Independent risk factors for COVID-19-associated coagulopathy

OBJECTIVE

Past three years since the beginning of the outbreak, we have obtained satisfactory data on COVID-19. However, data on risk factors of COVID-19-associated coagulopathy (CAC) are extremely limited. Prediction of CAC might be a game changer since it is related to poor prognosis. Seeking independent risk factors for CAC was the main aim of the study.

PATIENTS AND METHODS

510 hospitalized COVID-19 patients were retrospectively screened. Forty-eight of them were excluded due to irrelevant D-dimer or ferritin elevation. The remaining patients were stratified into three groups as overt coagulopathy, significant pulmonary microthrombosis, and patients without coagulopathy. The overt coagulopathy group included cases with macrothrombosis or disseminated intravascular coagulation (DIC). The significant pulmonary microthrombosis group covered the cases that had clinical deterioration with simultaneous marked D-dimer elevation. The group of patients without coagulopathy included the asymptomatic patients with normal or elevated D-dimer levels.

RESULTS

Overt coagulopathy developed in 3.2% and significant pulmonary microthrombosis in 10.1% of the patients. In the multivariate analysis, not receiving low molecular weight heparin (LMWH) (p=0.002), a level of D-dimer >15,000 U/ml (p=0.013) were associated with overt coagulopathy. In addition, levels of initial LDH >480 IU/L (p=0.022) and initial ferritin >1,000 ng/ml (p=0.036) were associated with significant pulmonary microthrombosis. Not receiving LMWH (p=0.001) was also associated with significant pulmonary microthrombosis, when multivariate analysis was performed by the parameters with a p-value <0.1 in the univariate analysis. Furthermore, all cases with DIC had Gram-negative bacterial sepsis.

CONCLUSIONS

Not receiving LMWH, high levels of D-dimer, initial LDH, and initial ferritin are independent risk factors for CAC. DIC does not appear to develop based on COVID-19.

Spatial distribution of pyrogenic carbon in Iberian topsoils estimated by chemometric analysis of infrared spectra

Understanding the global carbon (C) cycle is critical to accurately model feedbacks between climate and soil. Thus, many climate change studies focused on soil organic carbon (SOC) stock changes. Pyrogenic carbon (PyC) is one of the most stable fractions of soil organic matter (SOM). Accurate maps based on measured PyC contents are required to facilitate future soil management decisions and soil-climate feedback modelling. However, consistent measurements that cover large areas are rare. Therefore, this study aimed to map the PyC content and stock of the Iberian Peninsula, which covers contrasting climatic zones and has long-term data on wildfire occurrence. A partial least square (PLS) regression using the mid-infrared spectra (1800-400 cm^-1) was applied to a dataset composed of 2961 soil samples from the Iberian component of the LUCAS 2009 database. The values of PyC for LUCAS points were modelled to obtain a map of topsoil PyC by a random forest (RF) approach using 36 auxiliary variables. The results were validated through comparison with documented historical wildfire activity and anthropogenic energy production. A strong relationship was found between these sources and the distribution of PyC. Our study estimates that the accumulated PyC in Iberian Peninsula soils comprises between 3.09 and 20.39% of total organic carbon (TOC) in the topsoil. Forests have higher PyC contents than grasslands, followed by agricultural soils. The incidence of recurrent wildfires also has a notable influence on PyC contents. This study shows the potential of estimating PyC with a single, rapid, low cost, chemometric method using new or archived soil spectra, and has the ability to improve soil-climate feedback modelling. It also offers a possible tool for measuring, reporting and verifying soil C stocks, which is likely to be important moving forward if soils are used as sinks for C sequestration.

Biliary Stenting Prior to Pancreaticoduodenectomy and its Effects on Postoperative Outcome. Twenty Years of Experience with 805 Patients

BACKGROUND

The aim of this study was to evaluate the potential effects of biliary drainage before pancreaticoduodenectomy on postoperative outcomes.

METHODS

This study was conducted retrospectively on data from 820 cases of pancreaticoduodenectomy performed in the Gastrointestinal Surgery Department of Ankara City Hospital between April 1999 and August 2019. Twenty years of collected patient data were re-examined and 805 patients were divided into two groups as those who underwent preoperative biliary drainage (PBD) and those who did not (non-PBD). Demographic data of patients, and preoperative, operative and postoperative details, including morbidity, were collected and compared between the two groups.

RESULTS

There were 574 (71.3%) patients in the PBD group and 231 (28.6%) patients in the non-PBD group. Total complications according to Clavien-Dindo classification were significantly higher in the PBD group (P<0.001). Intraabdominal hemorrhage, delayed gastric emptying and wound infection were found to be higher in the PBD group but the rate of pancreatic fistula was similar in both groups. There was no difference between the two groups in terms of complications according to preoperative bilirubin levels. In drained patients with normal bilirubin levels, wound infections were significantly higher in a group with diameter of common bile duct>8 mm (P=0.020).

CONCLUSION

PBD is not associated with anastomotic leakage after pancreaticoduodenectomy. Wound infection, delayed gastric emptying and intraabdominal hemorrhage were significantly associated with PBD. Preoperative bilirubin level had no effect on these results. In subgroup analysis, in patients undergoing drainage, if bilirubin falls below 5 mg/dL, the risk of wound infection was still high in patients with bile duct diameter>8 mm.

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.

Single-Center Results of Choledochal Cysts in Turkish Population

BACKGROUND

Choledochal cysts are seen commonly in Asian populations, but rarely in Western populations. The pathogenesis of these premalignant lesions is not fully understood yet and the risk of malignant transformation increases with age. The overall malignancy risk is 10%-15% in East Asian countries. In this study, we aimed to present our surgical experience as a hepatobiliary center to the literature.

METHODS

We retrospectively analyzed the data from the medical records of 70 patients operated for choledochal cyst between 2008-2019.

RESULTS

Sixty-two of the 70 (89%) patients were female and 8 (11%) were male, the mean age was 45.89 ± 15.32 years. Overall, 44 (63%) patients had type I (a+b+c), 20 (28%) type V (Caroli), 2 (3%) type II, 2 (3%) type III and 2 (3%) type IVb cysts. The most common operation was cyst excision combined with hepaticojejunostomy (n: 26, 37%). The median diameter of the resected cysts was 3 cm (min- max: 1-11 cm). Malignancy was observed only in three (4%) patients with type III, type Ib, and type V cyts, who were 19, 38, and 72 years old, respectively. Mortality was not observed, morbidity was determined totally in 30 (43%) cases during early and late postoperative periods.

