What Value of Sixth Month Excess Weight Loss (Postsleeve Gastrectomy) Is Necessary for Better Sleep Quality?

BACKGROUND: Obesity, caused by caloric intake over output, is a global health problem. The relationship between sleep and obesity is discussed in the literature. Little is known about the compliance of sleep quality and patients' weight loss. This study aimed to review how sleep quality is affected by bariatric surgery, assess whether compliance with sleep quality can be predicted after bariatric surgery, and establish its correlation with excess weight loss. METHODS: A cross-sectional study was conducted for patients undergoing bariatric surgery (laparoscopic sleeve gastrectomy). Sleep quality was assessed with the Pittsburgh sleep quality index (PSQI) scale preoperatively and in the sixth postoperative month. A PSQI global score above 5 indicated poor sleep quality. Participants were divided into 2 groups: good and poor sleep quality. Receiver operating characteristics and logistic regression analysis were also performed to predict sleep quality. RESULTS: The questionnaire was completed by 100 subjects. All PSQI components, except the sixth (sleep medication) component, improved in patients at the sixth postoperative month versus baseline values. In the receiver operating characteristic analysis to test the availability of excess weight loss (EWL%) cutoff values relative to predict successful sleepers, 65.1 of the sixth month EWL% was found for the diagnosis of successful sleeper patients with 72.6% sensitivity and 63% specificity (area under the curve: 0.706, P =0.002, 95% CI, 0.586 to 0.825). CONCLUSIONS: For patients undergoing weight loss surgery, while assessing the sixth postoperative month, the EWL% value over 65.1 was recommended for better sleep quality.

Enhanced Recovery After Surgery Promotes Recovery in Sleeve Gastrectomy: A Randomized Controlled Trial.

Introduction: The most popular approach for treating obesity is laparoscopic sleeve gastrectomy (LSG). The enhanced recovery after surgery (ERAS) protocol aims to reduce the patient's surgical stress response, optimize their physiological function, and facilitate recovery. The purpose of this study was to investigate the efficacy and safety of the ERAS protocol in patients who have undergone LSG. Methods: Between January 2020 and March 2021, a single-center randomized controlled study with patients undergoing LSG was planned. Patient demographics, duration of surgery and anesthetic induction, postoperative nausea-vomiting (PONV) and pain scores, length of hospital stay, and emergency room readmissions within the first 30 days were also documented. Patients were divided into two groups: those who followed the ERAS protocol and those who did not. The senior surgeon was blinded for the preoperative and postoperative period, whereas the other surgeon was not. The groups were compared in terms of length of hospital stay, duration of surgery, visual analog scale (VAS) scores, PONV effect scores, and emergency service admissions within the first 30 days after surgery. Results: A total of 96 patients were included in this study. Of these, 49 were in the ERAS protocol group and 47 were in the traditional treatment group. The mean age of the patients in the ERAS and traditional treatment groups were 37.47 ± 10.11 years and 35.77 ± 9.62 years, respectively. While the ERAS group patients were hospitalized for a mean of 30.46 ± 11.26 hours, the traditional group patients were hospitalized for 52.02 ± 6.63 hours (P: .001). There was no difference between the groups in terms of the first 30-day readmission to the emergency department (P: .498). Both VAS and PONV effect scores at the 2nd and 12th hours of the ERAS group patients were lower (P: .001, .002, .001, .001, respectively). Conclusions: When compared with the conventional method, the ERAS protocol reduced patient hospitalization time, decreased postoperative nausea, vomiting, and pain scores, and did not vary in postoperative emergency department readmissions. In patients receiving LSG, the ERAS protocol can be employed safely and successfully. Clinical Trial Registration number: NCT04442568.

The role of leukocytes in predicting whether laparotomy is required in patients with penetrating abdominal stab wound.

