Changes in serum ghrelin and resistin levels after sleeve gastrectomy versus one anastomosis gastric bypass: prospective cohort study.

INTRODUCTION: Humoral factors and neural mechanisms play a central role in the pathogenesis of obesity and in weight loss following bariatric surgery. Although various hormones and adipokines, including ghrelin and resistin, are linked to obesity, studies analyzing the changes in fasting ghrelin and resistin levels in patients following one anastomosis gastric bypass are lacking. AIM: We aimed to investigate resistin and ghrelin levels before and after two commonly used bariatric procedures with different mechanisms of action: sleeve gastrectomy (SG) and one anastomosis gastric bypass (OAGB). PATIENTS AND METHODS: Fasting serum ghrelin and resistin levels were evaluated by using ELISA in a non-randomized, prospective cohort study for the pattern of changes in the preoperative period and one week, one month, three months and, 12 months after surgery in age and sex-matched patients with BMI ≥40 kg/m2 undergoing either sleeve gastrectomy (n=40) or one anastomosis gastric bypass (n=40). Their relationships with demographic parameters such as body weight, Body mass index (BMI), presence of T2DM, HbA1C, and HOMA-IR index were also evaluated. RESULTS: OAGB was superior in weight control compared to the SG group. There were significant differences in resistin and ghrelin levels between the OAGB and SG groups. Ghrelin decreased more in the SG group than the preoperative values. This change in ghrelin levels was more significant at one year after sleeve gastrectomy (preoperative mean(range) level of 334.2 (36.6-972.1) pg/mL decreased to 84 (9.1-227) pg/ml at one year) whereas in the OAGB group no significant change was observed (preoperative mean(range) level of 310 (146-548)pg/mL decreased to 264 (112-418)pg/mL at one year). Resistin levels decreased in both groups, especially after three months and onward following both operations (the mean(range) resistin levels were 2.6 (0.87-5.4)ng/mL and decreased to 1.1 (0.5-2.4)ng/mL in the SG group vs 2.48 (0.89-6.43)ng/mL decreased to 0.72 (0.35-1.8)ng/mL in OAGB group at one year), which was in parallel with changes in HOMA-IR index, body weight, and BMI changes at 1st year. HOMA-IR index changes were similar, but more prominent after OAGB. OAGB was also superior in T2DM control, parallel with weight loss, fasting resistin levels (especially after three months and onward), and HOMA-IR changes. CONCLUSION: This is the first study to compare fasting ghrelin and resistin levels after one anastomosis gastric bypass and sleeve gastrectomy. Although similar changes were observed, ghrelin changes were more prominent after SG, whereas resistin were observed after OAGB. OAGB was superior in T2DM control which was in parallel with weight loss, fasting resistin levels, and HOMA-IR changes suggesting a possible effect of resistin after OAGB in glucose metabolism and insulin resistance.

The Effect of Bariatric Surgery on Exocrine Pancreatic Function.

INTRODUCTION: After bariatric surgery (BS), patients might suffer from nutrient maldigestion, malabsorption, and vitamin deficiencies. In this study, our aim was to assess pancreatic functions after BS using fecal elastase-1 assay (FE-1). MATERIAL AND METHODS: Sixty patients (21M) undergoing BS and 20 (6M) healthy controls were included into the study. Stool samples were collected 1 year after surgery. Ten patients from one anastomosis gastric bypass (OAGB) and single anastomosis duodenal switch (SADS) groups with the lowest value of FE-1 and GIQLI scores were given pancreatic enzyme replacement therapy (PERT). After PERT, FE-1, excess weight loss (EWL), BMI, GIQLI scores, and vitamin D levels were measured. RESULTS: Vitamin D levels were detected as 19.04 (9-46.5) pg/ml, 15.1 (8.4-23.6) pg/ml, 17.8 (5-30) pg/ml, and 21.79 (11-40.3) pg/ml after sleeve gastrectomy (SG), OAGB, SADS, and control groups, respectively (p = 0.04). GIQLI scores in the first year were found to have increased in all patients (p = 0.02). FE-1 levels were found as 642.35 (566.3-711.4) µg/g, 378.52 (183.5-561.1) µg/g, 458.88 (252.5-593, 5) µg/g, and 518.2 (351.6-691) µg/g for the SG, OAGB, SADS, and control groups, respectively. There was a strong inverse correlation between EWL and FE-1 levels at the end of the first year (Spearman's rho = - 0.688, p = 0.003). After having performed PERT for patients with the lowest FE-1 levels, the levels increased to 683.39 (615.5-720) µg/g in the OAGB and 691.5 (643.1-720) µg/g in the SADS groups (p = 0.011). CONCLUSION: FE-1 measurements demonstrated that many patients suffer from malabsorption after OAGB or SADS, whereas functions remain normal after SG. PERT corrects pancreatic functions without affecting weight loss and also contributes to the normal serum level of vitamin D.

