Incidental gastrointestinal stromal tumor at a gastroscopic polypectomy specimen: A case report and review of literature.

Although gastrointestinal stromal tumors (GISTs) comprise less than 1% of all gastrointestinal (GI) tract tumors, they are the most common mesenchymal tumors of the GI tract. Gastrointestinal stromal tumors can occur anywhere along the GI tract, but the stomach and small intestine are the most frequently involved sites. Gastrointestinal stromal tumors are frequently asymptomatic, and one-third of all cases are found incidentally. Endoscopy, endoscopic ultrasonography, and computed tomography are useful tools in the diagnosis. Endoscopic mucosal resection, endoscopic submucosal dissection, laparoscopic endoscopic cooperative surgery, and surgery with either laparoscopic or open approaches are treatment modalities for GISTs. An R0 resection is the principle surgery. Imatinib is the main medical agent used in the adjuvant or neoadjuvant treatment of GIST. We present a 65-year-old woman with an asymptomatic GIST that arose from a gastric polyp treated via endoscopic polypectomy.

Ewing's Sarcoma of the Peritoneum: a Rare Location for Extraskeletal Ewing's Sarcoma.

A 38-year-old male presented to the emergency department with abdominal pain and bulge. He had a history of irritable bowel syndrome for 1 year with complaint of dyspepsia. Physical examination revealed a distended abdomen with a huge palpable mass located in the paraumblical region. Laboratory findings revealed a high white blood cell count with neutrophil predominance. Contrast-enhanced computed tomography (CT) showed a 23-cm, oval-shaped, grossly necrotic, low-attenuation mass with peripherally located dominant vessels. Magnetic resonance imaging (MRI) with diffusion weighted imaging (DWI) suggested a highly malignant tumor with prominent diffusion restriction especially at the periphery of the mass. On surgery, macroscopic examination showed a macrolobulated, hypervascular, reddish brown mass attached to the parietal peritoneum with a stalk. Ewing's sarcoma (ES) was diagnosed on histopathological examination with small round cells.

MicroRNA expression profile in patients with stage II colorectal cancer: a Turkish referral center study.

BACKGROUND: There are increasing data about microRNAs (miRNA) in the literature, providing abundant evidence that they play important roles in pathogenesis and development of colorectal cancer. In this study, we aimed to investigate the miRNA expression profiles in surgically resected specimens of patients with recurrent and non-recurrent colorectal cancer. MATERIALS AND METHODS: The study population included 40 patients with stage II colorectal cancer (20 patients with recurrent tumors, and 20 sex and age matched patients without recurrence), who underwent curative colectomy between 2004 and 2011 without adjuvant therapy. Expression of 16 miRNAs (miRNA-9, 21, 30d, 31, 106a, 127, 133a, 133b, 135b, 143, 145, 155, 182, 200a, 200c, 362) was verified by quantitative real-time polymerase chain reaction (qRT-PCR) in all resected colon cancer tissue samples and in corresponding normal colonic tissues. Data analyses were carried out using SPSS 15 software. Values were statistically significantly changed in 40 cancer tissues when compared to the corresponding 40 normal colonic tissues (p<0.001). MiR-30d, miR-133a, miR-143, miR-145 and miR-362 expression was statistically significantly downregulated in 40 resected colorectal cancer tissue samples (p<0.001). When we compared subgroups, miRNA expression profiles of 20 recurrent cancer tissues were similar to all 40 cancer tissues. However in 20 non-recurrent cancer tissues, miR-133a expression was not significantly downregulated, moreover miR-133b expression was significantly upregulated (p<0.05). CONCLUSIONS: Our study revealed dysregulation of expression of ten miRNAs in Turkish colon cancer patients. These miRNAs may be used as potential biomarkers for early detection, screening and surveillance of colorectal cancer, with functional effects on tumor cell behavior.

The effect of early warm plastic bag application on postoperative pain after hemorrhoidectomy: a prospective randomized controlled trial.