CONCLUSION

Type of surgery in choledochal cysts differs according to the type of the cyst. Malignancy was observed at a rate of 4% in all age groups. Although the frequency of malignancy varies, the main treatment of choice should be surgery because malignancy can be seen at a young age.

Schmallenberg virus affects T-bet, Gata3, RoRrγt, Foxp3 and Eomes in mice brain

Schmallenberg virus (SBV), a neurotropic member of the genus Orthobunyavirus, infects ruminants and causes neurological lesions and fetal malformations including cerebellar hypoplasia, hydranencephaly, and porencephaly. The aim of this study is to establish intracerebral (i.c.) infection of SBV in newborn BALB/c mice and to investigate some of the transcription factors in brain. For this aim, brain samples of newborn BALB/c mice which were infected with SBV i.c. were analyzed by plaque titration and real-time RT-PCR for T-bet, Gata3, RoRγt, Foxp3 and Eomes mRNA levels. Study results showed that SBV can replicate in BALB/c mice brain and cause death of newborn mice with generation of infectious viral particles. Analyses of transcription factor mRNA levels indicated up-regulation of T-bet, Gata3, RoRγt, Foxp3 and down-regulation of Eomes. In this report, we introduce preliminary data of T cell transcription factors affected by SBV infection of BALB/c mice. Keywords: Eomes; Foxp3; Gata3; RoRγt; Schmallenberg virus; T-bet.

Results of the simultaneous measurements of radon around the Black Sea for seismological applications

Results of measurements of radon around of the Black Sea are shown. Radon stations in zones of active faults were placed. Simultaneous hourly measurements of soil radon in 2005 were carried out in the Sivrice Fault Zone that is a segment of East Anatolian Fault System, in the town of Tbilisi (Georgia) and in the South Russia. In 2008 simultaneously hourly measurements of soil radon were carried out in the Western Caucasus (Russia) and in the Mytilene Island (Greece). In 2013 radon in underground waters simultaneously in midday was measuring in Crete (Greece), in the Pamukkale geothermal region (Southwest Turkey) and in the Western Caucasus. Measurements of radon concentration in the points located around of the Black Sea have shown identical regularities in changes of the data. Influence of meteorological, tidal and solar factors on changes of water radon concentrations and soil radon concentrations was observed in all researches points. But this influence was insignificant. Seismological application of observed results also was considered. Various mathematical methods of definition of anomaly in the radon data during earthquakes were considered. During researches in the Black Sea region basically earthquakes with M from 2.0 up to 5.0 and in a depth about 10 km were occurred. For these earthquakes method of daily subtraction of the data of the next and previous day was used. This method has allowed solving a problem with a choice of average value. Probability up to 0.69 (number of earthquakes with radon anomalies/total number of earthquakes) of detection of radon anomalies before earthquakes was achieved applying this method. Changes of radon maps before regional earthquakes were also observed. The frequency analysis of variations of the radon data on the basis of the Wavelet analysis was carried out. Occurrence of the short periods (about 2 days) was observed during regional earthquakes.

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.

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).

Laparoscopic versus open 1-stage resection of synchronous liver metastases and primary colorectal cancer

BACKGROUND

The aim of this study is to compare the perioperative and oncologic outcomes of open and laparoscopic approaches for concomitant resection of synchronous colorectal cancer and liver metastases.

METHODS

Between 2006 and 2015, all patients undergoing combined resection of primary colorectal cancer and liver metastases were included in the study (n=43). Laparoscopic and open groups were compared regarding clinical, perioperative and oncologic outcomes.

RESULTS

There were 29 patients in the open group and 14 patients in the laparoscopic group. The groups were similar regarding demographics, comorbidities, histopathological characteristics of the primary tumor and liver metastases. Postoperative complication rate (44.8% vs. 7.1%, P=0.016) was higher, and hospital stay (10 vs. 6.4 days, P=0.001) longer in the open compared to the laparoscopic group. Overall survival (OS) was comparable between the groups (P=0.10); whereas, disease-free survival (DFS) was longer in laparoscopic group (P=0.02).

CONCLUSIONS

According to the results, in patients, whose primary colorectal cancer and metastatic liver disease was amenable to a minimally invasive resection, a concomitant laparoscopic approach resulted in less morbidity without compromising oncologic outcomes. This suggests that a laparoscopic approach may be considered in appropriate patients by surgeons with experience in both advanced laparoscopic liver and colorectal techniques.

Local recurrence after laparoscopic radiofrequency ablation of malignant liver tumors: Results of a contemporary series

INTRODUCTION

The aims of this study were to determine the incidence of Local recurrence (LR) in patients at long-term follow-up after laparoscopic RFA (LRFA) and also to determine the risk factors for LR from a contemporary series.

METHODS

Patients undergoing LRFA between 2005 and 2014 by a single surgeon were reviewed. Demographic and perioperative data were analyzed from a prospective database.

RESULTS

LRFA was performed on 316 patients with 901 lesions. Median follow-up was 25 months, with 76% of whom completed at least one year of follow-up. The LR rate was 18.4%. The LR in patients followed for less than 12 months was 13.8%, 20.3% for 12 months, and 19.7% for 18 months (P = 0.02). One-fourth of the LRs developed after the 1st year. Morbidity was 8.9% and mortality 0.3%. Tumor type, size, ablation margin, and surgeon experience affected LR, with tumor type, size, and ablation margin being independent.

CONCLUSIONS

This study shows that 14% of malignant liver tumors will develop LR within a year after LRFA. Additional 4% of the lesions will demonstrate recurrence within 1 cm of the ablation zone, mostly as part of a multifocal recurrence. Ablation margin is the only parameter that the surgeon can manipulate to decrease LR.

Three-Port, Two Located on the Pfannenstiel Line, Laparoscopic Cholecystectomy Comparison with Traditional Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy (LC) is seen as a gateway to minimally invasive surgery. We defined a new three-port technique with different port sites and compared the postoperative results with traditional four-port LC procedure in a case-match study. Between June 2012 and May 2013, 104 consecutive patients underwent three-port LC by same experienced surgeon. In the same center, 2963 consecutive patients underwent four-port LC, and of these 2963 patients, a matched group of 104 patients was selected. Data included patient age, gender, body mass index, American Society of Anesthesiologists score, history of abdominal operations, intraoperative data about operating time and conversion to open surgery, and postoperative data about length of hospital stay and postoperative complications were recorded prospectively. We concluded that our new three-port technique with different port sites is as feasible and safe as traditional four-port technique.