How can surgical continuity be maintained during the COVID-19 pandemic? A quality improvement study in the pre-vaccination period.

Objectives: During the COVID-19 pandemic, most of the elective surgeries had to be postponed. However, it is not possible to delay the surgical treat- ment of cancer patients for a long time. The aim of this study was to present how gastrointestinal system surgery operations are managed without delay and how employee safety is ensured , together with the results of the last five months. For this purpose, a preclinical and clinical screening system was created. Material and Methods: Data of the patients who presented to our outpatient clinic between April 1st 2020 and August 31st 2020 were retrospectively reviewed. Results: During the last five months of the pandemic, a total of 387 patients were hospitalized and 309 of these patients underwent surgical procedures. 165 of the patients who underwent surgery were newly diagnosed malignancy patients. All patients who were hospitalized were subjected to a screening for COVID-19 during the preclinical, clinical and surgical period. In the preclinical period, five patients were found positive and were directed to COVID-19 treatment without hospitalization. In the clinical period, six patients were isolated by showing symptoms during the hospitalization period. Only one of these patients received surgical treatment. The remaining five patients underwent endoscopic and interventional procedures. In this process, COVID-19 positivity was detected in a total of five healthcare workers. Conclusion: With this preclinical and clinical screening method, it is shown that a COVID-19 sterile environment can be provided by early detection of positive cases in both patients and healthcare workers. In this way, the possibility of surgical continuity was demonstrated.

Endoscopy in surgery.

In the last 20 years, there have been important developments in endoscopy. Initially, endoscopy was developed and used as a diagnostic tool. As new technology developed, these devices also became the basis for therapeutic maneuvers. In recent years, flexible endoscopes have been used to per- form procedures replacing traditional surgical approaches. Examples of this field are transanal minimally invasive surgery, natural orifice transluminal endoscopic surgery, endoscopic metabolic surgery and third space endoscopies. Throughout history, surgeons have played a vital role in the design and development of endoscopic techniques, procedures, and equipment. Surgeons continue to lead the advancement of endoscopy, make important contributions, and serve as role models for innovation.

General Surgery Operating Room Practice in Patients with COVID-19.

The virus COVID-19, which emerged in China in December 2019, was announced by the World Health Organization as a pandemic in January 2020. It is known that infection is not severe and may even progress without symptoms in patients who have come into contact with COVID-19. Although various organizations have been informed about how to take measures to protect the patient and the surgeon in case of diseases requiring urgent or elective surgery in people infected with COVID-19 or in cases with high suspicion, there is still no definite judgment between patients, physicians and health authorities. In this study, which was prepared with the initiative of the Turkish Surgical Association, we tried to shed light on what should be done and how surgeons should act in patients whose operation is mandatory in light of the available data.

Changes in HOMA-IR index levels after bariatric surgery: Comparison of Single Anastomosis Duodenal Switch-proximal approach (SADS-p) and One Anastomosis Gastric Bypass-Mini Gastric Bypass (OAGB-MGB).