BACKGROUND: This study aimed to determine the importance of leukocytes, leukocyte subgroups, platelets, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio in deciding whether laparotomy is required during observation in patients with penetrating abdominal stab wounds who were followed up because there was no indication for an emergency laparotomy. METHODS: Patients who did not indicate an emergency laparotomy were monitored. After 48 hours from initial hospitalization, patients who did not require laparotomy were discharged nonoperatively. The total leukocytes, leukocyte subsets, platelets, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio of patients who underwent laparotomy during the follow-up compared with those who were discharged nonoperatively. The sensitivity and specificity of these laboratory values in predicting the necessity of laparotomy were calculated. RESULTS: In the operated group (n = 71), leukocytes, neutrophils, monocytes, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio examined during observation were significantly higher (P < .001). Eosinophils and lymphocytes were significantly lower (P < .001) than in nonoperated (n = 476). Based on the deviation in the reference ranges of leukocyte and its subgroups, we report the sensitivity and specificity for predicting the necessity of laparotomy as 86% and 72% for leukocyte, 88% and 75% for neutrophil, 92% and 83% for neutrophil-to-lymphocyte ratio, and 72% and 77% for platelet-to-lymphocyte ratio, respectively. In receiver operating characteristic curve analysis, the cut-off value was found to be 4 for neutrophil-to-lymphocyte ratio and 125 for platelet-to-lymphocyte ratio (area under the curve/receiver operating characteristic curve of 0.929 and 0.808, respectively). CONCLUSION: Leukocyte, leukocyte subgroups, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio may be useful to determine if a laparotomy is necessary in patients in whom the necessity of laparotomy is undetermined owing to unclear examination findings.

Relationship between monocyte-to-high-density lipoprotein cholesterol ratio and excess weight loss in laparoscopic sleeve gastrectomy.

Aim: The present study evaluates the relationship between the monocyte-to-high-density lipoprotein cholesterol ratio (MHR) and the percentage of excess weight loss (%EWL) in patients undergoing laparoscopic sleeve gastrectomy. Method: This prospective cohort study evaluated 125 patients who underwent laparoscopic sleeve gastrectomy. The MHR before and at 6 months after surgery were compared in patients with <50 and ≥50 %EWL. Results: The MHR was lower in patients with a %EWL of <50 than in patients with a %EWL of ≥50 (p = 0.019). The decrease in the MHR at postoperative 6 months was more remarkable in patients with a %EWL of ≥50 (p < 0.001). Conclusion: The present study suggests that MHR decreased more remarkably at postoperative 6 months in patients with high %EWL, predicting a decrease in cardiovascular risk.

Lay abstract The primary focus of laparoscopic sleeve gastrectomy is to achieve sufficient weight loss to reduce cardiovascular events while minimizing surgical morbidity. The present study found a significant relationship between the percentage of excess weight loss and monocyte-to-high-density lipoprotein cholesterol ratio (MHR), the decrease in MHR being more remarkable with increasing excess weight loss and mostly attributable to the monocyte component. MHR can be used as a marker of atherosclerosis to monitor patients if they have achieved a reduction in cardiovascular risks. Monocyte count can be used as a simple substitute in conditions where MHR is not readily available.

Is the increased incidence of pathologically proven acute appendicitis more likely seen in elderly patients? A retrospective cohort study.

AIM: Although appendicitis is a disease of the young, it has been speculated that its incidence has increased among the elderly people. In this study, it was aimed to evaluate annual changes of appendicitis seen in older patients (≥60 years) throughout a 10-year period. METHODS: All adult patients who were surgically treated for acute appendicitis were retrospectively analyzed with respect to pathological analysis, gender, age and proportion of the patients aged 60 or over in an annual base. Variability in the mean age and proportion of the older patients aged 60 or over throughout the study years were regarded as the main outcomes. RESULTS: There were 3296 patients with a mean age of 30.42 ± 12 years. Distribution of gender was similar (p = 0.636). There was a significant positive correlation in the mean age of the patients throughout the study years (p = 0.043). Stratification by the age of 60 yielded a significant increase in percent of the older patients, from 0.93% at 2007 to 4.28% at 2016 (p = 0.019). CONCLUSIONS: The mean age of the patients with acute appendicitis is going to increase. Therefore, it is expected that all surgeons are more likely to be confronted with elderly patients with appendicitis in the near-future.

Recovery from hemorrhoids and anal fissure without surgery.

