Treatment outcomes and prognostic factors in patients with driver mutant non-small cell lung cancer and de novo brain metastases

Central nervous system (CNS) metastases can be seen at a rate of 30% in advanced stages for patients with non-small cell lung cancer (NSCLC). Growing evidence indicates the predictive roles of driver gene mutations in the development of brain metastases (BM) in recent years, meaning that oncogene-driven NSCLC have a high incidence of BM at diagnosis. Today, 3rd generation targeted drugs with high intracranial efficacy, which can cross the blood-brain barrier, have made a positive contribution to survival for these patients with an increased propensity to BM. It is important to update the clinical and pathological factors reflected in the survival with real-life data. A multi-center, retrospective database of 306 patients diagnosed with driver mutant NSCLC and initially presented with BM between between November 2008 and September 2022 were analyzed. The median progression-free survival (mPFS) was 12.25 months (95% CI, 10-14.5). While 254 of the patients received tyrosine kinase inhibitor (TKI), 51 patients received chemotherapy as first line treatment. The median intracranial PFS (iPFS) was 18.5 months (95% CI, 14.8-22.2). The median overall survival (OS) was 29 months (95% CI, 25.2-33.0). It was found that having 3 or less BM and absence of extracranial metastases were significantly associated with better mOS and iPFS. The relationship between the size of BM and survival was found to be non-significant. Among patients with advanced NSCLC with de novo BM carrying a driver mutation, long-term progression-free and overall survival can be achieved with the advent of targeted agents with high CNS efficacy with more conservative and localized radiotherapy modalities.

Neoadjuvant Chemotherapy and Pathologic Complete Response in HR+/HER2- Breast Cancer: Impact of Tumor Ki67 and ER Status

INTRODUCTION

Neoadjuvant chemotherapy (NAC) is extensively employed in breast cancer (BC), primarily for aggressive subtypes like triple-negative and human epidermal growth factor receptor 2 (HER2) positive BC, and in estrogen receptor-positive (ER+)/ HER2- BC with high-risk features. In ER+/HER2- breast cancer, pathological complet rates are much lower (<10%), while axillary dissection rates are higher. This study focuses on hormone receptor positive (HR+)/HER2- BC patients undergoing NAC, examining its impact on pathological complete response (pCR) rates, with specific attention to tumor Ki67 and ER status.

METHODS

Retrospective data analysis from Kartal Dr. Lütfi Kırdar City Hospital included HR+/HER2- BC patients who received NAC. Clinicopathological factors, NAC response, and surgical outcomes were assessed. Statistical analyses evaluated the association between Ki67, ER status, and pCR.

RESULTS

Of 203 patients, 11.8% achieved pCR. Ki67 (p<0.001) and ER percentage (p<0.001) significantly correlated with pCR. Higher Ki67 was associated with increased pCR likelihood (HR: 1.03, 95% CI: 1.01-1.05). A Ki67-pCR probability curve revealed a cutoff of 23.5%. ER%-pCR analysis showed decreasing pCR rates with higher ER percentages. Multivariate analysis confirmed Ki67 (p=0.003, HR: 1.02) and ER percentage (p=0.019, HR: 0.97) as independent predictors of pCR probability.

CONCLUSION

Consideration of Ki67 and ER percentage aids in NAC decisions for HR+/HER2- BC, identifying patients with high NAC response rates, facilitating axillary preservation, and potentially avoiding axillary dissection. The pCR rates in patients with Ki67 ≤ 24 are particularly low, especially in patients with a high ER percentage. In these cases, upfront surgery and adjuvant treatment should be considered instead of NAC.

Prognostic scores in pulmonary large cell neuroendocrine carcinoma: A retrospective cohort study

Introduction

Pulmonary large cell neuroendocrine carcinoma (PLCNEC) is a rare but aggressive subtype of lung cancer with an incidence of approximately 3 %. Identifying effective prognostic indicators is crucial for guiding treatments. This study examined the relationship between inflammatory markers and PLCNEC patient overall survival (OS) and sought to determine their prognostic significance in PLCNEC.

Methods

Patients diagnosed with PLCNEC between 2007 and 2022 at the oncology center, were retrospectively included. Patients who underwent surgery were pathologically re-staged post-surgery. Potential prognostic parameters (neutrophil/lymphocyte ratio, platelet/lymphocyte ratio [PLR], panimmune inflammatory value, prognostic nutritional index and modified Glasgow prognostic score [mGPS]) were calculated at that time of diagnosis.

Results

Sixty patients were included. The median follow-up was 23 months. Thirty-eight patients initially diagnosed with early or locally advanced. The mGPS was identified as a poor prognostic factor that influenced disease free survival (DFS) fourfold (p = 0.03). All patients' median OS was 45 months. Evaluating factors affecting OS in all patients, statistically significant relationships were observed between OS and the prognostic nutritional index (p = 0.001), neutrophil/lymphocyte ratio (p = 0.03), platelet/lymphocyte ratio (p = 0.002), and pan-immunoinflammatory value (p = 0.005). Upon multivariate analysis, the platelet/lymphocyte ratio was identified as an independent poor prognostic factor for OS, increasing the mortality risk by 5.4 times (p = 0.002).

Conclusion

mGPS was significantly linked with prognosis in non-metastatic PLCNEC, with patients with higher mGPS exhibiting poorer long-term DFS. This finding contributes to the evolving understanding of PLCNEC. The multivariable predictive model we employed suggests that PLR is an independent predictor of OS at all stages. A lower PLR was correlated with worse overall survival. Thus, PLR can be a readily accessible and cost-effective prognostic factor in PLCNEC patients.

Successful Anesthesia Management of Pediatric Living Donor Liver Transplant With Mild Bilateral Pulmonary Artery Stenosis Due to Alagille Syndrome: A Case Report

Alagille syndrome is an autosomal-dominantinherited disease characterized by intrahepatic bile duct involvement, congenital heart disease, eye anomalies, skeletal and central nervous system involvement, kidney anomalies, and facial appearance. Liver transplant is the only treatment option for patients with end-stage liver disease and Alagille syndrome. Bilateral peripheral pulmonary artery stenosis is a contraindication for liver transplant due to high mortality, and the decision for liver transplant in patients with bilateral peripheral pulmonary artery stenosis is extremely challenging for anesthesiologists andtransplant surgeons.Wepresent a 2-year-oldfemale patient with successful anesthetic management of a pediatric living donor liver transplant with mild bilateral pulmonary artery stenosis, mild aortic stenosis, and mitral regurgitation due to Alagille syndrome. Anesthesiologists should know the underlying pathophysiological condition and perform a comprehensive preoperative evaluation to determine the correct anesthesia plan in patients with Alagille syndrome who will undergo liver transplants to treat multiple system disorders. Successful perioperative management of Alagille syndrome requires effective communication and collaboration between specialists through a multidisciplinary team approach.

The association of microRNAs in the development of retinopathy of prematurity

INTRODUCTION

Retinopathy of prematurity (ROP) is one of the main reasons of preventable childhood blindness. In the development of ROP, MicroRNAs may be effective in the balance of factors that inhibit and activate angiogenic factors. We aimed to determine the changes in the blood levels of miR-146a, miR-143, miR-210, miR-21, miR-126, miR-211, miR-221, miR-106 and let 7f and to investigate their association with ROP. We hypothesed that the level of these miRNAs changed significantly in ROP cases.

MATERIALS AND METHODS

This observational study was conducted prospectively in preterm infants with ROP. Serum levels of 8 miRNAs were measured. The relationship between disease stage and progression with miRNA gene expression was analysed. Preterm infants without ROP were taken as the control group.