Three-Port, Two Located on the Pfannenstiel Line, Laparoscopic Cholecystectomy Comparison with Traditional Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy (LC) is seen as a gateway to minimally invasive surgery. We defined a new three-port technique with different port sites and compared the postoperative results with traditional four-port LC procedure in a case-match study. Between June 2012 and May 2013, 104 consecutive patients underwent three-port LC by same experienced surgeon. In the same center, 2963 consecutive patients underwent four-port LC, and of these 2963 patients, a matched group of 104 patients was selected. Data included patient age, gender, body mass index, American Society of Anesthesiologists score, history of abdominal operations, intraoperative data about operating time and conversion to open surgery, and postoperative data about length of hospital stay and postoperative complications were recorded prospectively. We concluded that our new three-port technique with different port sites is as feasible and safe as traditional four-port technique.

Can N-terminal pro B-type natriuretic peptide, neutrophil-to-lymphocyte ratio, C-reactive protein help to predict short and long term mortality?

BACKGROUND

There is limited data about ICU, short and long-term mortality prediction of severe CAP with neutrophil-to-lymphocyte ratio (NLR): N-terminal proB- type natriuretic peptide (NT-proBNP): C-reactive protein (CRP).

AIM

Besides the known severity indexes of ICU, can NLR, NT-proBNP, CRP predict ICU, short and long term mortality?

METHODS

A retrospective cohort study was carried out in a level III ICU of a tertiary training hospital for chest diseases and thoracic surgery.

RESULTS

Over the study period, a total of 143 patients were enrolled in the study. The APACHE II scoring showed a significantly higher predicting performance for ICU mortality (p = 0.002). The performance for predicting short term mortality NLR (p = 0.039) and long term mortality NTproBNP (p = 0.002) had a significantly higher performance. The survival analysis revealed that mortality was significantly higher in patients with CURB65 score ≥ 4 (p = 0.047).

CONCLUSION

NLR, NTproBNP > 2000pg/mL can be used to predict pneumonia severity in ICU alike CURB65 and PSI. Higher NLR, APACHE II and atrial fibrillation can cause an important mortality factor in long term. Consequently, clinicians should take an attention for good cardiac evaluation and cardiac follow-up of patients with CAP (Tab. 4, Fig. 3, Ref. 36).

High hemodialysis vascular access flow and impaired right ventricular function in chronic hemodialysis patients

There are limited data showing right ventricular preload increase due to high-flow arteriovenous fistulas (AVFs). This cross-sectional study investigated whether high AVF flow had an impact on right ventricular function in patients undergoing hemodialysis. Sixty-four patients aged between 18 and 85 years who were on routine hemodialysis with >2 hemodialysis sessions per week for at least 3 months via an AVF were studied. Patients with inadequate flow fistulas, severe chronic obstructive pulmonary disease, history of pulmonary embolism, primary pulmonary hypertension, severe mitral, aortic or pulmonary regurgitation, and/or stenosis were excluded. After an initial evaluation, 44 patients (mean age: 58.50 ± 16.84, male:female = 23:21) were considered eligible. Right ventricular function was assessed by tricuspid annular plane systolic excursion (TAPSE). AVF blood flow was measured with duplex ultrasound. There were 15 patients (34.1%) with a TAPSE of <16 mm. AVF blood flow was significantly higher in patients with impaired versus normal right ventricular function (1631.53 ± 738.17 vs. 1060.55 ± 539.92 min/ml, respectively, P = 0.003). Low left ventricular ejection fraction (odds ratio [OR]: 1.15, 95% confidence intervals [CI]: 1.007-1.334, P = 0.04), high interventricular septum thickness (OR: 1.64, 95% CI: 1.104-2.464, P = 0.01), and high AVF blood flow (OR: 1.00, 95% CI: 1.000-1.003, P = 0.03) were independent predictors of impaired right ventricular function. In addition to known risk factors that predominantly increase right ventricular afterload, excessive AVF blood flow was found to be independently associated with impaired right ventricular function, possibly by increasing right ventricular preload.

What is the neutrophil/lymphocyte ratio in sarcoidosis?

AIM

Information regarding the Neutrophil/Lymphocyte ratio (NLR) in sarcoidosis and the data from studies recommending its use as an indicator of inflammation and in the differential diagnosis and prognosis, are limited. With this study, it was aimed to obtain data regarding the NLR level in the patients at the time of presentation to the hospital and to determine the characteristics of patients in whom the NLR value was > 2.

RESULTS

During the study period, of the 3434 patients with the sub-diagnosis of D86, 1300 cases whose complete blood count values had been recorded at the time of presentation were included in the study. Of the cases, 40 % were pulmonary sarcoidosis, 7 % were pulmonary sarcoidosis with sarcoidosis of the lymph nodes, 8 % were lymph node sarcoidosis, 1 % were sarcoidosis, of other combined areas, and 40 % of the cases were sarcoidosis that were unspecified. The F/M of the cases were 947/353, and the average age of the cases was 44. When the sarcoidosis groups were grouped into NLR < 2 (Group 1) and NLR ≥ 2 (Gorup 2), 27 % were Group 1, 73 % were Group 2, and a significant correlation was found between the two groups. When the inflammatory indicators were compared with NLR, the PLT/MPV was found to be statistically insignificant, and the ACE, ESR and CRP were found to be statistically significant.

CONCLUSION

The Neutrophil/Lymphocyte ratio in the complete blood count, which is an easy and cheap test, can be used as an indicator of inflammation in Sarcoidosis. In clinical practice, wide-based studies comprising the activity and the staging in the prognosis of sarcoidosis are required (Tab. 2, Fig. 2, Ref. 26).

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 impact of PET/CT on the management of hepatic and extra hepatic metastases from gastrointestinal cancers

PURPOSE

To investigate the efficacy of positron emission tomography/computed tomography (PET/CT) in detection and management of hepatic and extrahepatic metastases from gastrointestinal cancers.

