Identifying Factors Associated with Non-mesenterovascular Pathology in Patients Undergoing Surgical Treatment for Acute Mesenteric Ischemia.

AIM: To identify factors that can help us to avoid a preoperative incorrect diagnosis of vascular occlusion by evaluating patients who underwent laparotomy with a probable preoperative diagnosis of acute mesenteric ischemia (AMI), but later at laparotomy, were diagnosed to have a different pathology than AMI. MATERIAL AND METHODS: A total of 213 patients who were operated with the diagnosis of AMI were enrolled in this study. Based on their operational, clinical, and pathological findings, they were divided into two groups. Patient demographic data, along with the American Society of Anesthesiology (ASA) score, Charlson comorbidity index, history of previous abdominal surgery, and computed tomography (CT) findings were compared between groups. RESULTS: There were 37 patients in Group 1 (non-mesenterovascular pathology) and 176 patients in Group 2 (mesenterovascular pathology). The percentage of ASA 4 patients was higher in Group 2, with 48.3%, compared to 35.1% in Group 1 (p-value: 0.028). Upon admission, Group 2 had a higher rate of pathologic findings on CT examinations. 21.8% of the patients with non-mesenterovascular pathology had normal intra-abdominal findings. In univariate and multivariate analysis for no-nmesenterovascular pathology, patient age less than 65, Charlson comorbidity index 1-2, INR level >1.2, history of previous abdominal operation, and pneumatosis intestinalis were identified as independent risk factors. DISCUSSION: The possibility of non-mesenterovascular pathology in presumed AMI patients should be kept in mind, especially if the patients have a history of abdominal surgery, a low comorbidity index, an elevated international normalised ratio (INR), and are younger than 65 years of age. CONCLUSION: Evaluating the significant parameters identified in this study among patients with a preliminary diagnosis of AMI may prove useful in avoiding misdiagnosis and unnecessary surgeries.

Regulatory T cells and monocytes crosstalk in patients with gastric cancer.

INTRODUCTION: Primary function of regulatory T(Treg) cells is to control and regulate the immune responses. In many patients with tumor tissues, increased Treg cell numbers have been reported. In this study, we aimed to measure the cellular content of blood samples in patients with gastric cancer (GC) and define their role in tumor progression. METHODS: We prospectively evaluated 34 gastric cancer cases and 20 healthy control samples. The blood was collected from both the gastric coronary and peripheral veins of the patients and only from the peripheral vein of the control group. Cellular content and lymphocyte subset including, regulatory T cells, were determined by flow cytometric analysis. RESULTS: The GC patients revealed similar percentages of T cells, B cells, neutrophils, and eosinophils in the venous samples from periphery vein and gastric coronary. The percentage of monocytes from the tumor-draining gastric coronary vein was significantly lower than monocytes from the peripheral vein in gastric cancer patients (p=0.03). T-regulatory cells had a higher percentage in samples obtained from gastric cancer patients compared with the control group. CONCLUSION: Our findings confirmed that patients with gastric cancer have a significantly higher percentage of regulatory T cells than the control group, suggesting that they may contribute to the tumor progress. Regulatory T cells and monocytes interact in patients with GC, which can be used as a parameter in the clinical follow-up of patients with GC. KEY WORDS: Gastric cancer, Treg cell, Flow cytometry, FoxP3.

The prognostic value of Tumor Volume Index in patients with esophageal cancer who had curative resection A single center experience.