Hemorrhoidectomy is used for the surgical treatment of high-grade hemorrhoids. The most prominent complaint after hemorrhoidectomy is pain. Postoperative pain management is still a big problem after surgery in patients with hemorrhoidectomy. The aim of the study was to assess the effect of early application of warm bag on postoperative pain after hemorrhoidectomy. All patients were randomly divided into warm plastic bag and control groups by using sealed envelopes, which were prepared preoperatively. After standard spinal anesthesia, all patients underwent standard Milligan-Morgan hemorrhoidectomy using Ligasure™. Although the study group received the warm bag application, the control group did not receive such a treatment. Two separate visual analog scale (VAS) measurements were performed for postoperative pain assessments on postoperative days, one during the resting state and the other one during the straining phase after the onset of peristaltic bowel movement. Postoperative VAS scores were significantly lower among the warm plastic bag group as compared with the control group on Days 1 and 3 for the resting state and on Day 3 for defecation. Additionally, a significant difference existed between the two groups in terms of the need for additional anesthesia. Local thermal application appears to be a safe and effective method for pain relief after hemorrhoidectomy.

Comparison of emergency surgeries for obstructed colonic cancer with elective surgeries: A retrospective study.

OBJECTIVE: Colon cancer patients presented with obstruction were known to have worse postoperative morbidity and mortality rates, but conflicting data has been reported in recent years. We aimed to investigate postoperative complication rates, and short and long-term oncological outcomes in patients with colon cancer treated with either emergency surgery due to obstruction or elective surgery. METHODS: Two hundred fifty two patients were analyzed. Patients presented with obstruction and underwent an emergency surgery, and patients operated under elective circumstances were compared according to their demographic variables, tumor characteristics, and short and long term treatment outcomes. RESULTS: Distribution of age, gender and comorbidities were similar between both the groups. Need for an end colostomy was significantly higher in obstructed patients (22.7% vs 1.6%, respectively). Obstructed patients were tending to be at an advanced stage. Postoperative morbidity and mortality, and prognosis of colon cancer patients presented with obstruction is worse than patients operated under elective circumstances. CONCLUSIONS: Colon cancer patients presented with obstruction constitutes more than one quarter of all patients. These patients have significantly higher morbidity and mortality rates. Obstructed colon cancer usually appears at advanced stage. Primary resection and anastomosis is safe in most of the cases.

Comparison of depression, anxiety and long-term quality of health in patients with a history of either primary closure or Limberg flap reconstruction for pilonidal sinus.

OBJECTIVE: Pilonidal sinus is characterized by high operative morbidity mainly due to wound problems. We aimed to compare the quality of health, comfort and psychological status in patients who underwent surgery for pilonidal sinus. METHODS: A total of 205 pilonidal sinus patients operated on with either primary closure or Limberg flap reconstruction were compared in terms of depression, anxiety, and long-term quality of health by using Short Form 36, Beck Depression Inventory, and Beck Anxiety Inventory scales. RESULTS: There were 107 patients in the primary closure group with a mean follow-up of 29.6 ± 7.7 months and 98 patients in the Limberg flap group with a mean follow-up of 34.1 ± 7.3 months. In the SF-36 analysis, the mental health and bodily pain scores (59 ± 6 and 56 ± 11 in the primary closure group and 62 ± 8 and 61 ± 10 in the Limberg flap group) were significantly higher in the Limberg flap group (p = 0.014 and p = 0.002, respectively). The mean Beck Depression Inventory (19 ± 6.13 vs. 16 ± 4.90 p<0.001) and Beck Anxiety Inventory (19 ± 6.27 vs. 16 ± 4.90 p<0.001) scores were lower in the Limberg flap group. CONCLUSION: Limberg flap reconstruction produced better quality of health scores according to the SF 36, especially in terms of mental health and bodily pain. There was a higher tendency towards anxiety and depression in the primary closure group.