BACKGROUND/AIMS: An anal fissure (AF) is a linear tear in the distal anal canal and is one of the most common causes of anal pain. Hemorrhoidal disease (HD) is a symptomatic growth and distal displacement of normal anal cushions. Numerous studies have addressed the contributing factors of these conditions, yet the results remain controversial. In this study, we hypothesize that increasing patients' awareness of hidden risk factors could reduce the rate of HD and AF. MATERIALS AND METHODS: A questionnaire-based controlled study was planned. After power analysis, patients with HD (n=60) and AF (n=60) were enrolled consecutively into the study group and compared with the control group (n=60) of healthy individuals. The survey was designed to assess the participants' toilet and dietary habits and anxiety risk. Odds ratios were calculated and a binary logistic regression model was constructed to identify associated factors. RESULTS: Hard stools, spending more than 5 minutes in the toilet, frequent straining during defecation, and increased spice intake were more frequent in the patients with HD; and hard fecal consistency, time elapsed in toilet greater than 5 min, straining during defecation, and high anxiety risk were more frequent in the patients with AF as compared to the control group (p<0.05). CONCLUSION: Possible associations were identified between habitual factors or conditions (i.e., fecal consistency, the time elapsed in the toilet, straining during defecation) and anxiety and benign anorectal diseases (i.e., HD and AF). Patients should be advised about these hidden threats.

Presurgical Predictive Factors of Excess Weight Loss After Laparoscopic Sleeve Gastrectomy.

PURPOSE: Conditions associated with surgical technique and postoperative lifestyle changes, as well as the characteristics of patients, may affect weight loss following laparoscopic sleeve gastrectomy. In this study, the effects of age, gender, BMI, and excess weight at the time of surgery on weight loss during follow-up were examined. MATERIALS AND METHODS: Demographic data (age, gender), preoperative BMI, and weight values of the patients were recorded. TWL% and EWL% values of patients were recorded during follow-up at 1st, 3rd, 6th, 9th, 12th, and 18th months. Patients were grouped according to age (AGE1 < 30, AGE2 30-50, AGE3 ≥ 50 years), BMI at the time of surgery (BMI1 ≤ 50, BMI2 > 50 kg/m2), and EW at the time of surgery (EW1 ≤ 60, EW2 > 60 kg). EWL% values obtained in the follow-up visits were compared among the gender, age, BMI, and EW groups. RESULTS: A total of 456 patients (371 females, 85 males) were operated. Mean EWL% was lower in AGE3 group (p < 0.001). Patients in AGE1 group had the highest mean EWL%, while those in BMI2 and EW2 groups had lower mean EWL% values throughout the follow-up period (p < 0.001). Regression analysis showed that age and BMI were associated with EWL% at all follow-up visits (p < 0.05). CONCLUSION: Patients with less than 60 kg of excess weight, those with BMI ≤ 50 kg/m2 and younger patients may lose weight more effectively following LSG.

Risk factors for complications after endoscopic retrograde cholangiopancreatography A referral Center experience.

AIM: Endoscopic retrograde cholangiopancreatography (ERCP) is an important diagnostic and therapeutic tool in patients with hepato-pancreatobiliary diseases. In the present study, we sought to determine predictors of post-ERCP complications at our institution. METHODS: A retrospective analysis of patients who underwent ERCP in between January 2010 and November 2011 was done. Demographics, indications, ERCP findings, success rate, complications and the need of repeat procedure were evaluated with special emphasis on the difficulty in cannulation procedure, the primary etiology of the disease (benign/malign) and age. Chi-square analysis was applied for statistical analysis. The differences were considered statistically significant, if the p value was less than 0.05. RESULTS: A total of 112 ERCP was performed in 81 patients. Thirty-eight were male (46.9 %) and 43 were female (53.1%). Mean age was 61.3 (range 17-88), and 31 patients was seventy years and older (38.3 %). Complications were detected in 28 patients (34.6 %). Nine cases with difficult or unsuccessful cannulation (69.2 %) had complications (p=0.001). Patients with benign diseases showed less complications (21/70), in comparison with those with malignancies (7/11) (30 % vs. 63.6 %, respectively; p<0.05). Complication rate in patients 70 years and older was 32.2 % (n=10) compared to 35.3 % in patients younger than 70 (n= 18) (p<0.05). CONCLUSION: Risk factors such as difficult or incomplete cannulation and malignancy are considered as possible predisposing factors for complications. Age is an independent factor. KEY WORDS: Endoscopic cholangiopancreatography, Risk factors.