AIM: We aim to evaluate the prognostic significance of tumor volume in esophageal cancer. METHODS: Patients who underwent curative resection due to esophageal cancer between the years 2015 and 2019 were included in the study. The Tumor Depth Parameter (TDP) was defined as mucosa and submucosa =1, muscularis propria =2, adventitia =3, and invasion into adjacent organs=4. The Tumor Volume Index (TVI) was defined as the major axis X the minor axis X TDP. Two groups were formed based on TVI: Group 1 (low TVI) and Group 2 (high TVI). In the groups; patients were compared in terms of demographic and clinical features, intraoperative and postoperative outcomes, characteristics of the tumor and average survival. RESULTS: The patients were divided into two groups based on the cut-off value of 4,000. Group 1 (low TVI) consisted of 16 patients and Group 2 (high TVI) consisted of 28 patients. Male sex ratio was higher in Group 2 (50% vs 85%, p:0.011) Tumor diameter was observed to be larger in Group 2 (3.06 vs 5.54, p:0.000). Adenocarcinoma histologic type was more common in Group 2 (25% vs 64.3%, p:0.012). Incidence of respiratory complications was higher in Group 2 (0% vs 35.7%, p:0.024),Survival time (months) was shorter in Group 2 (36 vs 11, p:0.005). TVI's being over 4000 (HR)(95%-Confidence Interval ((Cl) 0.057 (0.011-0.311),p:0.001) was an independent risk factor to determine the rate of survival. CONCLUSION: TVI can be used as a prognostic factor in patients with esophageal cancer who underwent surgical therapy. TVI is closely associated with tumor histology and postoperative outcomes. KEY WORDS: Esophageal cancer, Prognosis, Postoperative complication, Surgical manangment, Survey, Tumor volume.

Surgical treatment and outcome for primary duodenal adenocarcinoma. Single center experience.

AIM: In this study, we aimed to evaluate patients who underwent curative surgical treatment for primary duodenal adenocarcinoma and to present our experience. MATERIAL AND METHODS: Patients diagnosed with primary duodenal adenocarcinoma between 2006 and 2018 participated in the study. The demographic and clinical characteristics of the patients, details of the operation, pathological features of the tumors, short- and long-term follow-up results, and mean survival were evaluated retrospectively. RESULTS: Nine patients with a mean age of 54.7 participated in the study. 55% of the patients were male. The most common presenting symptom was abdominal pain (n: 6; 67%). The most common tumor localization was D2-3 (n: 7; 78%), and the most common surgical operation was pancreaticoduodenectomy (n: 7; 78%). There were no intraoperative complications in any patient. The mean tumor diameter was 3.5 cm. The mean number of lymph nodes dissected was 8.3 and the mean number of metastatic lymph nodes was 2. The most common postoperative complication was pancreatic fistula (n: 3; 33%). The mean length of stay was 21.8 days. One patient developed septic shock and mortality happened within the 30-day period. The most common cause of unplanned admission to the hospital within 90 days was wound infection (n: 2; 22%). One patient developed local recurrence and two patients had systemic metastasis. We found an average survival of 40 months. DISCUSSION: Pancreaticoduodenectomy is the most common approach in its curative surgery and it has a long survival despite the high postoperative complication rate. We recommend radical resection in the surgical treatment of primary duodenal adenocarcinoma. KEY WORDS: Adenocarcinoma, Duodenum, Pancreaticoduodenectomy.

Prognostic significance of the neutrophil to lymphocyte ratio in patients with curative resection of esophageal cancer. A single center experience.

AIM: In this study, we aimed to determine the clinical value and prognostic significance of the Neutrophil / Lymphocyte Ratio in patients undergoing curative surgery due to esophageal cancer. MATERIAL AND METHOD: Patients who underwent curative resection for esophageal cancer between 2015-2019 were included in the study. Two groups, Group1 (low NLR) and Group2 (high NLR), were created. Demographic and clinical features, intraoperative and postoperative results, tumor characteristics and mean survival were compared in the groups. RESULTS: A total of 48 patients participated in our study. Group 1 consisted of 18 patients and Group 2 consisted of 30 patients. Male sex was dominant in both groups (66.7% vs 73.3%, p. 0.431). Preoperative CEA was higher in Group 2 (3.97 vs 9.57, p. 0.032). Tumor diameter was larger in Group2 (3.33 vs 5.40 cm, p. 0.000). Adenocarcinoma was higher in Group 2 (33% vs 53.3%, p. 0.047), while squamous cell carcinoma was higher in Group 1 (66.7% vs 33.3%, p. 0.047). Lymph node positivity was higher in Group 2 (66.7% vs 93.3%, p. 0.024). The anastomosis leak was higher in Group 2 (0% vs 20%, p. 0.048). Postoperative hospital stay was longer in Group 2 (13.27 vs 23.9 days, p. 0.009). 90-day readmission was higher in Group1 (33.3% vs 3.3%, p. 0.008). Survival duration was shorter in Group 2 (29 vs 15 months, p. 0.005). CONCLUSION: This study revealed that preoperative high NLR was associated with poor survival, along with greater tumor diameter, increased lymph node metastasis rate, and increased anastomosis leakage in patients with esophageal cancer. These results suggest that modifying inflammatory responses and modulating the immune system may improve survival outcomes in patients with esophageal cancer. KEY WORDS: Esophagus cancer, Neutrophil/lymphocyte ratio, Preoperative neutrophil/lymphocyte ratio, Prognosis.

