months of follow-up.

Effects of β-glucan on colon anastomotic healing in rats given preoperative irradiation

BACKGROUND

Radiation therapy is an essential therapeutic modality in the management of a wide variety of tumors. We aimed to investigate the short-term effects of pelvic irradiation on the healing of colon anastomoses and to determine the potential protective effects of β-glucan in this situation.

MATERIAL AND METHODS

Sixty Wistar albino rats were randomized into three experimental groups: a control group (n = 20), an irradiation (IR) group (n = 20), and an irradiation+β-glucan (IR+β-glucan) group (n = 20). Only segmental colonic resection and anastomosis were performed on the control group. The IR group underwent the same surgical procedure as the control group 5 days after pelvic irradiation. In the IR+β-glucan group, the same procedure was applied as in the IR group after β-glucan administration. The groups were subdivided into subgroups according to the date of euthanasia (third [n = 10] or seventh [n = 10] postoperative [PO] day), and anastomotic colonic segments were resected to evaluate bursting pressures and biochemical and histopathological parameters.

RESULTS

Bursting pressure values were significantly lower in the IR group (p < .001). Malondialdehyde (MDA) levels were significantly higher in the IR group, whereas β-glucan significantly decreased MDA levels on the third PO day (p < .001). Granulation tissue formation scores were significantly lower in the IR+β-glucan group compared with the control group and the IR group (p < .001).

CONCLUSIONS

The results of this study indicate that irradiation has negative effects on the early healing of colon anastomoses. The administration of β-glucan ameliorates these unfavorable effects by altering bursting pressures and biochemical parameters.

A prospective observational study of 468 patients undergoing D2 or D3 lymphadenectomy for gastric cancer

BACKGROUND/AIMS

A single-center, prospective observational study was performed to evaluate outcomes in patients undergoing D2 or D3 lymphadenectomy for gastric cancer.

METHODOLOGY

Lymphadenectomies were performed according to the classification published by the Japanese Gastric Cancer Association.

RESULTS

Of 468 consecutive patients, 370 underwent D2 and 98 underwent D3 lymphadenectomy. Postoperative complications were significantly less common in the D2 group than in the D3 group (19.2% vs. 35.7%, p=0.001). Postoperative mortality in the two groups was similar, being 3.8% in the D2 group and 5.1% in the D3 group (p>0.05). Median postoperative survival times were also similar, in the D2 group being 37.8 months (95% CI: 23-52.5), and in the D3 group 30.2 months (95% CI: 13-47.3, p>0.05).

CONCLUSIONS

In patients who underwent gastrectomy with curative intent, lymphadenectomy that was more extensive than D2 did not provide a survival benefit compared to D2 dissection.

Sildenafil accelerates liver regeneration after partial hepatectomy in rats

OBJECTIVE

The regeneration process causes the liver to achieve an adequate volume and function after major hepatectomy or living donor liver transplantation. Sildenafil, a selective phosphodiesterase-5 inhibitor used for erectile dysfunction, impacts the liver by enhancing the effects of nitric oxide. The aim of this study was to investigate the influence of sildenafil on liver regeneration in rats after partial hepatectomy.

METHODS

Sixty young female Wistar Albino rats were randomly divided into three equal groups before 70% hepatectomy. Thereafter, we administered intraperitoneal saline to the control group (G1); 10 μg/kg sildenafil to the low-dose group (G2) and 100 μg/kg to the high-dose sildenafil group (G3). Half of the rats per group were sacrificed on the first and the other half on the fifth postoperative day after partial hepatectomy. Regeneration was assessed using three methods: (1) the formula described by Kwon et al formula, (2) the average number of mitotic figures in 10 microscopic fields, and (3) the average of Ki-67-positive nuclei in 1000 cells using immunohistochemistry.

RESULTS

Although, the hepatic regeneration and mitosis rates were similar in all three groups, Ki-67 levels were significantly higher in both G2 and G3 than the control group on the first postoperative day. Hepatic regeneration was significantly greater in G2 and G3 than the control group as was the mitosis rate in the G2 group versus the two groups. By the 5th postoperative day Ki-67 levels were similar in the three groups.

CONCLUSION

Sildenafil treatment accelerated hepatic regeneration after partial hepatectomy in rats.

Superiority of ceftriaxon to cefazolin in a rat model of obstructive jaundice: an experimental study

OBJECTIVE

The objective of this study was to evaluate the serum and bile concentrations of cefazolin and ceftriaxone at the third and sixth hours in an experimental obstructive jaundice model and to identify the rate of excretion of these antibiotics into the bile.