BACKGROUND: Bariatric surgery plays a major role in ameliorating metabolic abnormalities of type 2 diabetes (T2DM). The aim of this study was to evaluate the early effects of "Single Anastomosis Duodenal Switch-proximal approach" (SADS-p) and "One Anastomosis Gastric Bypass-Mini Gastric Bypass (OAGB-MGB) on the "homeostasis model assessment of insulin resistance" (HOMA-IR) index levels in morbidly obese patients with T2DM. METHODS: In this retrospective 3-year trial, outcomes of SADS-p and OAGB-MGB patients were compared considering the changes in HOMA-IR index levels. All bariatric procedures were performed by a single primary surgeon recognized as a surgeon of excellence by IFSO-EC with the assistance of one or two additional attending surgeons. SADS-p was performed on 60(10 males) patients, and 200(27 males) patients underwent OAGB-MGB. Forty-six patients (78%) in the SADS-p group and 125 (63%) in the OAGB-MGB group had T2DM. Patients were evaluated before surgery and 1,3,9,12 months after surgery. RESULTS: In both groups, the HOMA-IR index levels decreased significantly after surgery (p < 0.05), and both procedures markedly improved glycemic control. In the SADS-p group the HOMA-IR index levels significantly decreased from 6.2 to 1.4 after the 12th month of surgery (p < 0.05), in OAGB-MGB group HOMA-IR index levels significantly decreased from 5,9 to 1.7 after the 12th month of surgery (p < 0.05). CONCLUSION: Both procedures are promising operations which offer excellent control on weight, HOMA-IR index and diabetes.

Diagnosis and management of acute appendicitis. EAES consensus development conference 2015.

Unequivocal international guidelines regarding the diagnosis and management of patients with acute appendicitis are lacking. The aim of the consensus meeting 2015 of the EAES was to generate a European guideline based on best available evidence and expert opinions of a panel of EAES members. After a systematic review of the literature by an international group of surgical research fellows, an expert panel with extensive clinical experience in the management of appendicitis discussed statements and recommendations. Statements and recommendations with more than 70 % agreement by the experts were selected for a web survey and the consensus meeting of the EAES in Bucharest in June 2015. EAES members and attendees at the EAES meeting in Bucharest could vote on these statements and recommendations. In the case of more than 70 % agreement, the statement or recommendation was defined as supported by the scientific community. Results from both the web survey and the consensus meeting in Bucharest are presented as percentages. In total, 46 statements and recommendations were selected for the web survey and consensus meeting. More than 232 members and attendees voted on them. In 41 of 46 statements and recommendations, more than 70 % agreement was reached. All 46 statements and recommendations are presented in this paper. They comprise topics regarding the diagnostic work-up, treatment indications, procedural aspects and post-operative care. The consensus meeting produced 46 statements and recommendations on the diagnostic work-up and management of appendicitis. The majority of the EAES members supported these statements. These consensus proceedings provide additional guidance to surgeons and surgical residents providing care to patients with appendicitis.

STEAP4 and HIF-1α gene expressions in visceral and subcutaneous adipose tissue of the morbidly obese patients.

AIM AND BACKGROUND: Obesity is a multifactorial disease in which environmental and genetic factors play an integrated role. Determining such target genes will help to elucidate the mechanisms underlying complex diseases such as obesity and diabetes which are usually seen together. Present study investigates the expression levels of STEAP4 and HIF-1α in visceral and subcutaneous adipose tissue. PATIENTS AND METHODS: 30(6M) morbidly obese patients undergoing bariatric surgery were included in the study. The patients were grouped according to the BMI as Group I (BMI <50kg/m(2)) and Group II (BMI ≥50kg/m(2)). Samples from visceral (omentum) and subcutaneous adipose tissues were obtained from each patient and real-time PCR (qPCR) was carried out for STEAP4 and HIF-1α gene expressions. Correlations between expression levels and clinical parameters were analyzed. RESULTS: Mean age of the patients recruited to the study was 37.4 (18-64) years. Mean BMI was 46 (36-60) kg/m(2). STEAP4 expression in visceral adipose tissue was significantly higher than subcutaneous tissue. Visceral STEAP4 expression was also found to be reduced with increased BMI. It was also lower in patients with HbA1C over 6. Furthermore, expression of subcutaneous and visceral HIF-1α was significantly higher in Group II. There was a significant correlation between BMI, glycosylated hemoglobin, STEAP4 and HIF-1α gene expression. CONCLUSIONS: Obesity and related disease are linked with the fact that there is a low grade inflammation in the adipose tissue of the obese individuals. Counter-regulatory processes such as STEAP4 protein family are overwhelmed by the proinflammatory stimuli. HIF-1α expression is increased due to tissue hypoxia and pro-inflammatory stimuli in the obese individuals, which results in increased visceral STEAP4 expressions.

