Early and Long-Term Morbidity and Mortality Following Pancreaticoduodenectomy for Periampullary Tumors in Elderly Patients.

AIM: The growing elderly population is facing an increasing risk of cancers, consequently raising the pancreatic cancer surgery rate. This study aimed to determine whether advanced age is a risk factor for morbidity and mortality following pancreaticoduodenectomy (PD) for periampullary tumors. MATERIALS AND METHODS: The present study included 90 patients who underwent PD for periampullary tumors. Patients were divided into two age-related groups, including those aged 60-74 years (n = 60) (Group 1) and those aged ≥75 years (n = 30) (Group 2). Each patient's characteristics, perioperative features, morbidity, and long-term results were evaluated retrospectively. RESULTS: In both univariate and multivariate logistic regression analyses, old age (≥75 years) was not a risk factor for morbidity and hospital mortality. The multivariate analysis demonstrated that male gender (p = 0.008), pancreatic duct diameter (<3 mm) (p < 0.001), and length of hospital stay (p = 0.005) were independent risk factors for pancreatic fistula post-operation and reoperation. Additionally, hospital mortality was significantly associated with reoperation (p = 0.011). The overall median survival was 27 ± 4.1 (18.8-35.1) months. Lymph node positivity (p < 0.001), neural tumor invasion (p = 0.026), and age ≥75 years (p = 0.045) were risk factors affecting the overall survival rate. Moreover, there was no statistically significant difference in terms of PD rates during the Coronavirus disease-19 (COVID-19) period among groups, and PD during this period was not related to the occurrence of pancreatic fistula. CONCLUSION: PD can be performed effectively in selected elderly patients with tolerable morbidity and mortality rates.

Impact of positive-to-total lymph node ratio on prognosis in stage 3 colorectal cancer. A multicenter study.

BACKGROUND: Colorectal cancer remains a health problem despite advances in diagnostic and treatment methods. This study aimed to determine the impact of positive-to-total lymph node ratio on survival in colorectal cancer. METHODS: Patients with stage 3 colorectal cancer were included. Patients age; sex; operation type (emergency or elective); tumor size, grade, and location; TNM stage; vascular and perineural invasions; numbers of lymph nodes examined and negative lymph nodes, positive-to-total lymph node ratio, and administration of postoperative chemotherapy were examined. RESULTS: Median follow-up period was 34.7 months. Most patients were in stage 3b (67.9%), and the median number of dissected lymph nodes was 15. The number of metastatic lymph nodes, positive lymph node ratio, and negativeto- positive lymph node ratio were 3, 16.7, 11, and 5, respectively. The overall survival rate was 48.6%. Mean life expectancy was 51.5 months. Multivariate Cox regression analysis revealed positive-to-total lymph node ratio >23.3%, age, and absence of postoperative chemotherapy as risk factors for overall survival (p<0.05). Positive-to-total lymph node ratio >23.3% was associated with poor overall survival and 3.726-fold poorer survival. DISCUSSION: Positive-to-total lymph node ratio >23.3% is a risk factor affecting overall survival in stage 3 colorectal cancer. Increased positive-to-total lymph node ratio (>23.3%) is associated with poor overall survival. KEY WORDS: Colorectal Cancer, Overall Survival, Positive Lymph Node Ratio, Stage 3 Cancer.

Effect of the MiR-99b and MiR-135b on peritoneal carcinomatosis and liver metastasis in colorectal cancer.

AIM: This study aimed to evaluate the expression levels of miR-99b and miR-135b in peritoneal carcinoma and liver metastases associated with Colorectal Cancer (CRC), assess their association with the intracellular signaling pathway proteins Kirsten Rat Sarcoma Virus (KRAS) and Akt, and investigate their effects on survival. MATERIALS AND METHODS: Changes in the KRAS gene and Akt proteins, expression levels of miR-99b and miR-135b, and factors affecting survival were compared between colorectal cancer-associated peritoneal carcinomatosis and liver metastasis. RESULTS: The expression levels of miR-99b and miR-135b and the immunohistochemical grade classification score of Akt were higher in colorectal cancer, peritoneal carcinomatosis, and liver metastasis than in normal tissues (p < 0.05). MiR-99b expression was highest in CRC, whereas miR-135b expression was highest in peritoneal carcinomatosis (p < 0.05). The expression level of miR-99b decreased and that of miR-135b increased in peritoneal and liver metastases compared with that in the tumor tissue. MiR-99b, Akt, and recurrence were risk factors that affected the overall survival rate in the model of clinical predictions (p = 0.045, p = 0.006, and p = 0.012, respectively). CONCLUSION: While the expression of miR-99b was highest in the primary tumor, its decrease in liver metastasis and peritoneal carcinomatosis suggests that miR-99b has a protective effect against liver metastasis and peritoneal carcinomatosis. However, the detection of miR-135b expression was highest in peritoneal carcinomatosis and liver metastasis compared with that in the colorectal cancer tissues suggesting that it facilitates peritoneal carcinomatosis and liver metastasis. Furthermore, miR-99b, KRAS mutations, and Akt are risk factors for the overall survival of colorectal cancer.