MATERIAL AND METHODS

Thirty-two Wistar albino rats were used in this study. The bile and serum levels of cefazolin were measured at the third hour in the A1 group and at the sixth hour in the A2 group, with cefazolin administered as 5 mg/rat; while the bile and serum levels of ceftriaxone were studied at the third hour in the B1 group and at the sixth hour in the B2 group, with ceftriaxone administered as 5 mg/rat.

RESULTS

After 3 hr of cefazolin administration, the serum concentration in the A1 group reached a mean of 1.8 μg/ml, while the bile concentration was 90% of the serum concentration, with a mean of 1.6 μg/ml; whereas in the B1 group, the third-hour serum concentration of ceftriaxone was 18.6 μg/ml, while the bile concentration was found to be as high as 330% of this level, i.e., 56 μg/ml. The serum value of cefazolin decreased to 1.4 μg/ml in the A2 group and ceftriaxone decreased to 3.7 μg/ml in the B2 group at the sixth hour.

CONCLUSIONS

Although the excretory level of cefazolin and ceftriaxone into the bile reaches therapeutic doses, the duration for which these levels are above those required for bactericidal activity is short. Ceftriaxone is better concentrated in the serum and bile than cefazolin.

Management of hepatic artery aneurysms

BACKGROUND

Hepatic artery aneurysm (HAA) is a rare clinical entity that can lead to potentially life threatening complications. We reported our personal experience of 4 cases, in which we used different procedures.

METHODS

The first case had a pseudo-aneurysm involving the right hepatic artery. The second case had a pseudo-aneurysm, which was localized distal to the accidentally ligated right hepatic artery from the previous cholecystectomy operation. The third case had multiple aneurysms with accompanying dissecting abdominal aortic aneurysm. The fourth case had a pseudo-aneurysm originating from the proper hepatic artery. A covered stent was successfully placed in the case 1. In the second case, the right hepatic artery was ligated distal to the aneurysm. In the third case, vascular structures were not appropriate for vascular reconstruction, and a covered stent placement and embolization were unsuccessful. In the fourth case, ligation of the proper hepatic artery and cholecystectomy was performed.

RESULTS

The third case with multiple aneurysms died from multi-organ failure due to sepsis. The remaining cases (case 1, 2, and 4) are disease free and alive.

CONCLUSION

HAAs are more commonly observed clinical entities, and their treatment should be handled for each patient separately. Computerized tomography-Angiography and intraoperative Doppler ultrasound are useful radio-diagnostics for determination of aneurysm and planning the operative procedure (Fig. 5, Ref. 15).

Presence of free cancer cells in the peritoneal cavity of patients who underwent curative gastrectomy with lymph node dissection

BACKGROUND/AIMS

The aim of this study was to determine the ratio of patients with positive peritoneal cytology who underwent radical gastrectomy for gastric cancer, to evaluate the factors effecting risk of positive cytology and to analyze the effects cytology findings on survival.

METHODOLOGY

Peritoneal lavage samples were obtained from 255 patients who underwent radical gastrectomy with D2 (184 patients) or D3 (71 patients) lymph node dissection between January 2000 and December 2007.

RESULTS

Thirty-six (14.1%) of 255 patients had free cancer cells in the wash cytology samples. T stage (T4) and differentiation were found to be independent risk factors for positive peritoneal cytology in multivariate analysis. Survival rate of cytology negative patients was significantly higher, however cytology findings were not found to be an independent prognostic factor for survival. T stage, lymph node metastasis and Borrmann classification (Borrmann type 4) appeared to be independent prognostic factors for survival in multivariate analyses.

CONCLUSIONS

Peritoneal cytology does not provide additional information according to the TNM (1997) staging system. However, it should be employed intraoperatively before potentially curable serosa involved gastric carcinomas, especially for T4 tumors. Surgery alone will not be enough for patients with positive cytology and further therapies should be employed.

Management of choledochal cysts in adults: a retrospective analysis of 23 patients

BACKGROUND/AIMS

Choledochal cysts are rare congenital anomalies of the pancreaticobiliary system, whose etiology remains unknown. We aimed to review patients with choledochal cysts and to compare our results with current literature.

METHODOLOGY

Twenty-three patients diagnosed as having choledochal cysts between January 2004 and July 2010 were evaluated retrospectively.