Predictors of poor outcome in gastrointestinal bleeding in emergency department.

AIM: To determine the prognostic risk factors of gastrointestinal bleeding in emergency department cases. METHODS: The trial was a retrospective single-center study involving 600 patients over 18-years-old and carried out with approval by the Institutional Ethics Committee. Patient data included demographic characteristics, symptoms at admission, past medical history, vital signs, laboratory results, endoscopy and colonoscopy results, length of hospital stay, need of intensive care unit (ICU) admission, and mortality. Mortality rate was the principal endpoint of the study, while duration of hospital stay, required interventional treatment, and admission to the ICU were secondary endpoints. RESULTS: The mean age of patients was 61.92-years-old. Among the 600 total patients, 363 (60.5%) underwent upper gastrointestinal endoscopy and the most frequent diagnoses were duodenal ulcer (19.2%) and gastric ulcer (12.8%). One-hundred-and-fifteen (19.2%) patients required endoscopic treatment, 20 (3.3%) required surgical treatment, and 5 (0.8%) required angiographic embolization. The mean length of hospital stay was 5.21 ± 5.85 d. The mortality rate was 6.3%. The ICU admission rate was 5.3%. Patients with syncope, higher blood glucose levels, and coronary artery disease had significantly higher ICU admission rates (P = 0.029, P = 0.043, and P = 0.002, respectively). Patients with low thrombocyte levels, high creatinine, high international normalized ratio, and high serum transaminase levels had significantly longer hospital stay (P = 0.02, P = 0.001, P = 0.019, and P = 0.005, respectively). Patients who died had significantly higher serum blood urea nitrogen and creatinine levels (P = 0.016 and P = 0.038), and significantly lower mean blood pressure and oxygen saturation (P = 0.004 and P = 0.049). Malignancy and low Glasgow coma scale (GCS) were independent predictive factors of mortality. CONCLUSION: Prognostic factors for gastrointestinal bleeding in emergency room cases are malignancy, hypotension on admission, low GCS, and impaired kidney function.

Improved oxidative status in major abdominal surgery patients after N-acetyl cystein supplementation.

BACKGROUND: Increased levels of reactive oxygen species during and after surgery may affect inflammatory response, post-operative adhesion molecule formation, and hemodynamic stability. The glutathione redox cycle is an important regulator in oxidative stress and its reduced forms scavenge free radicals. N-acetyl cysteine, a precursor of reduced glutathione, is considered as a potentially therapeutic wide spectrum agent in clinical practice. We therefore examined whether N-acetyl cysteine improves some biochemical parameters in cancer patients undergoing major abdominal surgery. METHODS: Thirty-three patients diagnosed with pancreas, stomach, rectum, colon malignancies, and undergoing major abdominal surgery at Ankara Numune Training and Research Hospital were randomly divided into two groups; control (CON) and N-acetyl cysteine (NAC). The NAC group had 1,200 mg N-acetyl cysteine starting two days before the operation day, in addition to isonitrogenous and isocaloric total parenteral nutrition of 1.2 g/kg protein, 25 kcal/kg, and 60:40 carbohydrate/fat ratio. Blood and urine samples were drawn two days before the operation, on operation day, and on the first, third, and fifth days post-operation. RESULTS: Plasma malondialdehyde was significantly lower in the NAC group (P < 0.001). N-acetyl cysteine treatment did not affect plasma levels of vitamin A, C or E. The NAC group exhibited a higher ratio of reduced glutathione to oxidised glutathione (P = 0.019). Urinary nitrate level was also significantly lower in the NAC group (P = 0.016). CONCLUSION: The study demonstrated the clinical importance of N-acetyl cysteine supplementation on antioxidant parameters in abdominal surgery patients. In these patients N-acetyl cysteine and vitamin administration can be considered as an effective method for improvement of oxidative status.

Current adjuvant therapeutic approaches for pancreatic cancer.

Pancreatic cancer continues to be the fourth leading cause of death despite advancements in surgical and adjuvant therapeutic approaches. In the present review, the current cytotoxic therapeutic approaches and advanced targeted therapies are objectively discussed with consideration to the current literature.