Effect of tumor size on prognosis in colorectal cancer.

AIM: This study aimed to reveal the effect of tumor size on overall survival and disease-free survival. MATERIAL AND METHODS: This study retrospectively evaluated the data of 593 patients who underwent colorectal surgery for colorectal cancer (CRC) between May 2012 and December 2018. The patients were divided into two groups based on their tumor size; those with a tumor size <5 cm were grouped as group 1 and those with a tumor size ≥ 5 cm were grouped as group 2. RESULTS: The present study included 222 patients with colorectal adenocarcinoma. The median follow-up period of the patients was 36.0 (1.4-107.4) months, mean tumor size was 5.1±2.3 cm, and number of patients with a tumor size of ≥5 cm was 117 (52.7%). There were statistically significant differences between the groups in terms of overall survival (Log-Rank = 12.559, p<0.001). DISCUSSION: According to the American Joint Committee on Cancer's Cancer Staging Manual (8th edition), the CRC staging system considers the tumor's depth of invasion of the intestinal wall but not the tumor's size. Moreover, it considers the size of the tumors developing in the parenchymal organs (breasts and lungs) but not tumors developing in luminal organs (stomach, colon, etc.). CONCLUSIONS: Tumor size ≥5 cm was found to be a risk factor for poor prognosis. To a certain extent, we believe that this study will aid in elucidating the link between tumor size in and prognosis of patients with CRC. KEY WORDS: Colorectal cancer, Prognosis, Tumor size.

ANALYSIS OF DIAGNOSTIC EXCISIONAL LYMPH NODE BIOPSY RESULTS: 12-YEAR EXPERIENCE OF A SINGLE CENTER.

Lymph node biopsy is indicated in patients with suspected malignancy or lymphadenopathy due to unclarified reasons. Lymph node biopsy can be performed as fine needle aspiration biopsy, core biopsy, or excisional lymph node biopsy. In particular, the diagnosis of malignant lymphoma is considered insufficient for oncological treatment unless classified into subgroups. Core biopsy and excisional biopsy can be performed to diagnose lymphoma and classify it into subgroups. Core biopsy may also be limited in some cases for the diagnosis of lymphoma. Therefore, patients are referred to surgical departments for excisional lymph node biopsy. It was aimed herein to analyze the results of excisional lymph node biopsies performed for diagnostic purposes in our department. Data on 73 patients having undergone diagnostic excisional lymph node biopsy at Sakarya University Medical Faculty Training and Research Hospital between January 2008 and January 2020 were retrospectively analyzed. Patients were evaluated in terms of age, gender, biopsy site, pathological diagnosis, number and diameter of lymph nodes excised. Patients younger than 18 years of age, those with sentinel lymph node biopsies, and lymph node dissections performed for any known malignancy were excluded from the study. Statistical data analysis was done using SPSS statistical software. There were 37 (50.7%) female and 36 (49.3%) male patients, mean age 52.07 (18-90) years. Axillary lymph node biopsy was performed in 32 patients, inguinal lymph node biopsy in 29 patients, cervical lymph node biopsy in 3 patients, intra-abdominal lymph node biopsy in 6 patients, mediastinal lymph node biopsy in 1 patient, and supraclavicular lymph node biopsy in 2 patients. All of the lymph node biopsies were performed as excisional biopsy. Malignancy was detected in 36 (49.3%) patients. In 37 (50.3%) patients, the causes of lymphadenopathy were found to be benign pathologies. When the causes of malignant disease were examined, it was observed that 23 (31.5%) patients were diagnosed with lymphoma. Hodgkin lymphoma was detected in 5 patients diagnosed with lymphoma, and non-Hodgkin lymphoma was found in 18 patients. Metastatic lymphadenopathy was observed in 13 (17.8%) patients. Reactive lymphoid hyperplasia (26%) and lymphadenitis (20.5%) were found among the causes of benign lymphadenopathy. The number of excised lymph nodes was between 1 and 4, and their diameter was between 9 and 75 mm (mean: 29.53±15.56 mm). There was no statistically significant difference between benign and malignant patients according to gender, age, lymph node diameter, number of lymph nodes excised, and excisional lymph node biopsy site. For diagnostic lymph node biopsy, fine-needle aspiration biopsy and core biopsy should be performed primarily. If lymphoma is suspected in the diagnosis, fine-needle aspiration biopsy is not necessary. In this case, it is believed that it is more appropriate to perform core biopsy first. If the core biopsy is insufficient for diagnosis, it is more appropriate to perform surgical biopsy in order to cause no delay in diagnosis and treatment. Excisional biopsy is a method that can be safely performed and does not cause severe morbidity in palpable peripheral lymphadenopathies. Although it does not cause severe morbidity because it is an invasive procedure, excisional biopsy should be performed in a selected patient group.