RESULTS

Thirteen patients had type I (56.5%), 3 patients type II (13%), 3 patients type III (13%), 1 patient type IV-A (8.3%) and the remaining 3 patients had type V (13%) choledochal cysts. All patients with type I cysts underwent cyst excision with Roux-en-Y hepaticojejunostomy. Two patients with type II cysts underwent cyst excision with choledochoduodenostomy, whereas cyst excision with T-tube drainage was applied to the other. Endoscopic unroofing was performed type III cysts. The patient with type IV-A cyst was not eligible for surgery due to low cardiopulmonary performance status but ERCP was applied successfully more than 3 times for the extraction of the stones which fell from the intrahepatic ducts into the common bile duct. Patients with Type V cysts underwent left hepatectomy, choledocoduodenostomy and cadaveric liver transplantation, respectively. Wound infection developed in 5 patients and anastomotic leakage occurred in 3; one died from sepsis.

CONCLUSIONS

Choledochal cysts are rare congenital malformations. Although treatment varies depending on the type of the cysts, complete excision of the cysts should be performed if possible.

Surgical outcome of patients with perforation after endoscopic retrograde cholangiopancreatography

BACKGROUND

The most important criterion in the management of endoscopic retrograde cholangiopancreatography (ERCP)-related perforations is the delineation of the injury pattern. The aim of the present study was to evaluate in a retrospective manner the patients who undergo surgery due to ERCP-related perforations.

PATIENTS AND METHODS

Between January 2006 and December 2010, a total of 9209 ERCPs were performed at Turkiye Yuksek Ihtisas Teaching and Research Hospital, Ankara, Turkey. From these, perforation was diagnosed in 52 patients (0.56%). Twenty-four patients (46.2%) underwent surgery. Patients were evaluated according to age, gender, ERCP indication, comorbid disease, the time between diagnosis and perforation, the time between ERCP and surgical intervention, radiological and clinical signs, localization of the perforation, surgical procedure, hospitalization period, and postoperative outcome.

RESULTS

Twenty-four patients underwent surgery. Thirteen patients (54.1%) had lateral duodenal wall perforation, 4 patients (16.7%) had perforation in the afferent loop (these patients had Billroth-II gastroenterostomy at ERCP admission), 2 patients (8.3%) had bile duct perforation, and 1 patient (4.1%) had esophageal perforation. In 4 patients (16.7%), the localization of the perforation could not be found. Nine patients (37.5%) died in the postoperative period. Six patients had lateral duodenal wall perforation, 2 patients had afferent loop perforation, and one patient had esophagus perforation. Three patients died of nonsurgical reasons (myocardial infarction, serebrovascular occlusion, and cardiac dysrhythmia).

CONCLUSIONS

Duodenal wall perforations have a serious fatal outcome even if early surgical intervention is performed. In contrast to duodenal wall injuries, perivaterian and choledochal injuries have a better outcome.

Effects of thyroid hormone supplementation on anastomotic healing after segmental colonic resection

BACKGROUND

Alterations of thyroid hormones in colorectal surgery were previously studied. The aim of the present study was to determine the effects of triiodothyronine (T3) supplementation on anastomotic healing after segmental colectomy.

MATERIAL AND METHODS

Thirty male Wistar albino rats were divided into sham (n = 6), control (n = 12), and experimental (n = 12) groups. Sham group rats were immediately sacrificed after segmental colonic resection. Control and experimental group rats underwent resection and anastomosis. Experimental group rats received a single dose of T3 (400 μg/100 g) in postoperative day 1. Half of both control and experimental group rats were sacrificed on postoperative d 3 and the remaining half were sacrificed on postoperative d 7. Hydroxiproline (HP), myeloperoxidase (MPO), thyroid stimulating hormone (TSH), free T3 (FT3), and free thyroxine (FT4) levels, bursting pressure, and histologic analyses of the anastomotic segments were compared.

RESULTS

FT3 levels significantly decreased in control groups rats compared with the sham group (P < 0.01). However, T3 hormone given rats had no decline in FT3 levels. Anastomotic bursting pressure was significantly higher in the experimental group rats on postoperative d 7 (P = 0.015). Histopathologic analyses of the anastomotic segments determined significantly more severe edema and necrosis in control group rats (P < 0.05). Collagen deposition in the anastomotic tissue was significantly higher in experimental group rats on postoperative d 7 (P = 0.015).