MATERIALS AND METHODS

Between February 2008 and July 2010, patients histopathologically diagnosed with gastrointestinal cancer and showing suspected metastasis on CT screening were subsequently evaluated with PET/CT. All patients were subgrouped according to histopathological origin and localization of the primary tumor. Localization of gastrointestinal cancers was further specified as lower gastrointestinal system (GIS), upper GIS, or hepato-pancreato-biliary (HPB). Both accuracy and impact of CT and PET/CT on patient management were retrospectively evaluated.

RESULTS

One hundred and thirteen patients diagnosed histopathologically with gastrointestinal cancers were retrospectively evaluated. Seventy-nine patients had adenocarcinoma and 34 patients other gastrointestinal tumors. Forty-one patients were in the upper GIS group, 30 patients in the HPB group, and 42 patients in the lower GIS group. Evaluation the diagnostic performance of PET/CT for suspected metastasis according to histopathological origin of the tumor, revealed that the sensitivity of PET/CT - although statistically not different - was higher in adenocarcinomas than in non-adenocarcinomas (90% (95% CI, 0.78-0.96) vs. 71.4% (95% CI, 0.45-0.88), P=0.86). The specificity was not significantly different (85.7% (95% CI, 0.70-0.93) vs. 85% (95% CI, 0.63-0.94), P=1.00). In the overall patient group; CT was significantly more sensitive than PET/CT for detection of hepatic metastases (94.7% vs. 78.9%, P=0.042), whereas PET/CT was significantly more specific than CT (48% vs. 98.7%, P<0.001). In subgroup analysis, sensitivity was not significantly different (P>0.05) but specificity was significantly higher in PET/CT than CT (P<0.05). The specificity of PET/CT was highest in upper GIS (100%) and HPB (100%) subgroups. In the overall patient group; for detection of extrahepatic metastasis, the sensitivity of CT (75%) and PET/CT (87.5%) showed no significant difference (P=0.437). However, PET/CT was significantly more specific than CT (88.7% vs. 70.4%, P=0.007). In subgroup analysis, no significant difference was found between CT and PET/CT either in sensitivity or in specificity (P>0.05). The specificity of PET/CT was highest in the lower GIS subgroup (93%). The management of 45 patients (39.8%) was revised after PET/CT evaluation.

CONCLUSIONS

PET/CT has a higher specificity than CT in detecting suspected hepatic and extrahepatic metastases of gastrointestinal cancers, and has an impact of nearly 40% on changing patient management strategies.

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.

Effect of hypothermia in patients undergoing simultaneous carotid endarterectomy and coronary artery bypass graft surgery

Purpose

We sought to determine whether hypothermia provided any benefit in patients undergoing simultaneous coronary artery bypass graft surgery (CABG) and carotid endarterectomy (CEA) using one of two different surgical strategies.

Methods

Group 1 patients (n = 34, 88.2% male, mean age 65.94 ± 6.67 years) underwent CEA under moderate hypothermia before cross clamping the aorta, whereas group 2 patients (n = 23, 69.6% male, mean age 65.78 ± 9.29 years) underwent CEA under normothermic conditions before initiating cardiopulmonary bypass (CPB). Primary outcome of interest was the occurrence of any new neurological event.

Results

The two groups were similar in terms of baseline characteristics. Permanent impairment occurred in one patient (2.9%) in group 1. One patient from each group (2.9 and 4.3%) had transient neurological events and they recovered completely on the sixth and 11th postoperative days, respectively. Overall, there was no statistically significant difference between the two groups with regard to occurrence of early neurological outcomes (n = 2, 5.8% vs n = 1, 4.3%, p = 0.12).

Conclusions

This study could not provide evidence regarding benefit of hypothermia in simultaneous operations for carotid and coronary artery disease because of the low occurrence rate of adverse outcomes. The single-stage operation is safe and completion of the CEA before CPB may be considered when short duration of CPB is required.

Saphenous nerve injury after endovenous laser ablation of incompetent greater saphenous vein: An electroneuromyography study

AIM

To determine whether endovenous laser ablation of incompetent greater saphenous vein causes a detectable impairment in saphenous nerve conduction.

MATERIAL AND METHODS

Thirty-five patients (mean age: 44.78 ± 8.6, male/female ratio: 16/19) who were operated on for incompetent greater saphenous veins, underwent electroneuromyography before and two weeks after the operation. Dysesthesia was questioned as to whether having unpleasant abnormal sensation after the operation. Positive electroneuromyography findings for saphenous nerve injury included a sensory nerve action potential amplitude <2 µV or a nerve conduction velocity <48.0 m/s or a latency onset >5.0 ms.

RESULTS

Thirty-four patients were available at two-week follow-up. All patients achieved complete proximal closure. Three patients (8.8%) had dysesthesia at two weeks. Mean electroneuromyography values were not significantly different between preoperative and postoperative period. Postoperatively, none of the patients had abnormal sensory nerve action potential or latency onset, whereas nerve conduction velocity decreased below the lower limit in two patients. These two patients were not among those having dysesthesia and they had no other complaints.

CONCLUSION

Injury to saphenous nerve seems not likely during endovenous laser ablation of incompetent greater saphenous veins, as evidenced by normal electroneuromyography values found after the operation.

Prevalence, presentation and occupational risk factors of chronic venous disease in nurses

OBJECTIVE

In this study involving a group of nurses employed in a number of different medical services with relatively well-defined working conditions, the presence and symptoms of chronic venous insufficiency were screened and their association with work burden and physical working conditions was explored.

METHODS

Of the 294 actively employed nurses during the study period, 232 (79%) were recruited on the basis of their willingness for participation and fulfilment of the inclusion criteria.

RESULTS

Among the study subjects, 62.9% had at least one symptom of chronic venous insufficiency, and 50.4% were found to have chronic venous insufficiency according to Clinical-Etiology-Anatomy-Pathophysiology classification criteria. A significant association was found between the diurnal ankle circumference difference in the left-right ankles and the mean duration of hospital stay.

CONCLUSIONS

Our results have shown that the average duration of hospital stay, which is among the variables used to estimate the work burden of nurses, is associated with an increased frequency of the signs and symptoms of chronic venous insufficiency.

Initial experience with a new articulating energy device for laparoscopic liver resection

BACKGROUND

Although significant advances have been made in laparoscopic liver resection (LLR), most techniques still rely on multiple energy devices and staplers, which increase operative costs. The aim of this study was to report the initial results of a new multifunctional energy device for hepatic parenchymal transection.