A clinical and surgical challenge: Retrorectal tumors.

AIMS: Retrorectal tumors are rare, mostly benign tumors and named due to their localization. Diagnoses of these tumors are usually delayed because of nonspecific complaints and symptoms. Magnetic resonance imaging has beneficial uses both for diagnosis and treatment. In this study, we reviewed a case series of retrorectal tumors. SUBJECTS AND METHODS: The patients who were diagnosed with retrorectal tumors between 2008 and 2015 were analyzed. This investigation was conducted at a Tertiary Education and Research Hospital. Sixteen patients were included in this study. Patients' demographic data, imaging workups, surgical operation reports, pathologic examination results, postoperative complications, and follow-up results were examined. Descriptive statistics, median, and standard deviation for continuous variables were used. The primary outcomes measured were diagnostic conflict, knowledge, and preference for surgery. STATISTICAL ANALYSIS USED: Definitive statistical methods (mean, standard deviation, median, frequency, and percentage) were used to evaluate the study data. RESULTS: One patient refused operation and one was in preoperative preparation period. Fourteen of sixteen patients were operated. Two (14.3%) of operated patients have malignant histopathological result (one gastrointestinal stromal tumor, one ganglioneuroblastoma). Rest of the operated patients' histopathological reports was as follows: Four schwannomas, three epidermoid cysts, two tailgut cyst, one dermoid cyst, one teratoma, and one angiomyolipoma. Eight patients were operated by posterior incision, five patients with transabdominal approach, and one patient with combined approach. CONCLUSIONS: Retrorectal tumors are rare cases, and treatment of retrorectal tumors is surgery and should be operated in referenced hospitals to avoid diagnostic and therapeutic problems.

Does it matter if it is appendix mucocele instead of appendicitis? Case series and brief review of literature.

AIMS: Appendiceal mucocele (AM) is a rare pathology, and its reported incidence is 0.3% in all appendectomy specimens. Here, we report a case series of AM and make a brief review of literature. SUBJECTS AND METHODS: We conducted a retrospective review of a prospectively collected data of patients who diagnosed as AM by histopathological evaluation between January 2009 and June 2015 were demographic data including age and gender, intraoperative findings, and histopathological reports were recorded. All cases were followed-up by routine examination and telephone interview. STATISTICAL ANALYSIS USED: Definitive statistical methods (mean, standard deviation, median, frequency, and percentage) were used to evaluate the study data. RESULTS: Twelve patients were examined in the study with diagnose of AM. The mean age was 51.8 ± 18.6 years (26-83). Female-to-male ratio was 1.4 (7/5). Indications for surgery were acute abdomen in 8 (72.7%) patients with presumptive diagnosis of acute appendicitis and were AM in four patients diagnosed by imaging. Histopathological evaluation revealed mucinous cystadenoma in eight patients, simple retention cysts in three, and borderline mucinous tumor (pseudomyxoma peritonei) in one. The neuroendocrine tumor was obtained on the remaining portion of the appendix in one of the simple retention cysts patients. None of the patients died because of the AM with an average follow-up of 43 months (range: 7-74). CONCLUSIONS: Surgical resection is the first choice therapy for AM. Precise treatment modality can remain unclear in some patients because of insufficient preoperative diagnosis. It is nonmalign AM mostly however having mucocele matters because of the significant association with synchronous tumors.

An incidental giant preperitoneal fibrolipoma diagnosed during laparoscopic cholecystectomy.

Preperitoneal lipomas are rare in clinical practice. Here we report an unexpected diagnosis of a giant preperitoneal fibrolipoma detected intraoperatively during laparoscopic cholecystectomy in a 56-year-old woman. The mass was excised and a histopathological examination confirmed fibrolipoma. No recurrence was found on follow-up. In the literature, there have been many cases with unexpected diagnoses during laparoscopy. Here, we present an incidental giant preperitoneal fibrolipoma, which was overlooked by ultrasound and physical examination, but was detected during laparoscopic cholecystectomy.