Effect of the MiR-99b and MiR-135b on peritoneal carcinomatosis and liver metastasis in colorectal cancer

Abstract Aim This study aimed to evaluate the expression levels of miR-99b and miR-135b in peritoneal carcinoma and liver metastases associated with Colorectal Cancer (CRC), assess their association with the intracellular signaling pathway proteins Kirsten Rat Sarcoma Virus (KRAS) and Akt, and investigate their effects on survival. Materials and methods Changes in the KRAS gene and Akt proteins, expression levels of miR-99b and miR-135b, and factors affecting survival were compared between colorectal cancer-associated peritoneal carcinomatosis and liver metastasis. Results The expression levels of miR-99b and miR-135b and the immunohistochemical grade classification score of Akt were higher in colorectal cancer, peritoneal carcinomatosis, and liver metastasis than in normal tissues (p< 0.05). MiR-99b expression was highest in CRC, whereas miR-135b expression was highest in peritoneal carcinomatosis (p< 0.05). The expression level of miR-99b decreased and that of miR-135b increased in peritoneal and liver metastases compared with that in the tumor tissue. MiR-99b, Akt, and recurrence were risk factors that affected the overall survival rate in the model of clinical predictions (p= 0.045, p= 0.006, and p= 0.012, respectively). Conclusion While the expression of miR-99b was highest in the primary tumor, its decrease in liver metastasis and peritoneal carcinomatosis suggests that miR-99b has a protective effect against liver metastasis and peritoneal carcinomatosis. However, the detection of miR-135b expression was highest in peritoneal carcinomatosis and liver metastasis compared with that in the colorectal cancer tissues suggesting that it facilitates peritoneal carcinomatosis and liver metastasis. Furthermore, miR-99b, KRAS mutations, and Akt are risk factors for the overall survival of colorectal cancer.

Effects of preoperative biliary drainage methods and time to postoperative complications after biliary drainage in periampullary tumors.

OBJECTIVE: To compare postoperative morbidity and mortality results in patients with and without endoscopic and percutaneous transhepatic biliary drainage due to obstructive jaundice caused by a periampullary tumor and to examine the effect of intervals until surgery on postoperative morbidity and mortality in patients who underwent preoperative biliary drainage (BD). METHODS: Patients were divided into 3 groups according to their BD status. Group1, no biliary drainage (NBD), Group2, Endoscopic biliary drainage (EBD), Group3, Percutaneous transhepatic biliary drainage (PBD). Patients who underwent biliary drainage before pancreaticoduodenectomy (PD) were divided into 3 intervals according to the time interval between drainage and surgery: Short interval; patients undergoing surgery in 21 days and <, Medium interval; between 22-42 days, Long interval; 43 days and >. Groups and intervals were compared in terms of postoperative morbidity and mortality. RESULTS: Of the 122 patients who underwent PD, 76 (62.3%) were male, and 46 (37.7%) were female. Within these patients, 47 (38.52%) had NPD, 42 (34.42%) had EBD, and 33 (27.05%) had PBD. The rate of postoperative Grade B and C fistula was higher in the groups that underwent preoperative drainage compared to the group without preoperative drainage (p = 0.007). CONCLUSION: It was determined that the postoperative complication rate was lower in patients who did not undergo BD compared to patients who underwent biliary drainage. Besides, the endoscopic drainage method was observed to be associated with fewer complications than the percutaneous transhepatic drainage method. KEY WORDS: Preoperative biliary drainage, Pancreaticoduodenectomy, Periampullary tumors, Post procedure complication, Timing.

The role of hematological parameters in distinguishing acute appendicitis from lymphoid hyperplasia.