METHODS

Fourteen patients who underwent LLR using this new device were compared to 20 patients who had LLR using current laparoscopic techniques (CL). Data were collected prospectively.

RESULTS

The groups were similar demographics and tumor type and size. Although the type of resection was similar between the groups, the parenchymal transection time was less in the Caiman group (32 ± 5 vs. 63 ± 4 min, respectively, p = 0.0001). The operative time was similar (194 ± 21 vs. 233 ± 16 min, respectively, p = 0.158). There was reduction of the number of advanced instrumentation used in the Caiman group, including the staplers. Estimated blood loss, size of surgical margin, and hospital stay were similar. There was no mortality, and morbidity was 7 % in the Caiman and 20 % in the CL group.

CONCLUSIONS

This initial study shows that the new device is safe and efficient for LLR. Its main advantage is shortening of hepatic parenchymal transection time. This has implications for increasing efficiency and cost saving in LLR.

A new risk stratification algorithm for the management of patients with adrenal incidentalomas

BACKGROUND

Although adrenal incidentalomas (AI) are detected in ≤5% of patients undergoing chest and abdominal computed tomography (CT), their management is challenging. The current guidelines include recommendations from the National Institutes of Health, the American Association of Endocrine Surgeons (AAES), and the American Association for Cancer Education (AACE). The aim of this study was to develop a new risk stratification model and compare its performance against the existing guidelines for managing AI.

METHODS

A risk stratification model was designed by assigning points for adrenal size (1, 2, or 3 points for tumors <4, 4-6, or >6 cm, respectively) and Hounsfield unit (HU) density on noncontrast CT (1, 2, or 3 points for HU <10, 10-20, or >20, respectively). This model was applied retrospectively to 157 patients with AI managed in an endocrine surgery clinic to assign a score to each tumor. The utility of this model versus the AAES/AACE guidelines was assessed.

RESULTS

Of the 157 patients, 54 (34%), had tumors <4 cm with HU <10 (a score of 2). One third of these were hormonally active on biochemical workup and underwent adrenalectomy. The remaining two thirds were nonsecretory lesions and have been followed conservatively with annual testing. In 103 patients (66%), the adrenal mass was >4 cm and/or had indeterminate features on noncontrast CT (HU >10, irregular borders, heterogeneity), and adrenalectomy was performed after hormonal evaluation was completed (10 were hormonally active on biochemical testing). Seven of these patients (7%) had adrenocortical cancer on final pathology with tumor size <4 cm in 0, 4-6 cm in 1, and >6 cm in 5 patients. Of the hormonally inactive patients, 32% had a score of 3, 38% 4, and 30% 5 or 6. The incidence of adrenocortical cancer in these subgroups was 0, 0, and 25%, respectively.

CONCLUSION

This study shows that an algorithm that utilizes the hormonal activity at the first decision step followed by a consolidated risk stratification, based on tumor size and HU density, has a potential to spare a substantial number of patients from unnecessary "diagnostic" surgery for AI.

Factors affecting the surgical approach and timing of bilateral adrenalectomy

BACKGROUND

Laparoscopic adrenalectomy has gained widespread acceptance. However, the optimal surgical approach to laparoscopic bilateral adrenalectomy has not been clearly defined. The aim of this study is to analyze the patient and intraoperative factors affecting the feasibility and outcome of different surgical approaches to define an algorithm for bilateral adrenalectomy.

METHODS

Between 2000 and 2013, all patients who underwent bilateral adrenalectomy at a single institution were selected for retrospective analysis. Patient factors, surgical approach, operative outcomes, and complications were analyzed.

RESULTS

From 2000 to 2013, 28 patients underwent bilateral adrenalectomy. Patient diagnoses included Cushing's disease (n = 19), pheochromocytoma (n = 7), and adrenal metastasis (n = 2). Of these 28 patients, successful laparoscopic adrenalectomy was performed in all but 2 patients. Twenty-three out of the 26 adrenalectomies were completed in a single stage, while three were performed as a staged approach due to deterioration in intraoperative respiratory status in two patients and patient body habitus in one. Of the adrenalectomies completed using the minimally invasive approach, a posterior retroperitoneal (PR) approach was performed in 17 patients and lateral transabdominal (LT) approach in 9 patients. Patients who underwent a LT approach had higher BMI, larger tumor size, and other concomitant intraabdominal pathology. Hospital stay for laparoscopic adrenalectomy was 3.5 days compared to 5 and 12 days for the two open cases. There were no 30-day hospital mortality and 5 patients had minor complications for the entire cohort.

CONCLUSIONS

A minimally invasive operation is feasible in 93% of patients undergoing bilateral adrenalectomy with 65% of adrenalectomies performed using the PR approach. Indications for the LT approach include morbid obesity, tumor size >6 cm, and other concomitant intraabdominal pathology. Single-stage adrenalectomies are feasible in most patients, with prolonged operative time causing respiratory instability being the main indication for a staged approach.

An analysis of whether surgeon-performed neck ultrasound can be used as the main localizing study in primary hyperparathyroidism

BACKGROUND

Tc-99 sestamibi (MIBI) scan is the imaging study most frequently used in primary hyperparathyroidism (PHP). Transcutaneous cervical ultrasonography (US) is the other modality used for preoperative localization. The aim of this study was to determine whether surgeon-performed neck US can be used as the primary localizing study in PHP.

METHODS

This was a prospective study of 1,000 consecutive patients with first-time, sporadic PHP who underwent parathyroidectomy at a tertiary academic center. All patients had surgeon-performed neck US and MIBI before bilateral neck exploration.

RESULTS

The findings at exploration were 72% single adenoma, 15% double adenoma, and 13% hyperplasia. When US suggested single-gland disease (n = 842), MIBI was concordant in 82.5%, discordant and false in 8%, negative in 7%, and discordant but correct in 2.5%. When US suggested multigland disease (n = 68), MIBI was concordant in 47%, discordant and false in 41%, and negative in 12%. When US was negative (n = 90), MIBI was positive and correct in 43%, negative in 31%, and positive but false in 26%. Surgeon-performed neck US identified unrecognized thyroid nodules in 326 patients (33%), which led to fine-needle aspiration biopsy in 161 (49%) patients and thyroid surgery in 103 (32%) patients, with a final diagnosis of thyroid cancer in 24 (7%) patients.