RESULTS

47 patients with ROP and 14 controls, were included in the study. In the ROP group, miR-210, miR-146a, miR-21 were statistically significantly lower. In the ROP group the expression level of miR-143 was insignificantly lower, miRNA-221 was insignificantly higher, and miR-106, miR-126 and let 7f were variable.

CONCLUSION

It was observed that miR-210, miR-146a, miR-21 and miR-143 were significantly lower in patients with ROP compared to the control group. However, no association could be established between the type of miRNA and stage of ROP. These miRNAs may be used as adjunctive biomarkers for diagnosis of ROP.

Impact of low-level laser therapy as an adjunct to non-surgical periodontal treatment on the levels of tissue plasminogen activator and plasminogen activator inhibitor 1 in Stage 3-4, Grade C periodontitis patients: a split-mouth, randomized control study

AIM

To investigate the effects of low-level laser therapy (LLLT) as an adjunct to non-surgical periodontal treatment (NSPT) on the plasminogen-activating system.

MATERIALS AND METHODS

Stage 3-4 Grade C periodontitis and age-gender-matched healthy individuals participated in the split-mouth study (ClinicalTrials.gov identifier, NCT05233501). The study groups were Periodontitis/NSPT (Sham); Periodontitis/NSPT + LLLT (LLLT); Healthy (Control). Following NSPT, LLLT was applied on Days 0, 2 and 7. Clinical parameters were recorded at baseline and on Day 30. Gingival crevicular fluid (GCF) was collected at baseline, on days 7, 14, and 30; tissue-type plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1) levels were measured with ELISA.

RESULTS

Clinical parameters, total GCF tPA (tPAt) and PAI-1 (PAI-1t) levels significantly reduced in LLLT and Sham groups (< 0.001). GCF tPAt levels in LLLT were significantly lower (< 0.05) than Sham on Day 7. GCF tPAt levels in periodontitis groups were significantly higher than the Control at baseline, on Days 7 and 14 (< 0.01). By Day 30, both groups decreased to control levels (> 0.05). GCF PAI-1t levels were significantly lower in LLLT than the Sham on day 30 (< 0.01), comparable to healthy controls (> 0.05).

CONCLUSION

Adjunctive LLLT modulates the plasminogen activating system in severe periodontitis by altering GCF tPA and PAI-1 levels.

CLINICAL RELEVANCE

LLLT as an adjunct to non-surgical periodontal treatment in patients with Stage 3-4 Grade C leads to reduced plasminogen activation.

Pulmonary Embolism in a Liver Donor: A Case Report and Review of the Literature

Liver transplant is an important treatment option for end-stage liver disease, and living related donation is an option to shorten or eliminate the waiting period for the patients, especially when shortage of organs is of concern. It is crucial to provide optimal safety for the donors and to thoroughly examine them preoperatively in order to decrease perioperative and postoperative complications. Here, we report the case of a living donor who had undergone a left liver lobectomy and on postoperative day 2 presented with a radiologically severe pulmonary embolism, despite the absence of any risk factor for venous thromboembolism or pulmonary embolism. The patient was treated with tissue plasminogen activator and heparin infusions and was discharged 1 week later.

Is laparoscopic surgery safe and feasible in acute adhesive ileus?

Although the classical surgical treatment of adhesive ileus is performed using the open method, laparoscopic surgery has recently been performed in some centers. This study aimed to discuss the feasibility and role of laparoscopic surgery in the treatment of adhesive small bowel obstruction. In this retrospective study, the data of 830 patients who were operated for ileus in Başkent University Faculty of Medicine, Ankara Hospital, Department of General Surgery between January 2011 and September 2022 were analyzed. Missing data and intraabdominal cancer-related ileus were accepted as exclusion criteria and 648 patients were excluded from the study. The development of adhesion-related ileus and completeness of the data were accepted as inclusion criteria. Data were compared between the 2 groups [open group (OG; 152 cases) and laparoscopic group (LG; 30 cases]). When the patient characteristics were evaluated, it was found that the history of previous abdominal surgery (P < .001) and the number of previous abdominal surgery (P < .001) were statistically significantly higher in OG. Operation time was significantly longer in the LG (P = .022). There were no statistically significant differences between the groups in terms of intraoperative bowel injury (P = .216), bowel resection (P = .284), and stoma creation (P = .331). OG had a significantly higher rate of Clavien-Dindo grade ≥ 3 serious complications (P < .001) and mortality rate (P = .045). The first gas out occurred significantly earlier in the LG (P = .014). Oral intake was initiated earlier in the LG (P = .004). The length of hospital stay was significantly shorter in the LG (P < .001). There was no significant difference between the groups in terms of postoperative ileus, readmission, and reoperation. Laparoscopic surgery can be safely performed for the treatment of selected patients with adhesive small bowel obstruction. In addition, it is advantageous in terms of postoperative recovery.

Outcomes of surveillance versus adjuvant treatment for patients with stage-I seminoma: a single-center experience

INTRODUCTION

Testicular germ cell tumors (seminoma/non-seminoma) are the most common carcinomas in young males, comprising approximately 1% of all carcinomas. In stage-I disease, orchiectomy can cure approximately 85% of patients. Post-surgical options are adjuvant therapy and active surveillance. Our study examined the effects of management options on stage-I seminoma patients followed in our center.

METHODS

We evaluated the patients with stage-I testicular seminoma who underwent radical orchiectomy and followed up in the oncology center between 2001 and 2022. The outcomes of management options, survivals were retrospectively analyzed. The prognostic significance of risk factors for relapse on survival was evaluated.

RESULTS

Of the 140 patients with stage-I seminoma, 49 (35%) were treated with adjuvant therapy, and 91 (65%) underwent surveillance. The median follow-up duration was 37 months. During the follow-up period, nine patients in the active surveillance group and four in the adjuvant therapy group had a recurrence. There was no statistically significant difference between the two groups (p = 0.67). In the surveillance group, the univariate and multivariate analyzes identified the presence of lymphovascular invasion (p = 0.005, HR: 0.13) as significant prognostic factor for disease-free survival (DFS). In the surveillance cohort, the 5-year DFS rate was 60% for patients with lymphovascular invasion and 93% for those without. There was statistical significance between the two groups (p = 0.003).

CONCLUSION

Our study shows that adjuvant therapy does not significantly improve DFS compared to surveillance in patients. In addition, it has been shown that lymphovascular invasion is an important prognostic indicator for DFS in determining the treatment strategy.

The effect of alpha-lipoic acid on oxidative parameters, SCUBE-1 and SCUBE-2 in hepatic ischemia-reperfusion injury in cholestatic rats

OBJECTIVE

The aim of the study was to evaluate the protective effects of alpha-lipoic acid (ALA) on the liver, oxidative parameters, and signal peptide-CUB-epidermal growth factor-like domain-containing proteins 1 and 2 (SCUBE-1 and -2) in an experimental cholestatic hepatic ischemia-reperfusion (IR) model.

MATERIALS AND METHODS

Twenty-four female rats were included in the study and divided into four groups of six rats each. Group 1 was the control group, in which only laparotomy was performed; Group 2 underwent laparotomy and received alpha-lipoic acid (ALA) on a daily basis; bile duct ligation was performed in Group 3; bile duct ligation was performed, and ALA was administered to Group 4. All rats underwent relaparotomy on the seventh day, followed by 30 minutes of hepatic ischemia and 60 minutes of reperfusion in Groups 3 and 4. Liver tissue and blood samples were taken for histopathological and biochemical examinations. Alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), total bilirubin (TBIL), direct bilirubin (DBIL), albumin, ischemia modified albumin (IMA), SCUBE-1, SCUBE-2, total antioxidant status (TAS) and total oxidant status (TOS) levels were also examined.