Predictive value of liver transaminases levels in abdominal trauma.

INTRODUCTION: We aimed to evaluate whether hepatic transaminase levels could predict the presence and severity of liver injury following abdominal trauma. METHODS: We performed a retrospective analysis of 75 surgically treated patients and 21 non-surgically treated patients with liver injury who were managed between 2004 and 2012. We retrieved demographic, laboratory, radiologic, and intraoperative data, as well as surgical procedures and the outcome from the patients' medical records. We compared the findings between patients divided into 2 groups according to the severity of liver injury: group 1, including patients with Grade 1 or 2 liver injuries; and group 2, including patients with grade 3 to 5 liver injury. RESULTS: There were 87 (90.6%) males and 9 (9.4%) females. The mean age was 34 years (range, 17-90 years). The overall mortality rate was 14.6% (n = 14). The injury was blunt in 83 patients (86.5%) and penetrating in 13 patients (13.5%). There were multiple traumas in 60 patients (62.5%). Overall, 43 patients (44.8%) had a total of 61 coexisting intraabdominal injuries. The circulating aspartate aminotransferase, alanine aminotransferase, and lactate dehydrogenase (LDH) levels were significantly higher in group 2 than in group 1. CONCLUSIONS: In patients with abdominal trauma, abnormal hepatic transaminase and LDH levels are associated with liver injury. Alanine aminotransferase ≤76 U/L, aspartate aminotransferase <130 U/L, and LDH ≤410 U/L are predictive of low-grade liver injury, and patients with serum liver levels below these levels can be managed conservatively.

The epidemiology and cost analysis of patients presented to Emergency Department following traffic accidents.

BACKGROUND: Traffic accidents are ranked first as the cause of personal injury throughout the world. The high number of traffic accidents yielding injuries and fatalities makes them of great importance to Emergency Departments. MATERIAL AND METHODS: Patients admitted to Hacettepe University Faculty of Medicine Adult Emergency Department due to traffic accidents were investigated epidemiologically. Differences between groups were evaluated by Kruskall-Wallis, Mann-Whitney, and Wilcoxon tests. A value of p<0.05 was accepted as statistically significant. RESULTS: We included 2003 patients over 16 years of age. The mean age was 39.6 ± 16.1 and 55% were males. Admissions by ambulance and due to motor vehicle accidents were the most common. In 2004 the rate of traffic accidents (15.3%) was higher than the other years, the most common month was May (10.8%), and the most common time period was 6 pm to 12 am (midnight). About half of the patients (51.5%) were admitted in the first 30 minutes. Life-threatening condition was present in 9.6% of the patients. Head trauma was the most common type of trauma, with the rate of 18.3%. Mortality rate was 81.8%. The average length of hospital stay was 403 minutes (6.7 hours) and the average cost per patient was 983 ± 4364 TL. CONCLUSIONS: Further studies are needed to compare the cost found in this study with the mean cost for Turkey. However, the most important step to reduce the direct and indirect costs due to traffic accidents is the prevention of these accidents.

Relationship between LYVE-1, VEGFR-3 and CD44 gene expressions and lymphatic metastasis in gastric cancer.

AIM: To investigate the expression levels of lymphatic vessel endothelial hyaluronan receptor-1 (LYVE-1), vascular endothelial growth factor receptor-3 (VEGFR-3) and CD44 genes and the relationship between their levels and clinicopathological parameters in gastric cancer. METHODS: Tissue samples were obtained from 33 patients (8 females) with gastric cancer. mRNA levels of LYVE-1, VEGFR-3 and CD44 in normal and tumor tissues were quantitatively measured using real time polymerase chain reaction. The results were correlated with lymph node metastasis, histological type and differentiation of the tumor, T-stage, and presence of vascular, perineural and lymphatic invasions. The distribution of molecules in the tissue was evaluated using immunohistochemistry. RESULTS: LYVE-1, CD44 and VEGFR-3 gene expression levels were significantly higher in gastric cancer than in normal tissue. While there was no correlation between gene expressions and clinicopathologic features such as histologic type, differentiation and stage, gene expression levels were found to be increased in conjunction with positive lymph node/total lymph node ratio and the presence of perineural invasion. A significant correlation was also found between LYVE-1 and CD44 over-expressions and perineural invasion and lymph node positivity in gastric cancers. When the distribution of LYVE-1 antibody-stained lymphatic vessels in tissue was evaluated, lymphatic vessels were located intra-tumorally in 13% and peri-tumorally in 27% of the patients. Moreover, lymph node metastases were also positive in all patients with LYVE-1-staining. CONCLUSION: LYVE-1, VEGFR-3 and CD44 all play an important role in lymphangiogenesis, invasion and metastasis. LYVE-1 is a perfectly reliable lymphatic vessel marker and useful for immunohistochemistry.