Comparison of depression, anxiety and long-term quality of health in patients with a history of either primary closure or Limberg flap reconstruction for pilonidal sinus

OBJECTİVE: Pilonidal sinus is characterized by high operative morbidity mainly due to wound problems. We aimed to compare the quality of health, comfort and psychological status in patients who underwent surgery for pilonidal sinus. METHODS: A total of 205 pilonidal sinus patients operated on with either primary closure or Limberg flap reconstruction were compared in terms of depression, anxiety, and long-term quality of health by using Short Form 36, Beck Depression Inventory, and Beck Anxiety Inventory scales. RESULTS: There were 107 patients in the primary closure group with a mean follow-up of 29.6±7.7 months and 98 patients in the Limberg flap group with a mean follow-up of 34.1±7.3 months. In the SF-36 analysis, the mental health and bodily pain scores (59±6 and 56±11 in the primary closure group and 62±8 and 61±10 in the Limberg flap group) were significantly higher in the Limberg flap group (p = 0.014 and p = 0.002, respectively). The mean Beck Depression Inventory (19±6.13 vs. 16±4.90 p<0.001) and Beck Anxiety Inventory (19±6.27 vs. 16±4.90 p<0.001) scores were lower in the Limberg flap group. CONCLUSION: Limberg flap reconstruction produced better quality of health scores according to the SF 36, especially in terms of mental health and bodily pain. There was a higher tendency towards anxiety and depression in the primary closure group. .

Pretreatment neutrophil/lymphocyte ratio as a prognostic aid in colorectal cancer.

BACKGROUND: Colorectal cancers(CRC) are the third most common cancer in the western world, with surgery preferred for management of non-metastatic disease and post surgical treatment usually arranged according to the TNM staging system. However, there is still prognostic variation between patients who have the same stage. It is increasingly recognized that variations within disease course and clinical outcome in colorectal cancer patients are influenced by not only oncological characteristics of the tumor itself but also host response factors. Recent studies have shown correlation between the inflammatory response and clinical outcomes in various cancers. The neutrophil/lymphocyte ratio (NLR) has been described as a marker for immune response to various stimuli including cancer. MATERIAL-METHODS: Two hundred eighty-one CRC patients were included in our retrospective analysis, separated into two groups according to a cut-off value for the NLR. Patient data including age, gender, vertical penetration, anatomic location, and differentiation of the tumor, TNM stage, survival rate, and disease-free survival were analyzed for correlations with the NLR. RESULTS: Using ROC curve analysis, we determined a cut-off value of 2.2 for NLR to be best to discriminate between patient survival in the whole group. In univariate analysis, high pretreatment NLR (p=0.001, 95%CI 1.483-4.846), pathologic nodal stage (p<0.001, 95%CI 1.082- 3.289) and advanced pathologic TNM stage (p<0.001, 95%CI 1.462-4.213) were predictive of shorter survival. In multivariate analysis, advanced pathologic TNM stage (p=0.001, 95%CI 1.303-26.542) and high pretreatment NLR (p=0.005, 95%CI 1.713-6.378) remained independently associated with poor survival. CONCLUSIONS: High pre-treatment NLR is a significant independent predictor of shorter survival in patients with colorectal cancer. This parameter is a simple, easily accessible laboratory value for identifying patients with poorer prognosis.

Functional outcomes and complications after restorative proctocolectomy and ileal pouch anal anastomosis in the pediatric population.

BACKGROUND: Data regarding the long-term outcomes of restorative proctocolectomy and ileal pouch anal anastomosis including pouch function and quality of life in the pediatric population are limited in pediatric patients. STUDY DESIGN: Indications for surgery, complications, long-term function, and quality of life were evaluated in pediatric patients undergoing ileal pouch anal anastomosis. Assessment of quality of life was performed using the Cleveland Global Quality of Life score. RESULTS: There were 433 patients with a mean age of 18.04 ± 2.9 years. Final pathologic diagnoses were ulcerative colitis or indeterminate colitis (78.3%), familial adenomatous polyposis (15.7%), Crohn's disease (5.1%), and others (0.9%). There were 237 patients (54.7%) who underwent total proctocolectomy and ileal pouch anal anastomosis; 196 (45.3%) underwent initial subtotal colectomy followed by completion proctectomy with ileal pouch anal anastomosis. Anastomosis was stapled in 352 patients (81.3%) and hand-sewn in 81 (18.7%) patients. Mean follow-up was 108.5 ± 78.4 months. At the most recent follow-up, mean Cleveland Global Quality of Life score was 0.8 ± 0.2 and numbers of daytime and night-time bowel movements were 5.3 ± 3.1 and 1.6 ± 1.3, respectively. The majority of the patients (86.8%) were fully continent or only complained of rare incontinence. Most patients had no seepage (day, 84.3%; night, 72.4%) and did not wear any pads (day, 89.3%; night, 84.3%). Most denied dietary (71.3%), social (84.8%), work (85.7%), or sexual restrictions (87.6%) at the time of last follow-up. There were 92.7% of patients who said they would undergo ileal pouch anal anastomosis again and 95.2% would recommend surgery to others. CONCLUSIONS: Restorative proctocolectomy with ileal pouch anal anastomosis can be performed in pediatric patients with acceptable morbidity and is associated with good long-term results in terms of gastrointestinal function, quality of life, and patient satisfaction.