RESULTS

The SCUBE-1 and SCUBE-2 values in Group 4 were lower than in Group 3, but no significant difference was observed between all the groups. The AST, TBIL, and DBIL levels were significantly higher in Groups 3 and 4 than in Groups 1 and 2 (p<0.0001). Although TOS was the highest in Group 3, the measurements were similar across the groups (p=0.464). IMA and TAS were similar between Groups 3 and 4 but significantly higher in these groups than in Groups 1 and 2 (p=0.001). The hepatic injury observed in Groups 3 and 4 was significantly higher than that observed in Groups 1 and 2 (p<0.0001). In the histopathological examination, neutrophilic infiltration and bile duct proliferation were less commonly detected in the portal areas in Group 4 than in Group 3, and necrotic foci were not observed due to the administration of ALA.

CONCLUSIONS

The promising effects of ALA, known for its powerful antioxidant properties, on the IR injury of the liver can allow it to enter clinical practice in the future.

A novel approach to distinguish complicated and non-complicated acute cholecystitis: Decision tree method

It is difficult to differentiate between non-complicated acute cholecystitis (NCAC) and complicated acute cholecystitis (CAC) preoperatively, which are two separate pathologies with different management. The aim of this study was to create an algorithm that distinguishes between CAC and NCAC using the decision tree method, which includes simple examinations. In this retrospective study, the patients were divided into 2 groups: CAC (149 patients) and NCAC (885 patients). Parameters such as patient demographic data, American Society of Anesthesiologists (ASA) score, Tokyo grade, comorbidity findings, white blood cell (WBC) count, neutrophil/lymphocyte ratio, C-reactive protein (CRP) level, albumin level, CRP/albumin ratio (CAR), and gallbladder wall thickness (GBWT) were evaluated. In this algorithm, the CRP value became a very important parameter in the distinction between NCAC and CAC. Age was an important predictive factor in patients with CRP levels >57 mg/L, and the critical value for age was 42. After the age factor, the important parameters in the decision tree were WBC and GBWT. In patients with a CRP value of ≤57 mg/L, GBWT is decisive and the critical value is 4.85 mm. Age, neutrophil/lymphocyte ratio, and WBC count were among the other important factors after GBWT. Sex, ASA score, Tokyo grade, comorbidity, CAR, and albumin value did not have an effect on the distinction between NCAC and CAC. In statistical analysis, significant differences were found groups in terms of gender (34.8% vs 51.7% male), ASA score (P < .001), Tokyo grade (P < .001), comorbidity (P < .001), albumin (4 vs 3.4 g/dL), and CAR (2.4 vs 38.4). By means of this algorithm, which includes low-cost examinations, NCAC and CAC distinction can be made easily and quickly within limited possibilities. Preoperative prediction of pathologies that are difficult to manage, such as CAC, can minimize patient morbidity and mortality.

Comparison of COVID-19 patients who underwent thrombectomy with those in the pre-pandemic period in terms of etiology and prognosis

OBJECTIVE

We aimed at determining the effectiveness of mechanical thrombectomy (MT) in patients with major vessel occlusion and infected with COVID-19, evaluating its clinical outcome and comparing it with non-COVID patients.

PATIENTS AND METHODS

During the pandemic, 729 patients who underwent MT in stroke centers due to Acute Ischemic Stroke (AIS) with large vessel occlusion were evaluated. This study included 40 patients with a confirmed COVID-19 diagnosis by a positive PCR test between March 11, 2020, and December 31, 2020. These patients were compared to 409 patients who underwent MT due to major vessel occlusion between March 11, 2019, and December 31, 2019.

RESULTS

Of the patients with AIS who are infected with COVID-19, 62.5% were males, and all patients have a median age of 63.5 ± 14.4 years. The median NIHSS score of the COVID-19 group was significantly higher than that of the non-COVID-19 groups. Dissection was significantly more in the COVID-19 group. The mortality rates at 3 months were higher in the COVID-19 groups compared to non-COVID-19 groups.

CONCLUSIONS

This study revealed an increased frequency of dissection in patients with COVID-19. COVID-19-related ischemic strokes are associated with worse functional outcomes and higher mortality rates than non-COVID-19 ischemic strokes.

Our Pediatric Liver and Kidney Transplant Activities in 2021

OBJECTIVES

In children with end-stage renal disease, chronic liver failure, or acute liver failure, liver transplant and kidney transplant are the most effective modalities for better clinical outcomes compared with other therapies. However, children are particularly susceptible to surgical complications, so pediatric solid-organ transplants should be reserved for centers with substantial experience and multidisciplinary expertise. Here, we assessed liver and kidney transplants performed at our center in 2021.

MATERIALS AND METHODS

From November 3, 1975, to December 31, 2021, we performed 701 liver transplants and 3290 kidney transplants. From January 1, 2021, to December 31, 2021, we performed 21 liver transplants (19 in children) and 114 kidney transplants (12 in children). We recorded age, sex, body mass index, comorbidities, etiologies, laboratory values, and clinical outcomes.

RESULTS

For the year 2021, we performed 19 pediatric liver transplants and 12 pediatric kidney transplants. Mean age of liver recipients was 3.4 years, and 8 were male patients. The most common etiology was biliary atresia (n = 7). All liver grafts were from living related donors who were first-degree (n = 16) or second- degree (n = 3) relatives of the recipients. Mean hospital stay was 17.6 days. All but 2 liver transplant recipients were discharged successfully (2 died from sepsis in the early postoperative period). Mean age of kidney transplant recipients was 14.1 years, and 4 were male patients. The most common etiology was vesicoureteral reflux (n = 3). One kidney graft was from a deceased donor, with the rest from living related donors who were first-degree relatives of the recipients (n = 11; mother for 8 recipients and father for 3 recipients). Mean hospital stay was 4.3 days. All kidney transplant recipients were discharged successfully.

CONCLUSIONS

Solid-organ transplants for young children are often complex but can be performed successfully at experienced transplant centers.

Practical Utility of Diagnostic Clinical Breast Examination in the Diagnosis of Breast Cancer

Objectives We aimed to investigate the effectiveness of physician-performed diagnostic clinical breast examination (DCBE) for the diagnosis of breast cancer in clinical practice and to determine the rates of breast cancer diagnosed with DCBE compared to the results of breast ultrasonography (US), mammography (MG), and histopathology. Methods In the retrospective cohort study, the files of female patients diagnosed with breast cancer and admitted to the general surgery outpatient clinics of a university hospital over a 10-year period (2011-2021) were examined. Patients with complete DCBE findings in their files were identified and analyzed (n = 1,091). The examinations of the patients were performed by general surgery specialists with 5-22 years of experience and by radiologists with 4-15 years of experience. Results The mean age of breast cancer diagnosis of the patients was 55.1 ± 13.5 years. While the sensitivity of DCBE was found to be 88.9%, MG sensitivity was 89.8% and breast US sensitivity was 95.1%. Cancer was detected by MG, breast US, and DCBE in 47.9% (n = 523), by breast US and DCBE in 38.9% (n = 424), by MG and breast US in 5.6% (n = 61), by DCBE alone in 3.6% (n = 39), by MG and DCBE in 2.4% (n = 26), and by breast US alone in 1.6% (n = 18). Early-stage breast cancer (p = 0.00) consisted of 73.2% (n = 383) of cancers detected with DCBE, breast US and MG, 74.6% (n = 316) of cancers detected with DCBE and breast US, 93.4% of cancers detected with breast US and MG (n = 57), 92.3% (n = 24) of cancers detected with DCBE and MG, 94.4% (n = 17) of cancers detected with breast US alone, and 69.2% of cancers detected with DCBE alone (n = 27). Conclusions CBE still maintains its importance in societies where screening participation and awareness of breast cancer are low. A breast cancer diagnosis is often done after a complaint of a palpable mass in the breast, and only then are more advanced-stage breast cancers are seen. CBE is among the important diagnostic methods preventing breast cancer from being overlooked, especially in places where health resources are limited.