Evaluating factors affecting survival in colon and rectum cancer: A prospective cohort study with 161 patients.

CONTEXT: Colorectal cancers are frequent among cancers of gastrointestinal system. Whether there are any differences between survival in rectum and colon cancer patients is controversial. AIMS: In this study, we aimed to compare survival in surgically treated rectum and colon cancers and determine the factors affecting survival. SUBJECTS AND METHODS: The patients with colon and rectum cancer operated between 2009 and 2013 were examined retrospectively using prospective database. Patients were categorized as colon and rectum according to the tumor's location. Survival was identified as the primary outcome. Kaplan-Meier survival analysis and log-rank tests in survival assessment were used. RESULTS: One hundred and sixty-one patients with a mean age of 62.8 ± 12.7 years were included in the study. Male/female ratio was 1.6. Colon and rectum patients were counted as 92 (%57.1) and 69 (%42.9), respectively. Both groups were similar in demographic data (P > 0.05). It was observed that in 46 months (mean) of follow-up, 39.7% (n: 64) died, and 60.3% (n: 97) survived. Median survival time was 79 months, and 5-year cumulative survival rate was 60.8%. Five-year cumulative survival rates in stages for 1, 2, 3 and 4 were 88.2%, 64.7%, 48.5%, and 37.0%, respectively. It was noted that median survival time for colon cancer was 78 months and for rectum cancer was 79 months. Five-year cumulative survival rates for colon and rectum cancers were calculated as 56.7% and 63.4%, respectively. There were no significant differences in colon and rectum cancers in the means of survival rate (P: 0.459). CONCLUSIONS: While location of colorectal cancers shows no significant effect on survival, treatment in the early stages increases survival rate.

Fournier's gangrene: A retrospective analysis of 25 patients.

BACKGROUND: Fournier's gangrene is a surgical emergency that progresses rapidly and insidiously and results in high morbidity and mortality rates unless it is immediately diagnosed and managed. Here we analyze the outcomes of patients who were followed up and treated for Fournier's gangrene. METHODS: We conducted a retrospective analysis of the medical data of 25 patients operated on for Fournier's gangrene between January 2010 and June 2015. The diagnosis of Fournier's gangrene was made by performing a physical examination. Patients who had genital, perineal, and perianal tenderness; induration; cyanosis; gangrene; and subcutaneous crepitation were considered as having Fournier's gangrene. Following resuscitation, aggressive surgical debridement was performed and vacuum-assisted closure (VAC) was conducted in addition to debridement in select patient. Repeat debridements were performed as requirement. RESULTS: This study included 25 patients. Fourteen patients (56%) were females and 11 (44%) were males. The mean age of the patients was 54.3 years (range: 27-82 years). The mean duration of hospital stay was 21.4 days; the mean number of debridements performed was 2.4. Thirteen patients (52%) had perianal abscesses, and 20 (80%) had diabetes mellitus. All patients underwent extensive debridement; 16 patients (64%) underwent VAC in addition to debridement. Patients undergoing VAC had significantly longer durations of hospital stay and a higher mean number of debridements performed (p=0.004 and p=0.048, respectively). An ostomy was made in one patient, and one patient died. CONCLUSION: In Fournier's gangrene, early diagnosis, effective resuscitation, aggressive debridement, and VAC application in suitable cases may reduce the morbidity and mortality rates and the need for an ostomy.

Lumbar (Petit's) hernia: A rare entity.

Lumbar hernias are rare and diagnostically challenging for surgeons. We present the case of a middle-aged patient who presented with swelling in the left back. Subcutaneous lipoma was included in the differential diagnosis. Following diagnostic studies, computed tomography confirmed left lumbar hernia. Elective surgery was performed, and the results revealed Petit's hernia. The hernia was repaired with mesh.

Validation of microsatellite instability histology scores with Bethesda guidelines in hereditary nonpolyposis colorectal cancer.