BACKGROUND: One of the most misdiagnosed appendicular pathologies is lymphoid hyperplasia (LH) that can be managed con-servatively when identified early and is self-limiting. The aim of this retrospective study was to compare acute appendicitis (AA) with LH in terms of hematological parameters to determine whether there is a hematological predictor to distinguish the two diseases. METHODS: Complete blood cell counts of patients with AA were compared with those having LH. RESULTS: One-hundred-ninety-five patients (118 male/77 female) underwent appendectomy. Histopathological examination re-vealed acute AA in 161 patients (82.6%), and negative appendectomy (NA) in 19 patients (9.7%). Of the NA specimens, 16 were LH (8.2%). Thirteen patients (6.7%) had AA with simultaneous LH. White blood cell count (p=0.030, neutrophil (p=0.009), neutrophil per-centage (p=0.009), and neutrophil/lymphocyte ratio (p=0.007) were significantly higher in AA whereas lymphocyte count (p=0.027), lymphocyte percentage (p=0.006) were significantly higher in LH. Multi logistic regression analysis revealed white blood cell count as the only independent predictor in distinguishing AA from LH with a 69.1% sensitivity, 80.0% specificity, 77.5% positive predictive value, and 72.1% negative predictive value. The cut-off value for white blood cell count was 11.3 Ku/L, and every one unit (1000/mm3) increase in white blood cell count raises the risk of AA by 1.24 times, while values below this value will increase the likelihood of LH. CONCLUSION: The most predictive complete blood count parameter in distinguishing LH from AA appears to be as white blood cell count.

Morbidity and long-term results in patients with wild and mutant type Kirsten rat sarcoma viral oncogene homolog (KRAS) mutations undergoing colorectal cancer surgery.

BACKGROUND: In colorectal cancer (CRC), the mutation of the K(N)RAS gene has a significant impact on the clinical course, and is associated with a negative prognosis. We aim to present the morbidity and long-term results in patients with wild/mut-K(N)RAS, undergoing CRC surgery. METHODS: A total of 116 patients who underwent surgery for colorectal cancers with wild/mut-K(N)RAS were included in this retrospective study. The patients were divided into two groups: wild-K(N)RAS patients (Group 1) and mutant- K(N)RAS patients (Group 2). Results were evaluated for clinical, operative, morbidity and long-term survival outcomes. MATERIALS AND METHODS: The highest surgical site infection (SSI) rate (OR=140.339)(4.303-4581.307)(P=0.005) was seen in patients given Bevacizumab during neoadjuvant treatment. Meanwhile, the SSI site infection rate was at its lowest in cases where minimally invasive surgery was preferred (OR=0.062)(0.006-0.628)(P=0.019). In addition, the overall median survival rate for the total cohort was 38±3.1 (31-44) months. Multivariate analysis showed that CEA (>5ng/mL)(HR 2.94)(1.337-6.492))(P=0.007); tumor stage (P=0.034), T(T4) stage (HR 1.91)(1.605-252.6)(P=0.02); metastasectomy/ablation (HR 0.19)(0.077-0.520)(P=0.001); the number of removed metastatic lymph nodes (HR 1.08)(1.010-1.155)(P=0.025); tumor implant or nodule (HR 2.71)(1.102-6.706)(P=0.03); curative resection (HR 2.40)(0.878-6.580)(P=0.042) to be factors affecting the overall survival rate. CONCLUSION: Treatment with Bevacizumab during the neoadjuvant period in mut-K(N)RAS cases, surgical technique and complications of Grade 3 or higher are risk factors for SSI on morbidity in patients with mut/wild-K(N)RAS undergoing colorectal cancer surgery. Moreover, CEA (>5ng/mL), tumor stage, T stage, metastasectomy/ablation, the number of removed metastatic lymph nodes, tumor implant/nodule and curative resection are risk factors on the overall survival rate. KEY WORDS: Bevacizumab, Colorectal cancer, K(N)RAS mutation, Morbidity, Mortality.

An extensive pyoderma gangrenosum mimicking necrotizing fasciitis: An unusual case report.

INTRODUCTION: Pyoderma Gangrenosum (PG) is a rare, benign and inflammatory disease characterized by ulcerative skin lesions. We report the successful management of an unusual case of PG following a caesarean section, with extensive cutaneous skin involvement and mimicking necrotizing fasciitis. PRESENTATION OF CASE: A 36-year-old woman was admitted with extensive surgical site inflammation after a caesarean section. Despite antibiotic treatment and wound care, the clinical course deteriorated rapidly. Wound debridement following negative pressure closure was performed due to an immediate increase in skin necrosis. A diagnosis of PG was reached based on the absence of a positive wound culture, resistance to wound debridement and the histopathological results. A course of high-dose corticosteroids was started, and a successful clinical course was finally achieved. The patient is now in the 14th month of remission, with no recurrence. DISCUSSION: PG is often reported after bowel surgery, especially after complicated stoma or diverticulitis, breast surgery and occasionally after C-sections. The diagnosis of pyoderma gangrenosum may be challenging because of a wide variety of macroscopic features and its pronounced similarity to necrotizing fasciitis. Treatment with systemic corticosteroids is the most common management option, while surgical treatment is extremely controversial. CONCLUSION: An extensive PG following surgery can mimic necrotizing fasciitis. An interdisciplinary treatment approach provides early diagnosis and effective treatment resulting in less morbidity.