Effect of Adipose-Derived Stem Cells on Colonic Anastomosis in Rats Immunosuppressed With Everolimus: An Experimental Study

OBJECTIVES

Immunosuppressed patients sometimes require colorectal surgery. We investigated whether adipose tissue-derived stem cells contributed to anastomosis healing in rats immunosuppressed with the mTOR inhibitor everolimus.

MATERIALS AND METHODS

Sixty male Sprague-Dawley rats were randomly divided into 4 groups of 14 each, with all groups undergoing descending colon anastomosis; the 4 remaining rats were used for stem cell retrieval. Group 1 (control) underwent surgery only, group 2 received stem cell injection, group 3 received everolimus only, and group 4 received everolimus plus stem cell injection. After treatment, each group was randomly divided into 2 equal subgroups according to the day of euthanasia (posttreatment day 4 or day 7). We measured anastomosis bursting pressure and tissue hydroxyproline level and performed histopathological evaluation.

RESULTS

At both posttreatment days 4 and 7, median weight loss in group 3 was higher than in group 1, group 3 had higher severity of intraabdominal adhesion than group 4, and group 2 had mean hydroxyproline level higher than the other groups. At posttreatment day 4, mean bursting pressure was significantly different in group 1 versus groups 2 and 4 (P = .002) and group 2 versus groups 3 and 4 (P < .001). No significant differences were shown in pathological analysis except for vascular proliferation on day 7 (P = .003).

CONCLUSIONS

Injection of adipose tissue-derived stem cells in the anastomosis site prevented anastomosis leakage by contributing to healing. Injection of adipose tissue-derived stem cells in the anastomosis region, especially in the early period after solid-organ transplant in recipients and after gastrointestinal surgery in immunosuppressed patients, may help reduce mortality and morbidity.

The New Anterior Less Invasive Crescentic Incision for Living Donor Nephrectomy

OBJECTIVES

Living-donor nephrectomy is a devoted procedure performed in a healthy individual; for these procedures, it is essential to complete the surgery with the lowest possible risk and morbidity and allow donors to regain their normal daily activity. To minimize anatomic and physiologic damage, we modified a surgical technique. Here, we report our experiences with the new anterior less invasive crescentic donor nephrectomy technique.

MATERIALS AND METHODS

We retrospectively evaluated 728 donor nephrectomy patients who had the new anterior less invasive cresentic incision (n = 224), the classic open (n = 431), or the laparoscopic living-donor nephrectomy (n = 73) procedures. Demographic characteristics, preoperative and postoperative parameters, acute renal graft dysfunction, and firstyear graft and patient survival rates were compared between groups.

RESULTS

During the operation, the new cresentic incision living-donor nephrectomy allowed a safe and comfortable position for the patient and the anesthesiologist. Also, it procures safe access especially for grefts with multiple vessels. Patients had lower pain scores (P = .010), shorter hospital stays (2.25 vs 3.49 days) than those who received the classic open living-donor nephrectomy. Patients who received laparoscopic living-donor nephrectomy had significantly longer mean operation time (P = .016) and warm ischemia time (P ≤ .001) than those who had the new cresentic incision technique. All groups showed similar rates of first-year survival and delayed graft dysfunction.

CONCLUSIONS

The new anterior less invasive cresentic incision open-donor nephrectomy approach is a safe, comfortable, effective, and less invasive modification of the living donor nephrectomy. Also, it procures safe access for grefts with multiple vessels.

Liver and Kidney Transplant During a 6-Month Period in the COVID-19 Pandemic: A Single-Center Experience

OBJECTIVES

With the declaration of COVID-19 as a pandemic, many studies have indicated that elective surgeries should be postponed. However, postponement of transplants may cause diseases to get worse and increase the number in wait lists. We believe that, with precautions, transplant does not pose a risk during pandemic. Here, we aimed to evaluate our transplant results, which we safely performed during a 6-month pandemic period.

MATERIALS AND METHODS

Until September 2020, 3140 kidney and 667 liver transplants have been performed in our centers. We evaluated 38 kidney transplants and 9 liver transplants procedures performed during the pandemic (March 1 to September 2, 2020). Recipient and donor candidates were screened for COVID-19 with polymerase chain reaction and thoracic computed tomography. All recipients had routine immunosuppressive protocol. During hospitalization at our COVID-19-free transplant facility, we restricted the interactions during multidisciplinary rounds.

RESULTS

During the pandemic, 38 kidney transplants with an average length of hospital stay of 8.1 days were performed. Mean serum creatinine values of recipients were 0.91, 0.86, and 0.74 mg/dL on postoperative days 7, 30, and 90, respectively. During the pandemic, 9 living donor liver transplants (1 adult, 8 pediatric) were performed with an average length of hospital stay of 17.1 days. Mean serum total bilirubin levels were 0.9, 0.5, and 0.4 mg/dL on postoperative days 7, 30, and 90, respectively. Mean serum aspartate aminotransferase levels were 38.1, 28.3, and 22.3 U/L on postoperative days 7, 30, and 90, respectively. All recipients and donors were successfully discharged. Only 1 liver recipient died (on day 55 after discharge as a result of oxalosis-induced heart failure).

CONCLUSIONS

According to our results, when precautions are taken, transplant does not pose a risk to patients during the pandemic period. We attribute the safety and success shown to our newly developed protocol in response to the COVID-19 pandemic.

Clinical characteristics and myocardial function assessed by traditional and novel echocardiographic methods in competitive triathletes with and without myocardial fibrosis

Background

The aim of the present study was to compare clinical characteristics and cardiac structure and function in competitive triathletes with and without myocardial fibrosis.

Methods

Cardiac fibrosis in 61 healthy male competitive triathletes (&gt;10 hrs of training per week, age 45±10 yrs) was quantified using LGE-sequences in CMR (1.5 tesla scanner).

Transthoracic echocardiography, physical examination, past medical history and routine lab diagnosis for exclusion of other conditions were performed.

Baseline characteristics like blood pressure at rest (BP), bodymass-index (BMI), and systolic and diastolic echocardiographic parameters (left atrial volume index (LAVI), e', E, A, right ventricular pressure gradient) as well as global longitudinal strain, were analysed by two independent observers blinded to the CMR measurements. Triathletes were sub-divided into LGE-positives (LGE+) vs. LGE-negatives (LGE-).

Results

All individuals appeared healthy with no drug history. Focal non-ischaemic LGE was detected in 19 triathletes. Compared to LGE-negative triathletes, LGE-positives showed significantly higher systolic BP (142 vs. 128 mmHg, p=0.004). Logistic regression showed, that per 10 mmHg enhanced blood pressure the chance for LGE rises by 89%. Triathletes with and without LGE demonstrated no difference in conventional echocardiographic measurements such as left ventricular ejection fraction and volumes and no difference in diastolic parameters. But the presence of MF did mediate global longitudinal strain (GLS).