Ectopic adrenal tissue in a hernia sac in an adult. A case report.

The discovery of ectopic adrenal tissue in the hernial sac is very rare, and in the majority of reported cases it is in children, while it is never described in adult subjects. This could be due to a progressive previous atrophy of the ectopic tissue or to an insufficient examination of the sac removed surgically. The most frequent site of these ectopias is the kidney, adjacent to the adrenal glands. The presence of ectopic adrenal tissue is important because of its neoplastic and hyperplastic potential. We report a case of a 69-year-old male patient who underwent a surgical operation of a left inguinal hernia and that the presence of ectopic adrenal tissue was reported in the pathologist's report. Preoperative abdominal ultrasound should therefore be performed in patients destined for an inguinal hernia surgery, because also the rare existence of ectopic adrenal tissue in the hernial sac should be kept in mind. KEY WORDS: Adrenal, Adult, Ectopia, Herni sac.

Effects of bradykinin preconditioning in an experimental intestinal ischemia reperfusion model on rats.

PURPOSE: To investigate the effects of bradykinin on reperfusion injury in an experimental intestinal ischemia reperfusion model. METHODS: We used 32 Wistar-Albino rats. We composed 4 groups each containing 8 rats. Rats in sham group were sacrified at 100 minutes observation after laparotomy. Thirty minutes reperfusion was performed following 50 minutes ischaemia in control group after observing 20 minutes. Ischaemic preconditioning was performed in one group of the study. We performed the other study group pharmacologic preconditioning by infusional administration of 10 µg/kg/minute bradykinin intravenously. We sacrified all of the rats by taking blood samples to evaluate the lactate and lactate dehydrogenase (LDH) after resection of jejunum for detecting tissue myeloperoxidase (MPO) activity. RESULTS: Lactate and LDH levels were significantly higher in control and study groups than the sham group (P<0.001). There is no difference between the study groups statistically. (P>0.05). The results were the same for MPO levels. Although definitive cell damage was determinated in the control group by hystopatological evaluation, the damage in the study groups observed was lower in different levels. However, there was no significant difference between the study groups statistically (P>0.05). CONCLUSION: Either ischeamic preconditioning or pharmacologic preconditioning made by bradykinin reduced the ischemia reperfusion injury at jejunum.

Sigmoid colon cancer presenting as complete prolapse.

BACKROUND: The association of rectal prolapse and colorectal cancer is quite rare and only a few cases have been reported previously in the literature. It is unclear whether colorectal cancer triggers rectal prolapse. CASE PRESENTATION: A 77-year-old male patient presented to our emergency department with complete rectal prolapse, and an anterior resection was performed after rectal digital examination revealed a mass. The pathology result came back as mucinous adenocarcinoma in the sigmoid colon and the postoperative period was uneventful. CONCLUSIONS: Considering the age group in which rectal prolapse is most commonly seen, and the change in bowel habits, chronic constipation and irritation chronic seen in rectal prolapse may be responsible for the development of rectum cancer, therefore endoscopic screening should not be overlooked in rectal prolapse cases. KEY WORDS: Anorectal emergencies, Colon cancer, Rectal prolapse.

Prognostic value of E2F1 in rectal cancer.