Sclerosing angiomatoid nodular transformation presenting with thrombocytopenia after laparoscopic splenectomy - Case report and systematic review of 230 patients.

BACKGROUND: Sclerosing angiomatoid vascular transformation (SANT) is a rare vascular disease of the spleen, which is difficult to diagnose due to its pre-intervention appearance of malignancy. Case Report: An 85-year-old male was transferred to our clinic for thrombocytopenia and splenic mass. A contrast enhanced abdominal CT and MRI showed nodular lesions, the largest 50mm in diameter, and several areas of heterogeneous contrast field involvement in the spleen parenchyma. Laparoscopic splenectomy was performed with normal range of platelet level. The patient's postoperative course was uneventful and he was discharged on the 6th postoperative day. Histopathology revealed SANT. The patient is now in the 18 th month of remission with platelet levels within normal range and with no recurrence. RESULTS: Between 2004 and April 2020, a total of 230 SANT patients who underwent laparoscopic or open splenectomy or biopsy were reported in the literature. Most patients were female (52.1%), and the median age was 46 years (9 weeks-85 years). Most patients were asymptomatic (56%). Open splenectomy was performed on 166 patients (72.1%),laparoscopic splenectomy on 35 patients (15.2%) and laparoscopic partial splenectomy on 15 patients (6.5%). The median operation time and spleen weight were 143 minutes (88-213) and 260gr (68-2,720), respectively. Median follow-up time was 12 months (0-166). No recurrence was seen in patients undergoing total splenectomy. CONCLUSION: SANT is an unusual disease of the spleen. In the light of this systematic review, a minimally invasive method for total or partial splenectomy,specifically laparoscopy, can be preferred as the treatment of choice.

Reasons for Undesirable Pregnancy Outcomes among Women with Appendicitis: The Experience of a Tertiary Center.

BACKGROUND: Although laparoscopic appendectomy increases its popularity today, the answer to the question of whether to perform open or laparoscopic appendectomy during pregnancy is appropriate in many studies, and the choice of surgery depends on the surgeon. Herein, we aimed to evaluate the variables that affect undesirable pregnancy outcomes that occur as a result of appendicitis during pregnancy. METHODS: Seventy-eight pregnant patients with acute appendicitis who underwent laparoscopic or open technique intervention enrolled in this retrospective study. In addition to the demographic structure of the patients, surgical technique, the number of pregnancies, multiple pregnancy status, surgical pathologies, laboratory values, radiological imaging methods, and length of hospital stay were evaluated. The severity of appendicitis was classified according to the pathology results. The patients were divided into two groups according to the outcomes of their pregnancy. Preterm delivery and abortion involved in the study as a single complication section. RESULTS: The mean age of the pregnant patients was 28.6 ± 5. Of the 78 pregnant women with appendicitis, 47.4% had their first pregnancy, 37.2% had their second pregnancy, and 15.4% had 3 or more pregnancies. The preterm delivery and abortus were 19.5% in the open appendectomy (OA) group and 16.2% in the laparoscopic appendectomy (LA) group. No statistically significant difference was detected in this group in terms of appendicitis pathology triggering preterm delivery or abortion (p 0.075). When white blood count (WBC) and C-reactive protein (CRP) were evaluated by laboratory findings, CRP was found to be statistically significantly higher in patients with preterm birth (p 0.042). CONCLUSION: Consequently, acute appendicitis may cause serious intra-abdominal infection and inflammation in addition to the complexity of the diagnosis due to the nature of pregnancy, as well as undesired pregnancy outcomes with the surgical technique, or independently with other variables.

Intraoperative hemorrhage and increased spleen volume are risk factors for conversion to open surgery in patients undergoing elective robotic and laparoscopic splenectomy.