Global longitudinal strain was significantly reduced in LGE positive athletes (LGE+: −19.8±3.4; LGE-: −21.7±2.4, p=0.04)

Conclusions

Reduced global longitudinal strain mediated as an early echocardiographic marker for subclinical changes in asymptomatic competitive triathletes with myocardial fibrosis compared to triathletes without LGE. Novel echocardiographic parameter such as longitudinal strain might serve as an easy tool to identify high endurance athletes at higher risk for cardiovascular events and that individuals with enhanced blood pressure should undergo cardiac consultation before starting endurance-training in competitive disciplines.

Funding Acknowledgement

Type of funding source: None

An approach to evaluating the potential teratogenic and neurotoxic mechanism of BHA based on apoptosis induced by oxidative stress in zebrafish embryo (Danio rerio)

Butylated hydroxyanisole (BHA) has been widely used in the cosmetics, pharmaceutical, and food industries due to its antioxidant activity. Despite the antioxidant effects, reported adverse effects of BHA at the cellular level have made its use controversial. In this regard, this study was performed to elucidate the potential toxicity mechanism caused by BHA at the molecular level in zebrafish embryos. For this purpose, zebrafish embryos were exposed to BHA at levels of 0.5, 1, 5, 7.5 and 10 ppm and monitored at 24, 48, 72 and 96 hours. Survival rate, hatching rate and malformations were evaluated. We examined the potential for reactive oxygen species (ROS) production and apoptosis signalling accumulation in the whole body. Moreover, we evaluated histopathological and immunohistochemical (8-OHDG) characterization of the brain in zebrafish embryos at the 96th hour. We also examined apoptosis, histopathological and immunohistochemical (8-OHDG) characteristics in 96 hpf zebrafish larvae exposed to tertiary butylhydroquinone (TBHQ), one of the major metabolites of BHA, at doses of 0.5, 2.5, 3.75 and 5 ppm. Consequently, it has been considered that increased embryonic and larval malformations in this study may have been caused by ROS-induced apoptosis. After 96 h of exposure, positive 8-OHdG immunofluorescence, degenerative changes, and necrosis were observed in the brain of BHA and TBHQ-treated zebrafish larvae in a dose-dependent manner. BHA and TBHQ exposure could lead to an increase in 8-OHdG activities by resulting oxidative DNA damage. In particular, the obtained data indicate that the induction of ROS formation, occurring during exposure to BHA and/or multiple hydroxyl groups, could be responsible for apoptosis.

Effects of different pediatric drugs and toothbrushing on color change of restorative materials used in pediatric dentistry

Objective

The purpose of this study was to evaluate the effects of different pediatric drugs and toothbrushing on color changes of restorative materials used in pediatric dentistry.

Materials and Methods

Sixty specimens were prepared from each of three restorative materials (compomer [Dyract XP], glass hybrid [Equia Forte], and glass carbomer [GCP Glass Fill]). Specimens were divided into six solution groups (n = 10) and immersed in five different pediatric drugs (antibiotic, analgesic, common cold syrup, cough syrup, and an iron and vitamin formula) and distilled water. Two subgroups (brushed and unbrushed) were established for each group (n = 5). Specimens were agitated for 1 min every 8 h over 2 weeks. Color changes [CIEDE2000 (ΔE₀₀)] were calculated at baseline, 7, and 14 days. Data were subjected to 4-factor mixed-design ANOVA using a general linear model procedure for repeated measurements.

Results

After 14 days, the highest ΔE₀₀was found in the compomer/non-brushing group immersed in iron and vitamin formula (5.6 ± 0.27), and the lowest was in glass hybrid/brushing group immersed in distilled water (0.59 ± 0.8) pairwise. ΔE₀₀values were significantly greater for compomer than for glass hybrid or glass carbomer (P < 0.05). There were statistically significant differences between the brushing and non-brushing groups for all tested solutions on the compomer specimens (except antibiotic) and glass hybrid specimens (except antibiotic and cough syrup). The Δ₀₀ values in brushing groups were significantly lower statistically than in non-brushing groups (P < 0.05).

Conclusions

Toothbrushing dramatically affected the color stability of the aesthetic restorative materials. The content of pediatric drugs is also an important factor for color change. Glass hybrids and glass carbomers used with their surface sealants appeared to be more resistant to staining from pediatric drug formulations than compomers.

Incidence and Immunologic Analysis of Coronavirus Disease (COVID-19) in Hemodialysis Patients:A Single-Center Experience

OBJECTIVES

COVID-19 is a great threat to the modern world and significant threat to immunocompromised patients, including patients with chronic renal failure. We evaluated COVID-19 incidence among our hemodialysis patients and investigated the most probable immune mechanisms against COVID-19.

MATERIALS AND METHODS

Başkent University has 21 dialysis centers across Turkey, with 2420 patients on hemodialysis and 30 on peritoneal dialysis. Among these, we retrospectively evaluated 602 patients (257 female/345 male) with chronic renal failure receiving hemodialysis as renal replacement therapy; 7 patients (1.1%) were infected with SARS-CoV-2. We retrospectively collected patient demographic characteristics, clinical data, and immunological factors affecting the clinical course of the disease. We divided patients into groups and included 2 control groups (individuals with normal renal functions): group I included COVID-19-positive patients with normal renal function, group II included COVID-19-positive hemodialysis patients, group III included COVID-19-negative hemodialysis patients, and group IV included COVID-19-negative patients with normal renal function. Lymphocyte subsets in peripheral blood and typing of human leukocyte antigens were analyzed in all groups, with killer cell immunoglobulin like receptor genes analyzed only in COVID-19-positive patients and healthy controls.

RESULTS

No deaths occurred among the 7 COVID-19-positive hemodialysis patients. Group I patients were significantly older than patients in groups II and III (P = .039, P = .030, respectively) but not significantly different from group IV (P = .060). Absolute counts of natural killer cells in healthy controls were higherthan in other groups (but not significantly). ActivatedT cells were significantly increased in both COVID-19-positive groups versus COVID-19-negative groups. Groups showed significant differences in C and DQ loci with respect to distribution of alleles in both HLA classes.

CONCLUSIONS

Although immunocompromised patients are at greater risk for COVID-19, we found lower COVID-19 incidence in our hemodialysis patients, which should be further investigated in in vitro and molecular studies.

FRI0455 IS THERE AN INCREASE IN THE FREQUENCY OF INFLAMMATORY DISEASES IN THE FAMILIES OF PATIENTS WITH FMF?

Background:

Familial Mediterranean Fever (FMF) is the most common periodic fever syndrome in childhood with an autosomal recessive inheritance pattern and is characterized by unprovoked fever attacks, serositis episodes. The causative gene of the disease is MEFV that encodes pyrin protein. The pyrin protein takes a role in pathways related to inflammation, and mutations of it lead to increased inflammation. It is already shown that frequencies of some certain diseases like PAN, HSP increase in patients with FMF. Nevertheless, frequencies of inflammatory diseases in families of patient with FMF haven’t been investigated.

Objectives:

In this study, we have aimed to evaluate the comorbid disorders in a large cohort of families of patients with FMF.

Methods:

Four hundred and ninety-eight children with FMF, one hundred and forty patients with JIA and ninety-two healthy children were interviewed between December 2019 and January 2020. In JIA group and healthy control group, patients who have family history for FMF were excluded from the study. Patients were asked about characteristics of their disease attacks and if there is a relative with any inflammatory diseases who does not have FMF in patient’s 1stand 2th degree relatives.