OBJECTIVE: To evaluate whether E2F transcription factor 1 is a potential prognostic marker in patients with rectal cancer. MATERIAL AND METHODS: Eighty-two patients who were treated with curative resection because of rectal cancer in the Erciyes University School of Medicine, Department of General Surgery were included in the study and analyzed retrospectively. Data were obtained from patient files, pathology reports, and hospital information system. Nuclear and cytoplasmic staining of E2F transcription factor 1 was performed for immunohistochemical analysis on paraffin-embedded and blocked tumor tissue samples of patients. The findings of the study were assessed with using IBM Statistical Package for Social Sciences Statistics 20. RESULT: In the 5-year follow-up period, 34 (41.5%) patients were alive. Local recurrence was identified in 7 patients. According to E2F transcription factor 1 nuclear staining, the average survival rate in patients was 60% for strong nuclear staining and 28% for weak nuclear staining. There was significant statistical difference between groups according to their degree of nuclear staining (p=0.017). When the patients were evaluated according to cytoplasmic staining with E2F transcription factor 1, the average overall survival rate of patients with positive E2F transcription factor 1 cytoplasmic staining was 48.0±4.6% versus 55.9±7.9% for patients without staining (p=0.408). CONCLUSION: The survival rates are higher in rectal cancer patients with strong immunohistochemical nuclear staining of E2F transcription factor 1.

Plasma citrulline measurement in the diagnosis of acute mesenteric ischaemia.

BACKGROUND: The differential diagnosis in acute mesenteric ischaemia (AMI) is essential and sometimes life-saving. A marker for early diagnosis is lacking. Citrulline is an amino acid mainly synthesized by small bowel enterocytes from glutamine. In this study, we aimed to evaluate the diagnostic and prognostic values of citrulline with those of the D-dimer in patients with AMI. METHODS: The patients were divided into two groups; group 1: patients with acute abdominal findings which were attributed preoperatively to AMI, and group 2: patients with acute abdominal findings which were attributed preoperatively to causes other than AMI. All patients underwent surgical exploration. Blood samples were taken before surgery. The demographic features, laboratory examinations, citrulline concentration, D-dimer level and surgical findings were evaluated. RESULTS: Overall, 48 patients were enrolled in the study. AMI was diagnosed in 23 of the 48 patients. There was no significant difference between the groups with regard to gender, leucocyte count and creatinine levels but group 1 was significantly older than group 2. Citrulline, D-dimer and lactate levels were also significantly higher in group 1. Age, lactate, D-dimer and citrulline levels were statistically significant for mortality. The most significant factor was increased lactate level at admission. CONCLUSION: Plasma citrulline level may be helpful in the diagnosis of patients with AMI.

Laparoscopic surgery in functional and nonfunctional adrenal tumors: A single-center experience.

BACKGROUND: Laparoscopic adrenalectomy (LA) is a safe and minimally invasive operation for benign adrenal tumours. The purpose of this study was a retrospective analysis of outcomes following laparoscopic lateral transabdominal adrenalectomy performed for benign adrenal tumours responsible for various endocrinological disorders and non-functioning tumours. METHODS: A total of 100 laparoscopic adrenalectomy were carried out between January 2007 and March 2013 via the lateral transabdominal approach. The analysed factors included demographic data of patients, indication for surgery, tumour size and side, intraoperative and postoperative outcome of laparoscopic lateral transabdominal adrenalectomy including duration of surgery, length of hospital stay, the complication rate, as well as the conversion rate to open adrenalectomy. RESULTS: There were 34 patients with non-functioning tumours (Group 1) and 66 with functioning tumours (Group 2). The intraoperative and postoperative outcomes were not significantly different in the cases among the analysed groups of patients. The median operative time was 101 ± 4.3 (range, 30-210) minute in group 1 and 95 ± 5.9 (range, 30-190) minute in group 2, there was not statistically significant (p = 0.56). The median duration of the postoperative hospital stay in the group 1 was bigger than group 2, this did not differ significantly (p = 0.08). Peroperative complications were occured in 9 (9%) patients, observing 6 (9%) patients in Group 1 and 3 (8.8%) patients in Group 2. There was not statistically significant (p = 0.96). In the postoperative period, three patients in group I, 1 patient in group II developed complications, this difference was not statistically significant (p = 0.69). The conversion to open surgery was found in 9 (9%) patients. CONCLUSION: This study shows that laparoscopic lateral transabdominal adrenalectomy is a safe, effective, and technically feasible procedure in the treatment of both functioning and nonfunctioning benign tumours of the adrenal gland.

The effectiveness of gastric tonometry in the diagnosis of acute mesenteric ischemia in cases where a contrast-enhanced computed tomography cannot be obtained.