CONCLUSION

Anastomosis after colon resection is associated with decreased FT3 level. T3 supplementation ameliorates the reduction in FT3 and seems to provide constructive therapeutic effects on anastomotic healing.

The predictive value of mean platelet volume in differential diagnosis of non-functional pancreatic neuroendocrine tumors from pancreatic adenocarcinomas

OBJECTIVE

The aim of the present study is to evaluate in a retrospective manner the diagnostic value of mean platelet volume (MPV) in pancreatic adenocarcinomas and pancreatic neuroendocrine tumors (PNETs).

PATIENTS AND METHODS

A total of 92 patients, who were admitted for pancreatic adenocarcinoma (n=76) and PNET (n=16) between March 2007 and December 2009, were analyzed retrospectively for demographics and clinical information.

RESULTS

Thirty-nine patients (51.3%) had a resectable, whereas 37 patients (48.7%) had an unresectable pancreatic adenocarcinoma. Nine patients (56.3%) had a non-functional PNET, 6 patients (37.5%) had an insulinoma, and the remaining one patient had a gastrinoma. The mean age was 59.3±10.5 for pancreatic adenocarcinomas and 45.1±10.6 for PNETs. The mean age at diagnosis was significantly higher in patients with pancreatic adenocarcinomas than the patients with PNET (p<0.001). Preoperative mean hemoglobin levels were significantly lower in patients with pancreatic adenocarcinoma than those with PNET (12.4±1.8g/dl vs 13.7±2.2g/dl), (p<0.013). The preoperative median MPV levels were significantly lower in patients with PNET 7.8fL (7.2-9.4) than in patients with pancreatic adenocarcinomas 8.6fL (6.6-13.5), (p<0.014). In subgroup analysis, a significant difference in MPV levels was mainly caused by the difference between pancreatic adenocarcinomas and non-functional PNETs (p=0.017). The cut-off value of MPV level for detection of PNETs was calculated as≤7.8fL using ROC analysis [Sensitivity: 66.7%, specificity: 75.9%, AUC: 0.734 (0.587-0.880) p=0.022]. In logistic regression analysis, independent predictive factors for determining PNETs in the differential diagnosis of pancreatic adenocarcinomas were calculated as age (OR=0.068, 95% CI: 0.012-0.398), Ca 19-9 (OR=0.039, 95% CI: 0.006-0.263), MPV (OR=0.595, 95% CI: 0.243-1.458), and hemoglobin (OR=1.317, 95% CI: 0.831-2.086).

CONCLUSION

Age, Ca 19-9, MPV, and hemoglobin levels have diagnostic value for distinguishing PNETs from pancreatic adenocarcinomas.

Giant hemorrhagic adrenal pseudocyst in a primiparous pregnancy: report of a case

Adrenal cysts are rare and are usually discovered incidentally during diagnostic imaging, surgery, or autopsy. Most cystic lesions of the adrenal gland are nonfunctioning and become symptomatic when complicated by rupture, hemorrhage, or infection. A 40-year-old woman presented with a history of gradual-onset pain in her left flank region at 20 weeks' gestation. Ultrasound showed a 20-cm cystic mass in her left abdominal cavity. Pertinent laboratory tests were within normal limits. The patient underwent exploratory laparotomy, which revealed a 20 × 15-cm left adrenal cyst; thus, we performed left adrenalectomy with complete excision of the cyst. Histological examination confirmed a hemorrhagic adrenal pseudocyst. The patient had an uneventful postoperative course, and subsequent routine obstetric ultrasound examinations showed normal fetal activity and development until the pregnancy terminated with a stillbirth caused by pre-eclampsia at 34 weeks' gestation. To the best of our knowledge, this is only the 12th reported case of adrenal pseudocyst discovered during pregnancy. We analyze the clinicopathologic findings and discuss the possible association of pregnancy, with special reference to etiopathogenesis, presentation, diagnosis, and treatment.

Predictive factors for conversion to open surgery in patients undergoing elective laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy (LC) has become the standard surgical procedure for symptomatic gallbladder disease. The aim of this study was to identify factors that may be predictive of cases that would require a conversion to laparotomy.

METHODS

In the period of 2002-2007, 2015 patients who underwent elective LC were included in the study. Patients were divided into two groups. Group 1 (n = 1914) consisted of patients whose operation was successfully completed with LC. Group 2 (n = 101) consisted of patients who had a conversion. A prospective analysis of parameters, including patient demographics, laboratory values, radiologic data, and intraoperative findings, was performed. Multivariate stepwise logistic regression was used to determine those variables predicting conversion.