OBJECTIVES: Minimal invasive surgery is one of the most popular treatment approaches which is safe and effective in experienced hands in different clinical practices. In the present study, we aimed to evaluate the risks factors for conversion to open splenectomy and the performance of indirect hilum dissection technique. MATERIAL AND METHODS: A total of 56 patients who underwent laparoscopic or robotic splenectomy for isolated spleen diseases were included into the study. Patients were divided into two groups as robotic or laparoscopic splenectomy (Group 1; n= 48) and conversion to open surgery (Group 2; n= 8). Patients were retrospectively evaluated according to clinical, biochemical, hematological and microbiological parameters and morbidity. RESULTS: No statistically significant difference was found between the groups in terms of age, gender, body mass index (BMI), ASA score, co-morbid disease, operation time, hospital stay, follow-up period, accessory spleen, diagnosis, international normalized ratio (INR), red cell distribution width (RDW), platelet distribution width (PDW), platelet to lymphocyte ratio (PLR), neutrophil to lymphocyte ratio (NLR), reapplication, splenosis, surgical site infection, vascular thrombus and incisional hernia (p> 0.05). On the other hand, intraoperative splenic hilum hemorrhage and increased spleen size (p <0.05) were higher in the conversion to open surgery group. In logistic regression analysis, intraoperative splenic hilum hemorrhage (B= 4.127) (OR= 61.974) (95% CI= 3.913-981.454) (p= 0.003) and increased spleen volume (B= 3.114) (OR= 22.509) (95% CI= 1.818-278.714) (p= 0.015) were found as risk factors for conversion to open surgery. CONCLUSION: Intraoperative hemorrhage from the splenic hilum and increased spleen volume (> 400 cm3) are risk factors for conversion to open splenectomy in patients undergoing elective robotic or laparoscopic splenectomy. Indirect splenic hilum dissection can decrease intraoperative hemorrhage and conversion to open surgery.

Colonic metastasis of renal cell carcinoma following curative nephrectomy: A case report and review of the literature.

INTRODUCTION: Renal cell carcinoma (RCC) is a rare tumor that comprises only 3% of adult cancers, while renal parenchymal tumors constitute 85% of all RCC cases. RCC frequently metastasizes to the lungs, bones, brain or liver; however, the gastrointestinal tract, particularly the colon, is an unusual location for metastasis. CASE REPORT: A 63-year-old male patient was admitted complaining of hematochezia. The patient had undergone left-side nephrectomy for RCC, 5 years previously. Computed tomography and colonoscopy detected a splenic flexure tumor and after left hemicolectomy and splenectomy, histopathological examination revealed a colonic metastasis of the renal cell carcinoma. DISCUSSION: Cases of colonic metastasis following resection of a RCC are uncommon in the literature and their location can be very varied, but include the sigmoid colon, splenic flexure, transvers colon and hepatic flexure. Recurrence of RCC is frequently seen during the first three postoperative years, and surgical resection is suggested for solitary non-metastatic tumor. CONCLUSION: RCC rarely metastases to the colon but may occur years after curative resection. Therefore, RCC patients should be closely followed for the long term. In case of isolated metastasis, long-term survival can be achieved with R0 resection.

Early laparoscopic cholecystectomy is associated with less risk of complications after the removal of common bile duct stones by endoscopic retrograde cholangiopancreatography.

BACKGROUND/AIMS: Several studies recommend prompt laparoscopic cholecystectomy (LC) following endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis. However, histopathological alterations in the gallbladder during this time interval and the role played by ERCP in causing these changes have not been sufficiently elucidated. To compare early period LCs with delayed LCs following common bile duct stone extraction via ERCP with regard to operation time, hospitalization period, conversion to open cholecystectomy rate, morbidity, mortality, and histopathological alterations in the gallbladder wall. MATERIALS AND METHODS: A total of 85 patients were retrospectively divided into three groups: early period LC group (48-72 h; n=30), moderate period LC group (72 h-6 weeks; n=25), and delayed period LC group (6-8 weeks; n=30). RESULTS: The operation time was significantly shorter, and the total number of complication rates and hospital readmission was significantly less frequent in the early period LC group (p<0.05). Ultrasound showed a significantly thicker gallbladder wall (>3 mm) in the moderate and late period LC groups than in the early period LC group (p<0.001). Culture growth was significantly higher, and fibrosis/collagen deposition in the gallbladder wall with injury to the mucosal epithelium was significantly more frequently detected by histopathological examination in the moderate and late period LC groups than in the early period LC group (p<0.05). CONCLUSION: Early period LC following stone extraction by ERCP is associated with shorter operation time, fewer fibrotic changes in the gallbladder, and lower risk for the development of complications. Therefore, LC can be performed safely in the early period after ERCP.

Risk factors for morbidity in walled-off pancreatic necrosis and performance of continuous postoperative lavage: A single-center experience.