OBJECTIVE: The aim of the study was to evaluate the effectiveness of gastric tonometry in the diagnosis of acute mesenteric ischemia in cases where a contrast-enhanced computed tomography cannot be obtained. MATERIAL AND METHODS: The gastric pH (pHi) and gastric CO2 (gpCO2) were measured with gastric tonometry catheter, preoperatively and postoperatively at 24 hours, in patients with suspicion of acute mesenteric ischemia. Simultaneous evaluation of blood gases and blood lactate levels were performed. Patients were divided into two groups after surgery. Group 1 included patients with mesenteric ischemia, and Group 2 consisted of patients without mesenteric ischemia. RESULTS: Forty-two patients (26 males, 16 females) were evaluated. The mean age was 61.4±13.3 years. There was no significant difference between the groups in terms of demographic factors and co-morbid diseases. There were no significant differences between groups in terms of pHi and gpCO2 levels (7.24±0.2 and -3±12.0 in Group 1, 7.18±0.06 and -3±1.9 in Group 2, respectively), intra-abdominal pressure, lactate levels, and survival. Among all the study parameters, only arterial pH had statistical significance in the diagnosis of acute mesenteric ischemia (7.23±0.21 versus 7.35±0.07 for Groups 1 and 2, respectively,) (p<0.05). CONCLUSION: Gastric tonometry is not a useful method in the early diagnosis of acute mesenteric ischemia.

The length of necrosis and renal insufficiency predict the outcome of acute mesenteric ischemia.

BACKGROUND: Acute mesenteric ischemia (AMI) is a potentially life-threatening condition because of its diagnostic difficulty, operative challenges, and comorbidities a patient may have. The aim of this study was to identify factors associated with adverse outcomes in patients with AMI. METHODS: The hospital records and clinical data of all patients with AMI were reviewed for a recent 4-year period. Clinical outcomes and factors influencing mortality were analyzed. RESULTS: Included in the study were 104 patients (46 females and 58 males) with an overall mean age of 66 ± 13.4 years. The cause of AMI was arterial pathology in 74 (71%) patients, venous thrombosis in 15 (14%) patients, and nonocclusive ischemia in 12 (12%) patients. Abdominal pain was the most common presenting symptom (97% of patients). The 30-day mortality rate was 66%. Univariate analysis showed that mortality was associated with renal insufficiency (p = 0.004), an age greater than 70 years (p = 0.02), the presence of comorbidities (p = 0.001), a leukocyte count greater than 18,000/mL (p = 0.04), and small bowel necrosis of more than 100 cm (p < 0.0001). Logistic regression analysis showed that independent predictors of mortality were small bowel necrosis of more than 100 cm (p = 0.002) and a serum creatinine level greater than 2 mg/dL (p = 0.04). CONCLUSION: The length of the necrosis and renal insufficiency are the primary factors that result in a poor outcome in AMI patients. Prompt diagnostic evaluation and early therapeutic interventions may help to prevent the development of these fatal predictors.

A rare cause of acute mesenteric ischemia: JAK2 positivity and chronic active hepatitis B.

Short bowel syndrome occurs as a result of insufficiency in the total length of the small intestine to provide adequate supply of nutrients. Seventy-five percent of cases are due to massive intestinal resection. A 35-year-old male complaining of abdominal pain was admitted to the gastroenterology department. A CT scan was performed, showing total occlusion of the portal vein and superior mesenteric vein. During the operation, widespread edema and necrosis of the small intestine were found. The necrotic segments of the small intestine were resected. The spleen was larger than normal and, in some parts, infarcts were evident, thus asplenectomy was also performed during surgery. A second-look procedure was performed 24 hours later, and an additional 10 cm jejunal resection and anastomosis was performed. His further evaluations revealed myeloproliferative disease and chronic active hepatitis B leading to thrombosis. Essential thrombocytosis and portal vein thrombosis are common in hepatitis B infection. Patients with complaints of abdominal pain in the context of essential thrombocytosis and hepatitis B should be handled with caution as they are at risk of developing portal vein thrombosis.

Effects of piperine in experimental intestinal ischemia reperfusion model in rats.