Results:

Demographic features of study group have shown in Table 1. The most common MEFV mutations in patients with FMF were: M694V homozygotes (13.2 %), M694V heterozygotes (12 %), M694V homozygotes and R202Q homozygotes (6,8 %). Type II diabetes, asthma and hypothyroidism were the most commonly detected diseases in all cohorts. Frequency of Behçet’s disease, allergic rhinitis and type II diabetes were significantly higher in families of patients with FMF than other groups (p<0.05) (Table 2).

Table 1.

Demographic features of study population.

FMF†JIA††Healthy Controln: 498 (%)mean +/- SDn: 140 (%)mean +/- SDn: 92 (%)mean +/- SDFemale284 (57)91 (65)55 (59.8)Age (years)12.9 ± 8.211.7 ± 5.17.4 ± 4.6Age at Onset (years)4.3 ± 3.35.4 ± 4.1-Age at Diagnosis (years)6.3 ± 3.66.3 ± 4.5-Delay in Diagnosis (months)23.8 ± 29.211.3 ± 28.2-Follow-up Duration (years)6.9 ± 8.35.3 ± 4.0-Consanguinity100 (20)25 (17.8)8 (8.6)Family History of FMF282 (56.6)0 (0)0 (0)JIA subgroup-- Oligoarticular72 (51.4) Polyarticular (RF negative)16 (11.4) Polyarticular (RF positive)3 (2.1) Enthesitis Related Arthritis14 (10) Psoriatic Arthritis7 (5) Systemic23 (16.4) Other5 (3.5)Clinical Findings-- Fever392 (78.1) Abdominal Pain429 (86.1) Chest Pain102 (20.5) Arthralgia334 (67.1) Arthritis157 (31.5) Extremity Pain64 (12.8) Heel Pain44 (8.8) Myalgia43 (8.6) *ELE13(2.6) Serositis10 (2)

†Familial Mediterranean Fever††Juvenile Idiopathic Arthritis*Erysipelas like erythema

Table 2.

Comparison of frequencies of diseases detected among families of patient groups (shortened).

DiseasesFMFJIAHealthy Controlp1Type II Diabetes284 (57)64(45.7)44 (47.8)0.02Asthma139 (27.9)30 (21.4)20 (21.7)0.19Hypothyroidism122 (24.4)27 (19.2)14 (15.2)0.09Eczema68 (13.6)14 (10)5 (5.4)0.06Psoriasis49 (9.8)6 (4.2)7 (7.6)0.10Allergic Rhinitis49 (9.8)3 (2.1)1 (1)0.001Hyperthyroidism40 (8)9 (6.4)3 (3.2)0.24Behçet’s Disease31 (6.2)1 (1)2 (2.1)0.01Rheumatic Fever30 (6)10 (7.1)2 (2.1)0.25

Conclusion:

In this study, we have reported increased frequencies of Behçet’s disease, allergic rhinitis and type II diabetes in families of patients with FMF. Our results suggest that possible increased mutation load among families of patients with FMF may cause increased inflammatory diseases.

References:

[1]Yildiz M, Adrovic A, Tasdemir E, et al. Evaluation of co-existing diseases in children with familial Mediterranean fever.Rheumatol Int. 2020;40(1):57–64. doi:10.1007/s00296-019-04391-9

Disclosure of Interests:

None declared

PROTECTIVE EFFECT OF NIGELLA SATIVA OIL ON MYOCARDIUM IN STREPTOZOTOCIN-INDUCED DIABETIC RATS

Background

To evaluate the protective effect of Nigella sativa oil (NSO) on the myocardium in streptozotocin-induced diabetic rats.

Materials and methods

Thirty-two 7-8-week-old female Wistar albino rats (300-350 g) were equally divided into 4 groups: nondiabetic untreated animals (control), diabetes mellitus (DM), NSO, and DM+NSO groups. For the induction of diabetes, 45 mg/kg streptozotocin was applied to the rats in the DM and DM+NSO groups as a single intraperitoneal dose. NSO (400 mg/kg) was orally administered through an intragastric catheter once a day over 21 days. Formalin-fixed, paraffin-embedded tissue sections of the myocardium were evaluated histopathologically and immunohistochemically.

Results

Compared to the control, NSO, and DM+NSO groups, the myocardial tissue samples from the rats in the DM group had significantly higher myositis, hyaline degeneration, and Zenker's necrosis. Moreover, the Bcl-2 expressions were significantly higher in the control, NSO, and DM+NSO groups than in the DM group.

Conclusion

NSO has a protective effect on the myocardium of streptozotocin-induced diabetic rats, most likely via suppressing apoptosis.

Early Postoperative Infections After Liver Transplant

OBJECTIVES

Despite surgical advances and effective prophylactic strategies in liver transplant, infection is still a major cause of morbidity and mortality. Up to 80% of liver recipients will develop at least 1 infection during the first year after liver transplant. The spectrum and manifestations of these infections are broad and variable. Their diagnosis and treatment are often delayed because immunosuppressive therapy diminishes inflammatory responses. However, if an infection is not identified early enough and treated properly, it can have devastating consequences. In addition, prophylactic approaches remain controversial. Our aim was to review our early postoperative infection management after liver transplant.

MATERIALS AND METHODS

We retrospectively evaluated infections that occurred during the first hospital stay of transplant patients. Infections were grouped as surgical site and nonsurgical site infections. Consequences and treatment protocols of infections were stratified according to the Clavien scale.

RESULTS

Between December 1988 and January 2017, we performed 561 liver transplants at our center (patient age range, 6 months to 64 years), which included 401 living-donor (72%) and 160 deceaseddonor (28%) liver transplants. Early postoperative infections were detected in 131 patients (23.3%), comprising 67 surgical site (51%), 56 nonsurgical site (43%), and 8 combined surgical and nonsurgical site infections (6%). Although no mortalities occurred in patients with single nonsurgical or surgical site infections, there were 4 mortalities in patients with combined surgical and nonsurgical site infections. In the 4 other patients with combined infections, 3 patients required endoscopic or radiologic intervention and 1 recovered from single-organ dysfunction.

CONCLUSIONS

Initiation of appropriate prophylactic and therapeutic protocols at the right time decreases morbidity and mortality due to infection in liver transplant recipients. Increased understanding and effective approaches to prevent infection are essential to improving both graft and recipient survival.

Osteoblastoma originating from frontoethmoidal sinus causing personality disorders and superior gaze palsy

Osteoblastoma is a rare, solitary benign tumor that is usually situated in axial skeleton mainly in vertebra. It is rarely seen in ethmoid and frontal sinuses. A 40-year-old man who had osteoblastoma originated from frontal and ethmoidal sinuses that extends up to frontal lobe and gave rise to personality disorders by compressing the frontal lobe, and caused superior gaze palsy by compressing the superior rectus muscle. We present this rare case with clinical, radiological and histopathological findings.