CONCLUSION

Our results show that MIBI provides additional useful information in only a minority of patients with a positive US in PHP. Nevertheless, MIBI benefits about half of patients with a negative US. Because one-third of this patient population has unrecognized thyroid nodules as well, we propose that the most cost-effective algorithm would be to do US first and reserve MIBI for US-negative cases.

Clinical scenarios associated with local recurrence after laparoscopic radiofrequency thermal ablation of colorectal liver metastases

BACKGROUND

Over the last decade, radiofrequency thermal ablation (RFA) has been incorporated into the treatment algorithm of patients with unresectable colorectal liver metastases (CLM). For this population, the local recurrence (LR) rate is a key parameter used to assess the success of RFA. LR is defined as development of new tumor abutting and/or in 1 cm of an ablation zone. The aim of this study is to correlate LR with other hepatic or extrahepatic recurrence and patient survival.

METHODS

Between 2000 and 2011, 252 patients with CLM underwent laparoscopic RFA of 883 lesions. These patients were followed under a prospective protocol with quarterly liver computed tomography and blood work, including carcinoembryonic antigen levels quarterly for the first 2 years and then biannually. Clinical scenarios associated with LR were identified and categorized as being "isolated LR," "LR associated with new liver disease," or "LR associated with systemic disease." Demographic, clinical, and survival data were assessed using analysis of variance, Chi-square test, and univariate and multivariate Kaplan-Meier analysis.

RESULTS

One hundred eighteen patients (47%) developed LR after their initial laparoscopic RFA. These were 85 men (72%) and 33 women (28%), with a mean age of 70 ± 8 years. For this cohort, the mean of number of lesions was 3.1 ± 0.2 cm (range, 1-11) and dominant tumor size 2.9 ± 0.1 cm (range, 0.7-6.5) at the time of initial RFA. The LR rate per lesion was 29%. Of the patients who developed treatment failure at the RFA site, this was an isolated LR in 31 (26%) patients, associated with new liver disease in 51 (43%) and systemic metastases in 36 patients (31%). When patients with different clinical scenarios associated with LR were compared, no clinical predictors were identified to differentiate these subgroups. At a median follow up of 30 months (range, 3-113), the Kaplan-Meier median overall survival (OS) for patients with and without LR were 28 vs 31 months, respectively (P = .103). The OS for patients whose LR was isolated, associated with new liver and systemic recurrences was 39, 26, and 22 months, respectively (P = .009).

CONCLUSION

This study shows that, although the presence of LR does not negatively impact on survival, the pattern of recurrent disease does. LR after RFA for CLM is most often associated with new liver and systemic recurrences, reflecting the aggressive biology of cancer in patients channeled to this treatment modality.

A comparison of laparoscopic radiofrequency ablation versus systemic therapy alone in the treatment of breast cancer metastasis to the liver

OBJECTIVES

There is controversy about the roles of locoregional therapies in patients with liver metastases from breast cancer (LMBC). The aim of this study was to analyse survival after laparoscopic radiofrequency ablation (RFA) of LMBC and to compare this with survival in patients receiving systemic therapy (ST) alone.

METHODS

During 1996-2011, 24 patients who had failed to respond or had shown an incomplete response to ST underwent laparoscopic RFA for LMBC. Outcomes in these patients were compared with those in 32 patients with LMBC matched by tumour size and number, but treated with ST alone. Clinical parameters and overall survival were compared using t-tests, chi-squared tests and Kaplan-Meier analysis.

RESULTS

The groups were similar in hormone receptor status and chemotherapy exposure. In the laparoscopic RFA and ST groups, respectively, the mean ± standard deviation size of the dominant liver tumour and the number of tumours per patient were 3.7 ± 0.4 cm and 2.4 ± 0.4 cm, and 2.6 ± 0.4 tumours and 3.3 ± 0.4 tumours, respectively. These differences were not significant. At a median follow-up of 20 months in the laparoscopic RFA group, 42% of patients were found to have developed local liver recurrence, 63% had developed new liver disease and 38% had developed extrahepatic disease. Overall survival after the diagnosis of liver metastasis was 47 months in the laparoscopic RFA group and 9 months in the ST-only group (P = 0.0001). Five-year survival after the diagnosis of liver metastasis was 29% in the RFA group and 0% in the ST-only group.

CONCLUSIONS

This is the first study to compare outcomes in RFA and ST, respectively, in LMBC. The results show that survival after laparoscopic RFA plus ST is better than that after ST alone.

Efficacy of laparoscopic radiofrequency ablation for the treatment of patients with small solitary colorectal liver metastasis

BACKGROUND

Although radiofrequency ablation (RFA) has been incorporated to the treatment algorithm of patients with unresectable colorectal liver metastasis (CLM), its utility in patients with resectable disease has not been well studied. The aims of this study were to define the clinical profile of patients with a solitary CLM who underwent laparoscopic RFA and to analyze their oncologic outcomes.

METHODS

Between 2000 and 2011, 44 patients underwent laparoscopic RFA and 60 patients resection of solitary CLM ≤3 cm. Data were analyzed from a prospectively maintained institutional review board-approved database using Student's t test, Chi-square, and Kaplan-Meier tests.

RESULTS

The indications for RFA were patient decision in 61% (n = 27), comorbidities in 34% (n = 15), and intraoperative findings in 5% (n = 2). In comparison with the resection group, RFA patients had a greater American Society of Anesthesiologists score (3.0 ± 0.1 vs 2.6 ± 0.1, respectively; P = .002), more frequent incidence of cardiopulmonary comorbidities (60% vs 38%, respectively; P = .045), and tumors located deeper in the liver parenchyma (39% vs 12%) that would have required a formal lobectomy. The 2 groups were otherwise similar for age, gender, carcinoembrradyogenic antigen, synchronous versus metachronous presentation of CLM, tumor size, and tumor and nodal status of primary colorectal cancer. The local recurrence rate was 18% after RFA and 4% after resection (P = .012). The overall Kaplan-Meier, cancer-specific, 5-year survival was 47% for RFA and 57% for resection (P = .464). Median disease-free survival was 25 months after RFA and 22 months after resection (P = .973).

CONCLUSION

Our results suggest that laparoscopic RFA might spare a number of patients at greater risk with a small solitary CLM the risk of morbidity from a formal liver resection. Furthermore, laparoscopic RFA might also be acceptable as the first line of therapy for patients with tumors that otherwise would have required a formal lobectomy or open resection. Nevertheless, the local recurrence rate of RFA should be kept in mind and the patients followed closely to treat failures promptly.