BACKGROUND: Piperine is a spice principle, and its protective role against oxidative damage and lipid peroxidation has been reported. In this study, we aimed to investigate the effects of piperine in the prevention of ischemia-reperfusion injury to the small intestine. METHODS: Rats were allocated to three groups of 8 rats each. Rats in the sham group underwent laparotomy and observation only. Animals in the control and study groups underwent 45 minutes ischemia followed by 60 minutes reperfusion. In the study group, 10 mg/kg piperine was administered intraperitoneally just before the reperfusion procedure. Blood samples were obtained for measurement of lactate levels, and resection of the terminal ileum was performed to evaluate the histopathologic specimens and tissue malondialdehyde, superoxide dismutase, and glutathione activities. All results were expressed as mean±SD. Comparisons between groups were made by using the one way analysis of variance (ANOVA). RESULTS: Lactate and malondialdehyde levels were significantly higher in the control group than the study and sham groups (p<0.001). In the study group, superoxide dismutase, and glutathione activities were significantly higher than in the control group (p<0.001). The sham group had the highest activities. Histopathologic examination showed disruption of villous pattern and lamina propria in the control group. CONCLUSION: Intraperitoneal administration of 10 mg/kg piperine just before the reperfusion may reduce ischemia-reperfusion injury to the small intestine.

A huge solitary fibrous tumor localized in the pancreas: a young women.

CONTEXT: Solitary fibrous tumor is an uncommon spindle cell tumor which were first described in 1931 at pleura; it should be seen rarely in extra-pleural localization. CASE REPORT: We report the ninth case of pancreatic solitary fibrous tumor in a 24-year-old woman who presented with mild epigastric pain radiating to the back and chronic constipation. Imaging studies confirmed a solitary mass in the epigastric region that begins from posterior of stomach, fills little curvature and extends to pelvis, invades vascular structures by encircling them and extends to retroperitoneal regions that was considered as it may have mesenchymal origin. The patient underwent an enucleation of the mass which was diagnosed as solitary fibrous tumor, supported by immunohistochemical studies showing positivity for CD34, vimentin and SMA. CONCLUSION: There is limited data regarding biological behavior of solitary fibrous tumors with extra-pleural localization, because they are rare tumors. They are generally asymptomatic and slow growing tumors and it is difficult to distinguish them from other mesenchymal tumors. These issues as well as the prior nine cases are discussed.

Resection and radiofrequency ablation in the treatment of hepatocellular carcinoma: a single-center experience.

BACKGROUND: We have been utilizing both resection and laparoscopic radiofrequency ablation (RFA) to treat hepatocellular carcinoma (HCC). The aim of this study is to describe patient characteristics and outcome for each treatment modality from a single institution. METHODS: Medical records of HCC patients who underwent resection (n = 92) or laparoscopic (RFA) (n = 92) between 1997 and 2010 were reviewed. Univariate Kaplan-Meier and multivariate Cox proportional-hazards model were used to analyze survival. RESULTS: Patients with normal liver function and larger tumors were resected, and those with liver dysfunction, portal hypertension, and multiple tumors were ablated. Tumor size was larger in the Resection group, whereas number of tumors was higher in the RFA group. Child class and Barcelona Clinic Liver Cancer (BCLC) staging were more advanced in the RFA group. Hospital stay was longer, and morbidity and mortality higher in the Resection versus the RFA group. There was no difference in disease-free survival, but the 5-year actual survival was significantly higher (40% versus 21%) in the Resection group. On univariate analysis, number of tumors, tumor size, platelet count, BCLC stage, Child class, and type of surgery were predictors of overall survival. On multivariate analysis, Child class and number of tumors were independent predictors of overall survival. CONCLUSIONS: To our knowledge, this is the largest North American series reporting on RFA and resection for HCC from a single institution. Herein, we describe the perioperative and oncologic outcomes to be expected when these modalities are used in a certain treatment algorithm.

Multimodality treatment of neuroendocrine liver metastases.