Can horizontal diameter of colorectal tumor help predict prognosis?

OBJECTIVE: We aimed to investigate the relationship between the horizontal tumor diameter and prognosis. MATERIAL AND METHODS: Patients' records were analyzed retrospectively. Patient data, including age, gender, vertical penetration, anatomic location, differentiation of the tumor, tumor node metastasis (TNM) stage, survival rate, and disease-free survival, were analyzed to find out if there was any correlation with horizontal tumor diameter. RESULTS: A total of 439 colorectal cancer patients were enrolled. Patients were stratified into two groups according to the horizontal tumor diameter (≤4.5 cm vs. >4.5 cm). Poorly differentiated tumors were significantly larger than other differentiation groups (p=0.003). The horizontal diameter increased with increase in T-stage (p<0.001). Similarly, the number of positive lymph nodes increased significantly as the size of the horizontal tumor diameter increased (p<0.001). The relationship between TNM staging and the horizontal diameter of tumors in both groups was examined, and it was found that the progression of tumor stage was accompanied by increased horizontal diameter (p<0.001). It was also found that the horizontal tumor diameter was not correlated with local recurrence (p=0.063). However, distant metastasis was higher in patients with a tumor larger than 4.5 cm (p=0.02). Although the disease-free survival was shorter in patients with a horizontal tumor diameter more than 4.5 cm, the difference was not statistically significant. CONCLUSION: There is a significant relation between horizontal diameter of the tumor and depth of the tumor, lymph node involvement, overall survival, and distant metastasis. Horizontal diameter of the tumor can possibly be used as a prognostic factor in colorectal cancer patients.

Anal transitional zone neoplasia in patients with familial adenomatous polyposis after restorative proctocolectomy and IPAA: incidence, management, and oncologic and functional outcomes.

BACKGROUND: Restorative proctocolectomy and IPAA in patients with familial adenomatous polyposis may leave residual anal transitional zone mucosa that is prone to neoplasia. OBJECTIVE: The aim of this study was to evaluate the long-term control of neoplasia at the IPAA, the functional outcomes, and the influence of anastomotic technique on these results. DESIGN: : This research is a retrospective cohort study from a prospective database. SETTING: The investigation took place in a high-volume specialized colorectal surgery department. PATIENTS: Patients with familial adenomatous polyposis who underwent IPAA between 1983 and 2010 were included. MAIN OUTCOME MEASURES: The primary outcomes measured were functional outcomes, quality of life, and the incidence of neoplasia in the anal transitional zone. RESULTS: Eighty-six patients underwent mucosectomy and 174 underwent stapled anastomosis with mean 155 ± 99 and 95 ± 70 months follow-up. Eighteen patients (20.9%) in the mucosectomy group and 59 patients (33.9%) in the stapled group developed anal transitional zone adenomas (p = 0.03). One of 86 (1.2%) patients undergoing mucosectomy and 3 of 174 (1.7%) patients undergoing stapled anastomosis developed cancer in the anal transitional zone (p > 0.05). Three of these patients underwent an abdominoperineal resection, but one who refused abdominoperineal resection underwent transanal excision with neoileoanal anastomosis. Patients undergoing a mucosectomy had a significantly higher rate of anastomotic stricture, but other complications were similar. Incontinence, seepage, and pad usage were higher in the mucosectomy group. Cleveland global quality-of-life score was 0.8 ± 0.2 in patients with handsewn anastomoses and 0.8 ± 0.3 in patients with a stapled anastomoses (p > 0.05). LIMITATIONS: This study was limited by its nonrandomized retrospective design. CONCLUSIONS: Risk for the development of adenomas in the anal transitional zone is higher after a stapled IPAA than after a mucosectomy with handsewn anastomosis. However, control of anal transitional zone neoplasia results in a similar risk of cancer development. Because the stapled procedure is associated with better long-term functional outcomes than a mucosectomy, stapled IPAA is the preferable procedure for most patients with familial adenomatous polyposis.