RESULTS

One-hundred and one (5.0%) patients required a conversion. Significant predictors of conversion to open cholecystectomy in univariate analysis were increasing age, male gender, previous upper abdominal or upper plus lower abdominal incisions, an elevated white blood cell count, high aspartate transaminase, alkaline phosphatase and total bilirubin levels, preoperative ultrasound findings of a thickened gallbladder wall and dilated common bile duct, preoperative endoscopic retrograde cholangiopancreatography (ERCP), high-grade adhesion, and scleroatrophic appearance of the gallbladder intraoperatively. Multivariate analysis revealed that a history of previous abdominal surgery, preoperative ERCP, high-grade adhesion, and scleroatrophic appearance of the gallbladder predicted conversion.

CONCLUSIONS

Patient selection is very important for efficient, safe training in LC. Based on the presented data, pathways could be suggested that enable the surgeon to precisely decide, during LC, when to convert to open surgery.

Carbondioxide pneumoperitoneum prevents postoperative adhesion formation in a rat cecal abrasion model

PURPOSE

We aimed to investigate the role of the carbon-dioxide (CO(2)) pneumoperitoneum on the prevention of postoperative adhesion formation.

METHODS

Thirty adult male Sprague-Dawley rats (250-350 g) were used for this study. The rats were randomly divided into three groups; in the sham group (n = 10) only, laparotomy was made, in group 2 (n = 10), a pneumoperitoneum was applied for a half-hour duration, followed by laparatomy, and in group 3 (n = 10), pneumoperitoenum time was 2 hours and after a pneumoperitoneum laparotomy was made. A cecal abrasion model was studied for making an adhesion formation. On day 14, all rats were sacrificed and adhesions were scored. Tissue samples from adhesions and peritonea and the cecum wall were examined, both pathologically and biochemically, for tissue hydroxyproline content.

RESULTS

There was a statistically significant difference between the control and pneumoperitoneum groups, regarding adhesion numbers and grades (P < 0.001). Cecal tissue hydroxypyroline content level was lower in group 1, and statistically significant differences were observed between groups 1, 2, and 3 regarding hydroxyproline content (P < 0.001). There was a statistically significant difference between the control and pneumoperitoneum groups regarding inflammation (P = 0.002).

CONCLUSIONS

Pretreatment with the CO(2) pneumoperitoneum had a prophylactic effect on postoperative adhesion formation in this study.

Current Diagnosis and Management of Gastrojejunocolic Fistula

We herein report the case of a 51-year-old man with gastrojejunocolic fistula. It is one of the late severe complications of gastrectomy and gastrojejunostomy and is considered to be induced by a stomal ulcer due to inadequate resection of the stomach and incompleteness of vagotomy. The main clinical presentation of this condition is chronic abdominal pain, weight loss, diarrhea, gastrointestinal bleeding and fecal vomiting. The diagnostic workup should include barium enema, gastroscopy and sometimes colonoscopy and abdominal tomography for excluding and ruling out the possibility of malignant extraluminal disease. The historical approach of the treatment of this rare entity was 2–3-phased operations which included colostomy. However today, medical management has recently been recommended as the first-line therapy, with parenteral and enteral support treatments. The preferred surgical approach is single-stage gastrocolic resection and anastomosis and this has been favored to minimize mortality.

Surgical treatment for gastric cancer in Turkish patients over age 70: early postoperative results and risk factors for mortality

PURPOSE

The aim of this study was to evaluate the effects of advanced age on early postoperative results and to investigate risk factors for mortality in Turkish gastric cancer patients.

METHODS

From 2002 to 2007, 549 patients who underwent gastrectomy for gastric cancer were divided into two groups as patients younger than 70 years and patients aged 70 years or older.

RESULTS

There were 387 patients in the younger group and 162 in the older group. Morbidity rates were similar (25.1% vs. 29.0%). Mortality was higher among the elderly patients (2.6% vs. 9.9%). Advanced age, albumin levels lower than 3 mg/dl, higher American Society of Anesthesiologists score, palliative resections and resection of two or more additional organs were independent risk factors for mortality.

CONCLUSION

Age alone should not preclude gastric resection in elderly patients. However, for patients with multiple risk factors, more limited surgery should be considered.