The utility of intraoperative ultrasound in modified radical neck dissection: a pilot study

BACKGROUND

Although the value of surgeon-performed neck ultrasound (SPUS) for thyroid nodules has been validated, the utility of intraoperative ultrasound (US) in modified radical neck dissection (MRND) has not been reported in the literature. The aim of this study was to analyze the utility of intraoperative SPUS in assessing the completeness of MRND for thyroid cancer.

METHODS

Between 2007 and 2011, a total of 25 patients underwent MRND by 1 surgeon for thyroid cancer. All patients underwent intraoperative SPUS, which was repeated at the end of the neck dissection (completion US) to look for missed lymph nodes (LNs).

RESULTS

There were 10 male and 15 female patients. Pathology included 23 papillary and 2 medullary carcinomas. The number of LNs removed per case was 23 ± 2, and the number of positive was LNs 5 ± 1. In 4 (16%) cases, intraoperative US detected 7 residual LNs, which would have been missed, if completion US were not done. These missed LNs were located in low-level IV (3 nodes), high-level II (2 nodes), and posterior level V (2 nodes) and measured 1.4 ± 0.2 cm. At follow-up, recurrence was seen in 2 (8%) patients, including a superior mediastinal recurrence in a patient with tall cell cancer and a jugular LN recurrence at level II in another patient with papillary thyroid cancer.

CONCLUSION

This pilot study shows that intraoperative SPUS can help assess the completeness of MRND. According to our results, intraoperative completion US identifies LNs missed by palpation 16% of the time.

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).

Robotic versus laparoscopic adrenalectomy in obese patients

BACKGROUND

Recently, we demonstrated better perioperative outcomes with robotic versus laparoscopic adrenalectomy (LA) with the posterior retroperitoneal approach in general, and for removal of large adrenal tumors. It is unknown if robotic adrenalectomy (RA) is equivalent to LA in obese patients. The aim of this study is to compare perioperative outcomes of RA versus LA in obese patients.

METHODS

Between 2003 and 2012, 99 obese (BMI ≥ 30 kg/m(2)) patients underwent adrenalectomy at a tertiary academic center. Of these, 42 patients had RA and 57 had LA. The perioperative outcomes of these patients were compared between the RA and LA groups. Data were collected from a prospectively maintained, institutional review board approved database. Clinical and perioperative parameters were analyzed using Student t and χ(2) tests. All data are expressed as mean ± standard error of the mean.

RESULTS

The groups were similar in terms of age, gender, and tumor side. Body mass index was lower in the robotic versus laparoscopic group (35.4 ± 1.0 vs. 38.8 ± 0.8 kg/m(2), respectively, p = 0.01). Tumor size (4.0 ± 0.4 vs. 4.3 ± 0.3 cm, respectively, p = 0.56), skin-to-skin operative time (186.1 ± 12.1 vs. 187.3 ± 11 min, respectively, p = 0.94), estimated blood loss (50.3 ± 24.3 vs. 76.6 ± 21.3 ml, respectively, p = 0.42), and hospital stay (1.3 ± 0.1 vs. 1.6 ± 0.1 days, respectively, p = 0.06) were similar in both groups. The conversion to open rate was zero in the robotic and 5.2 % in the laparoscopic group (p = 0.06). The 30-day morbidity was 4.8 % in the robotic and 7 % in the laparoscopic group (p = 0.63).

CONCLUSIONS

Our study did not show any difference in perioperative outcomes between RA and LA in obese patients. These results suggest that the difficulties in maintaining exposure and dissection in obese patients nullify the advantages of robotic articulating versus rigid laparoscopic instruments in adrenal surgery.

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.

Hepar lobatum carcinomatosum associated with metastatic rectal carcinoma: an unusual cause of liver dysmorphy

OBJECTIVE

The aim of this study was to present a case of hepar lobatum resulting from metastatic rectal carcinoma.

CLINICAL PRESENTATION AND INTERVENTION

A 50-year-old man presented with a 2-year history of bleeding per anum, tenesmus, malaise and weakness. Initially, the patient received neoadjuvant chemoradiotherapy followed by abdominoperineal resection of the rectum. Abdominal computed tomography showed lobar enlargement and lobulated contour, mainly in the left lobe of the liver, but no primary or metastatic lesions were detected. Laparotomy revealed an irregularly lobulated hepatic deformity. Liver biopsy showed a necrotic tumor growth from adenocarcinoma of the rectum in subcapsular localizationof the liver.

CONCLUSION

This case showed a patient with hepar lobatum carcinomatosum caused by metastatic rectal carcinoma. The report further highlights the need for clinicians and surgeons to keep in mind the possibility of hepar lobatum carcinomatosum while caring for rectal carcinoma patients, especially when the lobulated contour of the liver is detected at preoperative imaging studies or when the coarsely lobated liver is encountered during surgery for carcinoma of the rectum.

Treatment challenges in pediatric stroke patients

Aim. In this study we presented our experience of 18 years on the etiology, risk factors, prophylactic and acute treatment, the effect of treatment to recurrence rate of patients with stroke. Methods. The population included 108 patients who had been treated for stroke at Pediatric Neurology Department of Ankara University with the diagnosis of arterial ischemic stroke and sinovenous thrombosis between January 1992 and August 2010. Forty-one girls (38%) and 67 boys (62%) with mean symptom age 3.1 ± 4.04 years, (0–18 years old) were followed up with a mean period of 4.9 ± 3.78 years (0–17 years). Results. 30 patients had no risk factors, 34 patients had only one risk factor and 44 patients had multiple risk factors. Recurrence was seen in three patients. There was no any statistical correlation between the recurrence of stroke and the existence of risk factors (P = .961). Seventeen patients received prophylactic treatment; 2 of them without any risk factors, 3 had one risk factor, 12 patients, who constituted the majority of our patients, had multiple risk factors (P = .024). Conclusion. With this study we showed that the right prophylaxis for right patients reduces the rate of recurrence.

Evaluation of surface contamination with staphylococci in a veterinary hospital using a quantitative microbiological method

OBJECTIVES

To evaluate microbial contamination of the environment in a veterinary hospital using standards recommended for human hospitals and to provide a baseline against which further investigations can be compared.