AIMS: Hereditary nonpolyposis colorectal cancer (HNPCC) is a subgroup of colorectal cancer (CRC) which should be differentiated because of the high risk for additional cancers and risk evaluation for other family members, especially for CRC. It is not practical to perform genetic testing for all CRC patients; therefore, various prediction modalities, for example, Bethesda guideline (BG) were studied in the literature. We aimed to assess the association of microsatellite instability (MSI), histology scores, and BG for predicting HNPCC risk. SUBJECTS AND METHODS: Data were collected from CRC patients between 2009 and 2012. A total of 127 patients were retrospectively reviewed for BG status and the MSI scores, MsPath, and PathScore. STATISTICAL ANALYSIS USED: Definitive statistical methods (mean, standard deviation, median, frequency, and percentage) were used to evaluate the study data. Comparison used Student's t-test, Continuity (Yates) correction, Fisher-Freeman-Halton test, Pearson correlation, and receiver operating characteristics curve analysis. RESULTS: Patients who were detected as Bethesda-positive had significantly higher MsPath and PathScore scores (P = 0.001 and P = 0.007, respectively). According to the cut-off value of 2.8 and 2.9 for MsPath and PathScore, respectively, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 90%, 43%, 22.8%, 95.8%, and 50.4% for MsPath, and 55%, 83.2%, 37.9%, 90.8%, and 78.7% for PathScore, respectively. CONCLUSIONS: The MSI scoring systems, MsPath, and PathScore, are reliable systems and effectively correlated with BG for predicting patients who need advanced analysis techniques because of the risk of HNPCC.

Importance of diagnostic laparoscopy in the assessment of the diaphragm after left thoracoabdominal stab wound: A prospective cohort study.

BACKGROUND: Stab wounds in the left thoracoabdominal region may cause diaphragmatic injury. The aim of the present study was to determine incidence of diaphragmatic injury and role of diagnostic laparoscopy in detection of injury in patients with left thoracoabdominal stab wound. METHODS: Total of 81 patients (75 male, 6 female; mean age 27.5±9.8 years; range 14 to 60 years) who presented with left thoracoabdominal stab wound between April 2009 and September 2014 were evaluated. Laparotomy was performed on patients who had hemodynamic instability, signs of peritonitis, or organ evisceration. Remaining patients were followed conservatively. After 48 hours, diagnostic laparoscopy was performed on patients without laparotomy indication to examine the left diaphragm for injury. Follow-up and treatment findings were prospectively evaluated. RESULTS: Thirteen patients underwent laparotomy while diagnostic laparoscopy was performed on remaining 68 patients. Left diaphragmatic injury was observed in 19 patients (23.5%) in the study group. Four injuries were diagnosed by laparotomy and 15 were diagnosed by laparoscopy. Presence of hemopneumothorax did not yield difference in incidence of diaphragmatic injury (p=0.131). No significant difference was detected in terms of diaphragmatic injury with respect to entry site of stab wound in the thoracoabdominal region (p=0.929). CONCLUSION: It is important to evaluate the diaphragm in left thoracoabdominal stab injuries, and diagnostic laparoscopy is still the safest and most feasible method.

Percutaneous cholecystostomy: A curative treatment modality forelderly and high ASA score acute cholecystitis patients.

BACKGROUND: Acute cholecystitis (AC) is a common emergency seen by general surgeons. Optimal treatment is laparoscopic cholecystectomy (LC); however, in cases where surgery cannot be performed due to high risk of morbidity and mortality, such as in elderly patients with comorbid diseases, other treatment modalities may be used. Percutaneous cholecystostomy (PC) is one alternative method to treat AC. PC can be used to provide drainage of the gall bladder and control infection. Subsequently, interval cholecystectomy can be performed when there are better conditions. Presently described is experience and results with PC in high risk, elderly patients with AC. METHODS: Medical records of all consecutive patients who underwent PC between January 2011 and January 2014 were identified. Tokyo Guidelines were used for definitive diagnosis and severity assessment of AC. Senior surgeon elected to perform PC based on higher risk-benefit ratio due to comorbidity, age, or duration of symptoms. All PC procedures were performed by the same interventional radiologist under local anesthesia with ultrasonographic guidance. RESULTS: Total of 40 PC procedures were performed during the study period. Of those, 22 (55%) were male and 18 were (45%) were female, with median age of 70.5 years (range: 52-87 years). All of the patients had American Society of Anesthesiologists classification of either 3 or 4. Success rate of PC was 100% with complication rate of 2.5% (n=1). One patient was operated on shortly after PC procedure due to bile peritonitis complication. PC drains were kept in place for 6 weeks. Total of 16 patients (40%) had surgery following removal of PC drain. In 3 (18.8%) cases, conversion from LC was required. Remaining 23 (57.5%) patients did not have subsequent operation after drain removal. No disease recurrence was observed in follow-up. CONCLUSION: When elderly patients present in emergency setting with AC and LC cannot be performed due to comorbid disease or poor general condition, PC can be performed safely. After removal of PC drain, LC may be performed with acceptable conversion rate of 18.8%.