Effect of pomegranate (Punica granatum L.) juice on kidney, liver, heart and testis histopathological changes, and the tissues lipid peroxidation and antioxidant status in lead acetate-treated rats

Pomegranate juice (PJ) contains relevant amounts of active biological compounds which alleviate the detrimental effects of chronic heavy metal exposure. This study investigated the protective potential of PJ against lead-induced oxidative stress. A total of forty adult male Sprague Dawley rats were divided into four experimental groups. The animals were fed a standard pellet diet and tap water ad libitum. The rats were divided into four groups (n=10 for each group): control, lead asetat (2000 ppm), low-treated PJ- a daily dose of 2.000 ppm lead plus 30µl pomegranate juice (included 1.050 µmol total polyphenols, gallic acid equivalent), and high-treated PJ- a daily dose of 2.000 ppm lead plus 60µl pomegranate juice (included 2.100 µmol total polyphenols, gallic acid equivalent). The treatments were delivered for 5 weeks. After the treatment period, the tissues samples (kidney, liver, heart and testis) were collected. Tissue lead (Pb) and mineral amounts (copper, zinc, and iron), tissues lipid peroxidation level and antioxidant status, and tissues histopathological changes were determined. The results showed that the highest rate lead loading was in the kidney and the testis. Pomegranate juice was decreased the lead levels of soft tissues examined; increased Zn amounts in tissues of which the lead accumulation was higher (kidney and the testis); decreased the copper, zinc and the iron levels of the liver and heart tissues, without creating a weakness in antioxidant capacity of these tissues, restricted the oxidative stress by decreasing lipid peroxidation, improved both of the activities of antioxidant enzymes such as superoxide dismutase (SOD) and catalaz (CAT), and the level of glutathione (GSH) in all the tissues examined in lead-treated groups. As histopathological findings, the cellular damage induced by lead in the tissues of the kidney, liver and the heart were observed to have been partially prevented by PJ treatment. The protective effect of PJ was more pronounced in the testis compared to those others.

Incisional Hernia After Liver Transplant

OBJECTIVES

An incisional hernia seriously burdens the quality of life after liver transplant. The incidence of incisional hernia after liver transplant is reported to be 4% to 20%. Here, we evaluated incisional hernias that occurred after adult liver transplant and incisional hernias intentionally made in infant liver transplant procedures.

MATERIALS AND METHODS

Between December 1988 and May 2016, we performed 536 liver transplant procedures in 515 patients. Demographic features, surgical outcomes, and predisposing factors were evaluated.

RESULTS

Of 452 liver transplant patients included, incisional hernias were diagnosed in 29 patients (6.4%; 7 pediatric, 22 adult). Most were males (77%) with Child-Pugh score C cirrhosis (62%), moderate/severe ascites (81%), and serum albumin levels <3.5 g/L (86%). Incisional hernia developed in 16 of 51 patients (31%) with wound infection. Twelve incisional hernias were seen in 40 recipients (30%) with body mass index ≥30 kg/m2. Eight of 45 patients (18%) with repeated surgery had incisional hernias. Five of 22 adult incisional hernias (23%) had primary fascia repair, and 17 (77%) were repaired with Prolene mesh graft (3 sublay, 14 onlay). No other complications and no hernia recurrence were shown during follow-up (range, 8-138 mo). Of 7 pediatric liver transplant patients with intentionally made incisional hernias during liver transplant, 5 patients had primary fascia repair and 2 patients had onlay mesh repair. No complications or recurrence were shown during follow-up (range, 12-60 mo).

CONCLUSIONS

Repeated surgery, postoperative wound infection, and obesity were found to be predisposing risk factors for incisional hernia development after liver transplant in adults. Abdomen closure in infant liver transplant with large-for-size grafts is a different area of discussion. Here, we suggest that an intentionally made incisional hernia with staged closure of the abdomen is safe and effective for graft and patient survival.

Results of Biliary Reconstruction Using a Polytetrafluoroethylene Graft in Liver Transplant Patients

OBJECTIVES

Biliary complications after liver transplant are a major concern with their high incidence, the need for repeated and long-term treatment, and their potential effects on graft and patient survival. We report our experience with biliary anastomosis using a spiral polytetrafluoroethylene graft.

MATERIALS AND METHODS

Between December 8, 1988, and July 2016, we performed 538 liver transplant procedures. We used a spiral polytetrafluoroethylene graft for biliary anastomosis in 10 patients: for biliary stricture reconstruction after liver transplant in 4 patients and during the primary liver transplant in 6 patients.

RESULTS

Four patients who underwent biliary stricture reconstruction are doing well, with normal liver function. Of the 6 patients who received the graft during primary liver transplant, 2 died from sepsis, although they maintained normal liver function. Of the 4 living patients, 1 had a biliary complication that was reconstructed surgically. The 4 living patients are currently doing well, with normal liver function.

CONCLUSIONS

Our small series of patients shows that the use of a spiral polytetrafluoroethylene graft is effective at reducing biliary complications in transplant patients.

Utility of Diffusion-Weighted MRI to Detect Changes in Liver Diffusion in Benign and Malignant Distal Bile Duct Obstruction: The Influence of Choice of b-Values

PURPOSE

The study sought to evaluate the potential of diffusion-weighted magnetic resonance imaging to detect changes in liver diffusion in benign and malignant distal bile duct obstruction and to investigate the effect of the choice of b-values on apparent diffusion coefficient (ADC).

METHODS

Diffusion-weighted imaging was acquired with b-values of 200, 600, 800, and 1000 s/mm². ADC values were obtained in 4 segments of the liver. The mean ADC values of 16 patients with malignant distal bile duct obstruction, 14 patients with benign distal bile duct obstruction, and a control group of 16 healthy patients were compared.

RESULTS

Mean ADC values for 4 liver segments were lower in the malignant obstruction group than in the benign obstruction and control groups using b = 200 s/mm² (P < .05). Mean ADC values of the left lobe medial and lateral segments were lower in the malignant obstruction group than in the benign obstructive and control groups using b = 600 s/mm² (P < .05). Mean ADC values of the right lobe posterior segment were lower in the malignant and benign obstruction groups than in the control group using b = 1000 s/mm² (P < .05). Using b = 800 s/mm², ADC values of all 4 liver segments in each group were not significantly different (P > .05). There were no correlations between the ADC values of liver segments and liver function tests.

CONCLUSION

Measurement of ADC shows good potential for detecting changes in liver diffusion in patients with distal bile duct obstruction. Calculated ADC values were affected by the choice of b-values.

Diagnosis and management of retained foreign objects

Retained surgical foreign objects (RFO) include surgical sponges, instruments, tools or devices that are left behind following a surgical procedure unintentionally. It can cause serious morbidity as well as even mortality. It is frequently misdiagnosed. It should be considered in the differential diagnosis of any postoperative case with unresolved or unusual problems. Risk factors for RFOs include emergency procedures, unplanned change in operation, and body mass index and are clarified as being more frequent approximately 1 in 700 emergent cases. Although human errors cannot be completely prevented, medical training and consistency to rules seem to reduce the incidence to a minimum. It is a legal issue and potentially dangerous medical error. The definition, types, incidence, risk factors, complications and prevention strategies from RFOs are reviewed, from the comprehensive series until the year 2014.

Predictors determining the status of axilla in breast cancer: Where is PET/CT on that?

PURPOSE

18 F-FDG PET/CT has an acceptable specificity but a low sensitivity on the prediction of axillary lymph node (ALN) metastasis in breast cancer. We analyzed the factors that could possibly affect this prediction.

METHODS

The records of 270 patients with T1-2 invasive breast cancer who underwent surgery, 116 of whom had been evaluated by preoperative 18 F-FDG PET/CT were reviewed. Prediction of ALN status by PET/CT according to tumor stage, estrogen receptor (ER), progesterone receptor (PgR) and HER2 status, histology, age and sentinel node properties was assessed.

RESULTS

ALN metastasis was present in 62 of 131 T1 (43.7%) and 106 of 142 T2 tumors (74.6%), 20 of 46 (43.5%) ER(-) and 146 of 222 (65.8%) ER(+) tumors, 38 of 71 (53.5%) PgR(-) and 127 of 200 (63.5%) PgR(+) tumors. On multivariate analysis only the tumor size (>2 cm) independently correlated with ALN metastasis (Odds ratio/OR=3.1). None of the other parameters had statistical significance in terms of ALN prediction on FDG-PET/CT.