BACKGROUND: The aim of this study was to evaluate the risk factors for morbidity in cases of walled-off pancreatic necrosis (WOPN) and the performance of continuous postoperative lavage (CPL) for patients who demonstrated resistance to a minimally invasive approach. METHODS: The study enrolled 19 of 28 consecutive patients with WOPN who underwent surgical treatment or an endoscopic necrosectomy at Sakarya University Education and Research Hospital. The patients were divided into 2 groups according to the length of time from the first diagnosis of acute pancreatitis (AP) (Group 1, n=19) to preoperation or endoscopic necrosectomy (Group 2) (n=19). All of the cases were retrospectively evaluated and compared in terms of demographic features, operative features, and complications. RESULTS: No statistically significant difference was found between the number of complications or the duration of hospital stay in terms of age, body mass index, size of the walled-off pancreatic necrosis, American Society of Anesthesiologists score, Ranson's criteria, operation time, and duration from AP to endoscopic necrosectomy or operation (p>0.05). Performance of an endoscopic necrosectomy was determined to be correlated with a decrease in the number of complications (B=-0.626, 95% confidence interval [CI]: -0.956 to -0.296; p<0.001), and when a high neutrophil-to-lymphocyte ratio (NLR) was detected at first admission, the number of complications was greater (B=0.032, 95% CI: 0.009-0.055; p=0.01). Reproduction in a culture and male gender were found to be risk factors for a prolonged hospital stay (B=0.669, 95% CI: 0.365-0.973; p<0.001), (B=0.484, 95% CI: 0.190-0.778; p=0.003), respectively. CONCLUSION: CPL is a safe and effective surgical treatment approach for WOPN. Reproduction in a culture, male gender, and a high NLR on first admission and a negative or not-available endoscopic necrosectomy were determined to be risk factors for a poor prognosis.

Porto-mesenteric venous thrombosis after laparoscopic sleeve gastrectomy: A case report and systematic review of the 104 cases.

INTRODUCTION: Porto-mesenteric venous thrombosis (PMVT) is a rare but fatal complication after bariatric surgery. However, an increasing number of PMVT complications have been observed in the last years after laparoscopic sleeve gastrectomy (LSG) operations. CASE REPORT: A 35-year-old male was admitted to the emergency clinic in a septic status with a sudden once of abdominal pain and vomiting. The patient underwent laparoscopic sleeve gastrectomy (LSG) 15 days ago. His physical examination revealed diffuse abdominal tenderness. Abdominal computerised tomography showed a thrombus which was elongated from vena mesenterica superior to vena porta. An emergent laparotomy was performed. A 40 cm of ischemic small bowel segment which began at the 60th cm of Treitz ligament was resected. The gastrointestinal continuity was provided by an end-to-end anastomosis. Patient's postoperative course was uneventful. He was discharged on the 7th postoperative day and was medicated on oral anticoagulation (Warfarin 5 mg/day) for six months. RESULTS: A total of 104 morbidly obese patients who developed PMVT after bariatric surgery are reported in the English literature between 2004 and April 2017. Most of the patients were female (63 cases, 60.5%). The median age was 42.5 years (14-68) and the median body mass index (BMI) was 44 kg/m2 (31.8-74.6). The most common cause of coagulopathy disorders was protein C and/or S deficiency (9.6%) followed by prothrombin gene mutation (6.7%). LSG was performed in 83 patients (78.8%) and the median intraoperative pressure was 15 mmHg (14-20). The median operation time was 70 min (min-max: 37-192). Fifty-five patients (52.8%) underwent preoperative oral anticoagulant prophylaxis. The median time for PMVT development was 14 days (min-max: 1-453). Of the 104 patients with PMVT, 75 cases (72.1%) underwent postoperative anticoagulant agents such as low-molecular weight heparin (LMWH), heparin drip or infusion, streptokinase or warfarin, whereas the remaining did not receive prophylactic medication. CONCLUSION: PMVT after sleeve gastrectomy is a rare but fatal complication. Therefore, anti-coagulation prophylaxis with LMWH should be considered at least one month postoperatively.

Comparison of open appendectomy and laparoscopic appendectomy with laparoscopic intracorporeal knotting and glove endobag techniques: A prospective observational study.