Rectocutaneous fistula with imperforate anus in an adult.

Adult presentation of a rectocutaneous fistula with imperforate anus is rare. We report the case of a 22-year-old man who presented with an anorectal malformation and a rectocutaneous fistula. The patient complained of faecal matter passing through the external orifis of a fistula located at the distal part of his scrotum. He was continent for solid faeces, but had leakage of flatus and faecal soiling. He had no other associated anomaly. The patient subsequently underwent a surgical procedure where anal transposition was done. Postoperative recovery was uneventful, and the patient was fully continent at control examination.

A rare clinical manifestation of rectal adenocarcinoma and synchronous scalp metastasis: A case report.

In this case report, our aim was to emphasize that cutaneous involvement can be seen at the time of diagnosis or during the clinical course of visceral organ cancers in general and in colorectal cancers particularly. We also aimed to demonstrate that cutaneous lesions occurring in patients under follow up for visceral organ cancers could be metastases. A rapid progressing scalp lesion was detected in a newly diagnosed rectal cancer patient and the tru-cut biopsy revealed adenocarcinoma metastasis. This patient died due to a myocardial infarction during neoadjuvant chemotherapy. Cutaneous metastatic lesions in colorectal cancers must be evaluated as a sign of advanced disease and treatment protocols should be determined accordingly.

Doppler-guided hemorrhoidal artery ligation: experience with 2 years follow-up.

Doppler-guided hemorrhoidal artery ligation (DGHAL) is a nonexcisional surgical technique for the treatment of hemorrhoidal disease, consisting of the ligation of the distal branches of the superior rectal artery, resulting in a reduction of blood flow and decongestion of hemorrhoidal plexus resulting in fibrosis. The aim of the study was to assess the efficacy and safety of DGHAL, define its indications, and identify its possible advantages and limitations for the treatment of second- and third-degree hemorrhoids. The procedure was performed using a specially designed proctoscope. The Doppler probe was used to locate all the terminal branches of hemorrhoidal arteries, which were then sutured. Patients were followed up for 2 years. From November 2006 to May 2009, 50 patients (29 female, mean age 38.2 years) underwent this procedure. The procedure was performed under local anesthesia. An average of five ligatures was placed. Average length of hospital stay was 2 hours and return to work was 2.5 days. The mean postoperative pain score was 1.72. There were no intra- or immediate postoperative major complications. In 44 patients (88%), surgery resolved the symptoms completely in a 2-year follow-up period. DGHAL is a safe and effective procedure. DGHAL can be the choice for second- and third-degree hemorrhoids with minimal postoperative pain and quick recovery.

Laparoscopic splenectomy for the treatment of wandering spleen in a pregnant woman: a case report.

Laparoscopic splenectomy became the gold standard recently for the removal of spleen. One of its rare indication is wandering spleen (WS). WS is characterized by incomplete fixation of the spleen. Patients usually have an asymptomatic abdominal mass. When they are symptomatic, abdominal pain with a mobile mass is the major finding. Laboratory data are nonspecific, but the diagnosis can be confirmed by imaging studies; computed tomography, magnetic resonance imaging, and ultrasonography are preferred modalities. It can predispose one to life-threatening complications such as splenic infarction, portal hypertension, pancretitis, and hemorrhage, due to torsion of its vascular pedicle. Herein, we present a female patient, a 24-year-old, 18-week primigravida. She was admitted with an intra-abdominal mass and lower abdominal pain. Ultrasonography revealed a mass behind the uterus. Magnetic resonance imaging was planned, and the spleen was seen at this area. We performed laparoscopic splenectomy for the treatment of a WS, which would be dangerous for pregnancy. The patient was discharged without any postoperative complication on the third day postoperatively. A healthy baby was delivered at term. Minimally invasive procedures should also be the primary choice in the treatment of such pregnant women. This is the first case of laparoscopic splenectomy in a pregnant woman for WS in the English literature.