BACKGROUND: Neuroendocrine liver metastases have a distinct tumor biology and symptomatology that render their management challenging. This difficulty is reflected in the literature, which lacks consensus on a treatment algorithm. The aim of this study is to propose a treatment algorithm based on patient morbidity and the efficacy of different treatment options. METHODS: The medical records of 127 patients with neuroendocrine liver metastases were reviewed. As first-line treatment, 69 of these patients underwent radiofrequency ablation (RFA), 29 patients were treated by liver resection, and 29 underwent embolization. Clinical characteristics and surgical parameters were analyzed with the chi-square test, and cumulative survival was analyzed with the Kaplan-Meier method. All data are expressed as mean ± standard error of the mean. RESULTS: Of the 3 treatment modalities, RFA was the most commonly used initial treatment for patients with up to approximately 16 discrete lesions. Resection was used to debulk large tumors of limited number. Embolization was the first-line treatment for more extensive disease not amenable to RFA or resection. RFA provided effective cytoreduction while affording patients a shorter duration of stay and lower complication rates. On univariate analysis, the size of dominant metastases, extrahepatic disease, resection of primary tumor, and treatment modality affected survival. On multivariate analysis, sex, the size of dominant metastases, and extrahepatic disease were independent predictors of survival. CONCLUSION: To our knowledge, this study is the largest report on a multimodality approach to the treatment of neuroendocrine liver metastases yet published in the literature. Because of the patient selection criteria used in our study, a direct comparison of the treatment arms is not strictly possible. We used an initial treatment algorithm based on the presentation of the patient. Because this disease has a multifocal nature and accompanying elevated recurrence rate, careful follow-up of patients and subsequent treatments are often needed to minimize disease burden.

Value of multislice computed tomography in the diagnosis of acute mesenteric ischemia.

OBJECTIVE: To define the value of multislice computed tomography (CT) in the diagnosis of acute mesenteric ischemia (AMI). MATERIALS AND METHODS: Two hundred patients (age range: 20-92 years) who were referred to the emergency CT department with a clinical suspicion of AMI were prospectively included in the study. CT examinations were performed with a multislice (16) CT scanner and the protocol included pre-contrast, arterial and venous phase acquisitions. Images were evaluated by using multiplanar reconstruction, maximum intensity projection and volume-rendering techniques at the CT workstation. RESULTS: Ninety-four patients (47%) underwent surgery for AMI or for other causes of acute abdominal pain. One hundred-six patients (53%) were followed conservatively according to clinical, radiologic and laboratory findings. Of the 94 patients who underwent surgery, 49 (25%) were found to have AMI. All of these 49 patients with a proven AMI diagnosis were diagnosed with CT. In the other 45 patients who underwent surgery, CT findings were negative for AMI. None of the patients, who were followed conservatively, were eventually diagnosed as having AMI except 1 patient. This patient was unfit for surgery although his clinical and radiologic findings were consistent with AMI and died in 3 days. The sensitivity and specificity values of CT for the detection of AMI were calculated to be 100% for each. CONCLUSIONS: Multislice CT is an effective imaging technique for the diagnosis of AMI with excellent sensitivity and specificity values.

Techniques of radiofrequency-assisted precoagulation in laparoscopic liver resection.

BACKGROUND: Although radiofrequency-assisted (RF) precoagulation has been described for open resections, there is little data evaluating precoagulation options in laparoscopic liver resection. The purpose of this study is to provide an algorithm for the use of monopolar and bipolar RF devices in laparoscopic liver resection. METHODS: Patients undergoing laparoscopic liver resection utilizing precoagulation during the period 2007-2009 were identified from a prospectively maintained, institutional review board-approved database. RF-assisted precoagulation was performed using a second-generation monopolar RF ablation catheter (Starburst XL, AngioDynamics) or bipolar RF device (Habib 4X, AngioDynamics). RESULTS: Precoagulation was utilized in 31cases (monopolar, n = 19, and bipolar, n = 12). Procedures performed included segmentectomy/wedge resection in 19 patients and bisegmentectomy in 12 patients. The bipolar RF device was used for left lateral sectionectomies (90%) in which there was linear transaction, whereas the monopolar RF catheter was used for nonlinear segmental and wedge resections involving the right lobe (95%). Time required for precoagulation was 22.5 ± 7.2 min for the bipolar and 33.6 ± 15.9 min for the monopolar device. No patient developed postoperative bleeding, bile duct injury, or liver abscess. At follow-up, one patient in the monopolar group developed a suspected local recurrence. CONCLUSIONS: We have suggested an algorithm to select a given device based on tumor location and type of resection. With approximately 30 min of time spent for precoagulation, the blood loss and rate of local recurrence were favorable. There also could be an oncologic benefit due to additional functional margin obtained with the RF effect.