METHODS

Surfaces were sampled twice daily for five consecutive days using a contact-based counting method to measure the levels of staphylococci in colony forming units (cfu) per cm².

RESULTS

Current recommendations for human hospitals were applied in this study; all samples with <2.5 cfu/cm² staphylococci were considered to have passed and those with ≥2.5 cfu/cm² to have failed. Of all the samples, 55.9% failed. The ICU did not have significantly higher failure rates than other areas of the hospital. The floor as a surface was associated with greater than a threefold increase in odds of elevated cfu concentrations relative to the door handle.

CLINICAL SIGNIFICANCE

This study provides information on the microbiological cleanliness of a veterinary teaching hospital using techniques and standards adopted by the food industry and recommended for human hospitals. This data can be used as a baseline for other hospitals, to evaluate the effectiveness in improvements in hygiene and cleaning measures and to design effective hospital cleaning protocols and assess ongoing hygiene standards.

A new oxidative stress marker in patients with nasal polyposis: advanced oxidation protein products (AOPP)

OBJECTIVES

The aim of this study was to determine whether levels of advanced oxidation protein products (AOPP) can be used a marker of oxidative stress in the etiology of nasal polyposis.

MATERIALS AND METHODS

Twenty-four patients diagnosed with nasal polyposis in Haseki Education and Research Hospital ENT Department between March and June 2008 were included in the study. The AOPP serum levels in NP patients and 24 healthy controls were measured with spectrophotometry and the results were compared statistically.

RESULTS

AOPP levels were significantly higher in the study group compared with the control group.

CONCLUSION

Our findings suggest that AOPP levels can be used as a marker of oxidative stress in patients with nasal polyposis. Future studies are neccessary to evaluate the efficacy of antioxidant therapy.

Predictors of intracytoplasmic sperm injection (ICSI) outcome in couples with and without male factor infertility

AIM

To find out the predictors of ICSI outcome.

METHODS

Forty-three pregnancies in 100 consecutive ICSI cycles.

RESULTS

Every 1,000 pg/ml increase in hCG-day E2 (OR = 0.46, CI: 0.25-0.83, p = 0.01) and 1% decrease in the rate of normal sperm morphology (OR = 0.81, CI: 0.67-0.98, p = 0.03) caused a significant decrease in clinical pregnancy rate and live birth rate (respectively, OR = 0.5, CI: 0.32-0.96, p = 0.03, OR = 0.66, CI: 0.5-0.86, p = 0.002) while every increase in the number of good quality embryos transferred caused a two-time increase in the clinical pregnancy rate (OR = 2.1, CI: 1.2-4, p = 0.01). On the other hand, every increase in the number of four-cell cleavage embryos (OR = 1.02, CI: 1.002-1.04, p = 0.03) and hCG-day endometrial thickness (OR = 1.6, CI: 1.15-2.24, p = 0.005) were found to increase the live birth rate. Implantation rate (m = 8.3 +/- 14.6) was significantly lower in cases with leucocytospermia (n = 33) compared to cases without leucocytospermia (n = 67, m = 17.4 +/- 24.6, p = 0.02).

CONCLUSION

Leucocytospermia, hCG-day E2 level and endometrial thickness, normal sperm morphology, and number of good quality embryos are predictors of implantation, clinical pregnancy and live birth rate following ICSI.

CD40 expression on human pancreatic duct cells: role in nuclear factor-kappa B activation and production of pro-inflammatory cytokines

AIMS/HYPOTHESIS

Human pancreatic duct cells are closely associated with islet beta cells, and contaminate islet suspensions transplanted in Type 1 diabetes mellitus patients. Activated duct cells produce cytotoxic mediators and possibly contribute to the pathogenesis of Type 1 diabetes mellitus or islet graft rejection. As CD40 transduces activation signals involved in inflammatory and immune disorders, we investigated CD40 expression on duct cells and their response to CD40 engagement.

METHODS

CD40 expression on human pancreatic duct cells was analysed by flow cytometry and immunohistochemical analyses. To assess the function of CD40 expression on duct cells, activation of the transcription factor nuclear factor-kappa B was determined using electrophoretic mobility shift assay and ELISA. Cytokine mRNA levels were quantified by real-time RT-PCR, and protein levels by Luminex technology.

RESULTS

Isolated human pancreatic duct cells and Capan-2 cell lines were found to express constitutively CD40. The expression of CD40 on duct cells was confirmed in vivo on human normal and pathological pancreatic specimens. CD40 ligation on Capan-2 cells induced rapid nuclear factor-kappa B activation, and supershift assays demonstrated that p50/p65 heterodimers and p50/p50 homodimers were present in the activated complexes in the nucleus. This activation was accompanied by tumour necrosis factor-a and interleukin-1beta mRNA accumulation. Tumour necrosis factor-alpha protein secretion was confirmed in CD40-activated Capan-2 cells and in isolated human pancreatic duct cells.

CONCLUSIONS/INTERPRETATION

Interaction between activated T lymphocytes expressing CD40 ligand and duct cells expressing CD40 may contribute to the immune responses involved in Type 1 diabetes mellitus and islet graft rejection. Interfering with CD40-mediated duct cell activation could alleviate beta cell damage of immune origin.

Lymph Node Staging in Lung Cancer Using [18F]FDG-PET

BACKGROUND

Mediastinal lymph node staging is essential to determine treatment options in patients with NSCLC. Positron emission tomography (PET) detects increased glucose uptake in malignant tissue using the glucose analogue 2-[(18)F]fluoro-2-deoxy-D-glucose (FDG).

PATIENTS AND METHODS

In the present study were evaluated 155 patients with focal pulmonary tumors who underwent both preoperative computed tomography (CT) and FDG-PET scanning (116 malignant and 39 benign lesions).

RESULTS

Findings in 155 patients included 116 malignant and 39 benign lesions. For N-staging, FDG-PET showed a sensitivity of 88%, a specificity of 91%, and an accuracy of 89%. Corresponding figures for CT were 77%, 76%, and 77%, respectively.

CONCLUSIONS

FDG-PET is an effective, noninvasive method for staging thoracic lymph nodes in patients with lung cancer and is superior to CT scanning in the assessment of hilar and mediastinal nodal metastases. With regard to operability, FDG-PET could differentiate reliable between patients with N1/N2 disease and those with unresectable N3 disease.