The prevalence of factor V (G1691A), MTHFR (C677T) and PT (G20210A) gene mutations in arterial thrombosis.

BACKGROUND: Factor V (FV) [G1691A], methylenetetrahydrofolate reductase (MTHFR) [C677T] and prothrombin (PT) [G20210A] mutations are all well-recognized genetic risk factors for venous thrombosis. Although their prevalence in coronary artery disease has been established through debate, their role in patients with arterial thrombosis remains to be clarified. We investigated the prevalence rates of FV, MTHFR and PT gene mutations in patients with arterial thrombosis and in healthy controls. METHODS: All subjects and controls were from Central Anatolia. Thirty (8F) patients with median (range) age of 63 (16-88) years and 90 (52F) healthy controls with median (range) age of 31 (20-73) years were studied. DNA was extracted using conventional methods (proteinase K/phenol-chloroform) followed by PCR amplification and restriction endonuclease digestion (using Hinf I and Hind III). Digested PCR products were identified using agarose gel electrophoresis and stained with ethidium bromide. RESULTS: The prevalence rates of MTHFR and PT gene mutations were not significantly different between the groups. The prevalence rate of FV mutation was significantly higher in patients with arterial thrombosis. Coinheritance of FV and MTHFR was found in 67% of patients, which was significantly higher in arterial thrombosis, suggesting the MTHFR mutation as a synergistic risk factor for thrombosis in patients with FV mutation. PT gene mutation has no effect on arterial thrombosis. CONCLUSION: The increased prevalence rate and coexistence of both FV and MTHFR found in this group of patients suggest that these mutations might increase the risk of arterial thrombosis.

The correlation between reactive oxygen species and histopathology of the liver, gut, and kidneys in animals with elevated intra-abdominal pressure.

BACKGROUND: Clinical and experimental studies have shown that the laparoscopic procedure provides a typical model of ischemia-reperfusion injury in the organs by oxygen-derived free radicals. A pneumoperitoneum produces ischemia during insufflation and reperfusion during desufflation. The aim of this study was to assess the causative role of free radical-mediated reactions in tissue damage under different intra-abdominal insufflation pressures. MATERIALS AND METHODS: Thirty five mature New Zealand white rabbits were assigned to three groups of 10 animals. In groups 1, 2, and 3, the designated pressures of 10, 15, and 20 mm Hg, respectively. The remaining 5 animals underwent laparotomy, using a 10-cm midline incision taken as group 4 (control). Blood samples were collected before (0 minutes) and at the end of the procedure (60 minutes). After the collection of the last blood samples, all animals were sacrificed and the samples from the liver, kidney, and gut were obtained for histologic evaluation and also measurements of tissue malondialdehyde (MDA) levels. RESULTS: The nitric oxide levels were not changed in groups 1 and 2, but increased significantly in group 3. Tissue MDA levels were significantly higher in groups 1 and 2 than groups 3 and 4. Histopathologic examination of the kidney revealed some findings of reversible hypoxic cell injury, including acute cellular swelling, vascular congestion, and some early findings of irreversible injury, such as lysis of the cytoplasmic membrane in all groups and focal parancymal bleeding area in only group 3 as a consequence of increased pressure. Liver histology revealed cellular swelling and karyorhexis in hepatocytes in group 1, whereas only congestion and sinusoidal dilatation was observed in groups 2 and 3. CONCLUSION: Our experimental study showed that abdominal insufflation causes ischemia and free radical production, which seems responsible for the cell damage that occured during laparoscopic surgery.