CONCLUSION

Though T2 tumors showed increased tendency to metastasize to the axilla, prediction of ALN metastasis in preoperative FDG-PET/CT was not associated with any of the predictive factors.

Liver Transplant for Fulminant Hepatic Failure: A Single-Center Experience

OBJECTIVES

Acute liver failure is a life-threatening condition with sudden onset liver injury, decreased liver functions, hepatic encephalopathy, and coagulopathy in patients without preexisting liver disease. In this study, we sought to evaluate the results of liver transplant as a treatment for acute liver failure.

MATERIALS AND METHODS

Between November 1988 and March 2015, we performed 482 liver transplants in 471 patients. We performed 36 liver transplants in 35 patients because of acute liver failure. Only 5 of these were from deceased donors. Thirty of those 34 patients were pediatric (85%) and 5 were adults (15%).

RESULTS

Five patients died (4 in early postoperative period and 1 during the 18th month of living-donor liver transplant). We diagnosed 11 acute rejections (32%); 6 biliary leaks (17%); 6 intraabdominal hemorrhage (17%); 5 hepatic arterial thromboses (15%), and 1 venous complication (3%) during the early postoperative period. We have no morbidity or mortality in living-donor liver transplants.

CONCLUSIONS

Living-donor liver transplants are an efficient and successful treatment for acute liver failure patients. In our center, we mostly consider and prefer living-donor liver transplants to deceased-donor liver transplant because of the paucity of organ donation, especially for pediatric patients. Considering acceptable postoperative complications, living-donor liver transplant is a lifesaving treatment for acute liver failure.

A Comparative Study of Conservative versus Surgical Treatment Protocols for 77 Patients with Idiopathic Granulomatous Mastitis

The purpose of this study was to analyze the clinical features and demographic data of patients with idiopathic granulomatous mastitis (IGM) and to compare the results of conservative versus surgical treatment protocols. The demographic data, clinical findings, microbiological and pathologic features, scanning and treatment methods, recurrence, and recovery rates of 77 patients were analyzed retrospectively. The patients were divided into two groups based on the type of treatment received. Core biopsies were used to diagnose 37 patients: 26 using incisional biopsies and 14 using excisional biopsies. Of the patient population with IGM, 31 were treated with surgical excision, one with a simple mastectomy, and one with a subcutaneous mastectomy combined with a breast implant, whereas 44 were treated with steroids. The recovery rates of the 44 patients who were treated conservatively were 6 (1-15) months while for the 33 patients who were treated surgically, it was 1 (1-5) month (p = 0.001). Nine patients from the conservative treatment group experienced a recurrence while there were no recurrences in the surgically treated group (p = 0.009). Among all patients, the recurrence rate was 11.7% (9/77) while the average follow-up period was 16.57 ± 18.57 months. As a comparative study between conservative treatment protocols and surgical ones for patients with idiopathic granulomatous mastitis (IGM), this study is the largest to date. A wide surgical excision is the preferred approach for treating patients with IGM because of the low recurrence rate.

Large-for-size liver transplant: a single-center experience

OBJECTIVES

The ideal ratio between liver transplant graft mass and recipient body weight is unknown, but the graft probably must weigh 0.8% to 2.0% recipient weight. When this ratio > 4%, there may be problems due to large-for-size transplant, especially in recipients < 10 kg. This condition is caused by discrepancy between the small abdominal cavity and large graft and is characterized by decreased blood supply to the liver graft and graft dysfunction. We evaluated our experience with large-for-size grafts.

MATERIALS AND METHODS

We retrospectively evaluated 377 orthotopic liver transplants that were performed from 2001-2014 in our center. We included 188 pediatric transplants in our study.

RESULTS

There were 58 patients < 10 kg who had living-donor living transplant with graft-to-bodyweight ratio > 4%. In 2 patients, the abdomen was closed with a Bogota bag. In 5 patients, reoperation was performed due to vascular problems and abdominal hypertension, and the abdomen was closed with a Bogota bag. All Bogota bags were closed in 2 weeks. After closing the fascia, 10 patients had vascular problems that were diagnosed in the operating room by Doppler ultrasonography, and only the skin was closed without fascia closure. No graft loss occurred due to large-for-size transplant. There were 8 patients who died early after transplant (sepsis, 6 patients; brain death, 2 patients). There was no major donor morbidity or donor mortality.

CONCLUSIONS

Large-for-size graft may cause abdominal compartment syndrome due to the small size of the recipient abdominal cavity, size discrepancies in vascular caliber, insufficient portal circulation, and disturbance of tissue oxygenation. Abdominal closure with a Bogota bag in these patients is safe and effective to avoid abdominal compartment syndrome. Early diagnosis by ultrasonography in the operating room after fascia closure and repeated ultrasonography at the clinic may help avoid graft loss.

Results of liver transplant in elderly patients: a single center experience

OBJECTIVES

With the increased life span, the need for liver transplant for elderly patients also increased in the world. In this study, we reviewed our experience to determine the outcomes and problems of patients aged > 60 years who had liver transplants.

MATERIALS AND METHODS

Data of recipients aged > 60 years were reviewed retrospectively. We analyzed 16 elderly patients who had liver transplant for chronic liver disease between 2001 and 2014 in our center.

RESULTS

In our series, there were 5 women and 11 men between age 60 and 65 years. The mean Child-Pugh score was 7.9 ± 1.7 and Model for End-Stage Liver Disease score was 14.1 ± 5.1. Primary liver disease was hepatitis B in 9 patients (34.5%), most of them with hepatocellular carcinoma. The other causes of liver failure were hepatitis C (n = 4), alcoholic cirrhosis (n = 2), and cryptogenic cirrhosis (n = 2); 1 patient had both hepatitis B and hepatitis C virus, and 1 patient had both hepatitis B virus and alcoholic cirrhosis. There were 9 patients who had hepatocellular carcinoma. Mortality was observed in 4 patients. The reasons for mortality were sepsis (n=3) and hepatocellular carcinoma (n=1).

CONCLUSIONS

Liver transplant can be safely performed and has acceptable long-term outcomes in low-risk elderly recipients. Age alone should not be a contraindication for liver transplant in elderly patients.

Treatment of biliary complications after liver transplant: results of a single center

Biliary complications are major sources of morbidity after liver transplant due to vulnerable vascularization of the bile ducts. Biliary complications are the "Achilles' heel" of liver transplant with their high incidence, need for repeated and prolonged treatment, and potential effects on graft and patient survival. Although standardization of reconstruction techniques and improvements in immunosuppression and organ preservation have reduced the incidence of biliary complications, in early reports the morbidity rates are 50%, with related mortality rate 25% to 30%. Prophylaxis is a major issue. Although many risk factors (old donor age, marginal graft, prolonged ischemia time, living-donor liver transplant, partial liver transplant, donation after cardiac death, hepatic arterial thrombosis, organ preservation, chronic rejection, and other donor and recipient characteristics) do not directly affect biliary complications, accumulation of the factors mentioned above, should be avoided. However, no accepted standard has been established. Treatment strategy is a subject of debate. Recently, nonoperative treatment of biliary complications have been preferred for diagnosis and therapy, because percutaneous or endoscopic treatment may prevent the need for surgical intervention. In this study, we reviewed our treatment of early and late biliary complications after liver transplant.