OBJECTIVE: Despite the recent increase in the use of laparoscopic appendectomy procedures to treat acute appendicitis, laparoscopic appendectomy is not necessarily the best treatment modality. The aim of this study is to examine the value of laparoscopic intracorporeal knotting and glove endobag in terms of various parameters and in terms of reducing the costs related to laparoscopic appendectomy procedures. MATERIAL AND METHODS: Seventy-two acute appendicitis patients who underwent laparoscopic appendectomy and open appendectomy surgery were enrolled in the study and were evaluated prospectively. The patients were divided into two groups: group 1 was treated with laparoscopic appendectomy using laparoscopic intracorpreal knotting and glove endobag (n=36) and group 2 was treated with open appendectomy (n=36). The two groups were statistically compared in terms of preoperative symptoms and signs, laboratory and imaging findings, operation time and technique, pain score, gas and stool outputs, duration of hospital stay, return to normal activity, and complications. RESULTS: No statistically significant differences were found between the groups in relation to gender, age, body mass index, or pre-operation findings, which included loss of appetite, vomiting, time when pain started, displacement of pain, defense, rebound, imaging methods, and laboratory and pathology examinations (p>0.05). Moreover, there were no differences between the groups with respect to drain usage, hospital stay time, or complications (p>0.05). In contrast, a statistically significant difference was found between the groups in terms of operation time, pain scores, gas-stool outputs, and return to normal activity in the laparoscopic appendectomy group (p=0.001). CONCLUSION: Laparoscopic appendectomy can be performed in a facile, safe, and cost-effective manner with laparoscopic intracorporeal knotting and glove endobag. By using these techniques, the use of expensive instruments can be avoided when performing laparoscopic appendectomy.

A Preventive Strategy for Staple Line Bleeding in Morbidly Obese Patients Undergoing Sleeve Gastrectomy.

BACKGROUND: Risk factors for staple line bleeding (SLB) during and after sleeve gastrectomy (SG) are various, including patient related factors, perioperative medications, and surgical technique, although there is little clarification in the literature of the role played by blood pressure during the stapling phase. The aim of the present retrospective cohort study was to identify possible risk factors liable to cause SLB. MATERIALS AND METHODS: Data collected prospectively from 120 consecutive patients who underwent SG were analyzed retrospectively according to age, gender, body mass index (BMI), international normalized ratio (INR) value, intraoperative systolic blood pressure (SBP), and mean arterial blood pressure (MABP). RESULTS: In univariate analysis, age, stapling phase SBP and MABP, and the duration of surgery were all significantly higher in patients with SLB than those without (P < .05). In distinguishing patients with SLB from those without, the cutoff threshold for SBP during the stapling phase was 120 mmHg with a 78.9% sensitivity, 97.6% specificity, 93.8% positive predictive value, 90.9% negative predictive value, and 91.7% accuracy (AUC = 0.908, 95% CI: 0.839-0.976, and P < .001). In multivariate logistic regression analysis, independent of age and operation time, SBP >120 mmHg significantly maintained its predictive power on SLB (95% CI: 32.410-1457.896, P < .001). CONCLUSION: A SBP >120 mmHg during the division of the stomach is an independent risk factor for SLB. Maintaining intraoperative SBP ≤120 mmHg during the stapling phase does not only decrease the risk of SLB but also the need for homeostatic agents such as clips and sutures, which in turn prolong the operative time and increase cost.

Neutrophil/Lymphocyte and Platelet/Lymphocyte Ratios are Not Different among Breast Cancer Subtypes

Background: Breast cancer is a heterogeneous complex of diseases comprising different subtypes that have different treatment responses and clinical outcomes. Systemic inflammation is known to be associated with poor prognosis in many types of cancer. The neutrophil / lymphocyte ratio (NLR) and platelet / lymphocyte ratio (PLR) are factors used as indicators of inflammation. In this study, we evaluated NLR and PLR ratios in breast cancer subtypes. Methods: A total of 255 breast cancer patients were evaluated retrospectively. Patients were classified into three subtypes: estrogen receptor (ER)- or progesterone receptor (PR)-positive tumors were classified as luminal tumors; human epidermal growth factor receptor-2 (HER2)-overexpressed and ER-negative tumors were classified as HER2-positive tumors; and ER, PR, and HER2-negative tumors were classified as triple-negative tumors. The NLR and PLR were calculated. Results: The median NLR and PLR were 3 (0.37­37,1) and 137 (37.1­421.3), respectively. 66.7% of the patients were luminal type, 19.2% were HER2 positive, and 14.1% were triple negative. NLR was not associated with grade (p: 0.412), lymphovascular invasion (p: 0.326), tumor size (p: 0.232) and metastatic lymph node involvement (p: 0.406). PLR was higher in the patients with lymph node metastasis than in those without lymph node metastasis (p: 0.03). The NLR was 2 in the luminal group, 1.8 in the HER2-positive group, and 1.9 in the triple-negative group, but the differences were not significant(p: 0.051). PLR was 141 in the luminal group, 136 in the HER2-positive group, and 130 in the triple-negative group, but the differences were not significant. Conclusion: We could not find any significant differences for NLR and PLR according to breast cancer subtypes.