Can C-reactive protein levels increase the accuracy of the Ranson score in predicting the severity and prognosis of acute pancreatitis? A prospective cohort study.

BACKGROUND/AIMS: Acute pancreatitis (AP) is an acute inflammatory disorder of the pancreas, and its severe form affects nearly all systems of the body. The purpose of this study is to assess the Ranson score and the C-reactive-protein level as a novel model for prediction of the disease severity and mortality. MATERIALS AND METHODS: A prospective cohort study was designed to evaluate the efficacy of the C-reactive-protein for the prediction of severe AP. We recorded the Ranson score and C-reactive-protein values in AP patients and determined the severity of the disease using the revised Atlanta classification. Four groups of criteria sets were created: Group 1: Ranson ≥3; Group 2: C-reactive-protein ≥150 mg/L; Group 3: Ranson ≥3 and C-reactive-protein ≥150 mg/L; Group 4: Ranson ≥3 or C-reactive-protein ≥150 mg/L. Identification of AP severity was accepted as the reference parameter for statistical analysis. Categorical variables were expressed as frequencies and percentages. The differences were considered as significant if the p value <0.05. RESULTS: Six hundred and thirty-eight patients with AP were included in our study. We recovered a statistically significant difference in our assessment of the prediction of the severity of AP among the various groups (p=0.001). Our analysis revealed that group 4 had the highest sensitivity of 90.1% and 93.5% to differentiate moderately severe and severe AP from mild AP, respectively. Group 3 had the highest specificity of 97.1% for both moderately severe and severe AP. CONCLUSION: With the use of our new model, C-reactive-protein levels increase the efficacy of the Ranson score for predicting the severity of AP.

Sinistral Portal Hypertension Due to Pancreatic Hydatid Cyst.

Hydatid disease is caused by Echinococcus granulosus. Hydatid cysts are commonly located in the liver and lungs. The occurrence of pancreatic hydatid cysts is very rare, even in endemic areas. Sinistral portal hypertension, which is rarely seen, occurs when a pathological process causes splenic vein occlusion. A 26-year-old male patient presented with abdominal pain. He had a history of operation for hydatid cyst of the lung 15 years ago. A left thoracotomy incision scar was observed during his physical examination. Laboratory findings revealed no abnormalities. Abdominal ultrasonography revealed a 96×69-mm lobular, contoured, well-circumscribed cystic lesion with thickened septation. Abdominal magnetic resonance imaging revealed a 100×76-mm smooth, bordered cystic lesion containing septations in the body and tail of the pancreas compressing the splenic artery and vein, causing sinistral portal hypertension. Dilatation was noted in the left gastroepiploic vein. The patient underwent cystotomy. Pancreatic fistula developed during the postoperative follow-up. The patient was discharged in 20 days without postoperative complications. No complications were observed during the follow-up period of 7 months. Surgery should be considered as a more conservative approach.

Intraoperative diagnosis of cecal diverticulitis during surgery for acute appendicitis: Case series.

OBJECTIVE: Cecal diverticulum is a rare entity, and can cause acute abdomen by the way of diverticulitis and perforation of diverticulitis. In this study, we aimed to perform an analysis of patients that have cecal diverticulitis, and presented with acute abdomen. MATERIAL AND METHODS: Patients who were admitted to emergency clinic between 2009-2012 and had acute abdomen due to cecal diverticulitis were included into study retrospectively. RESULTS: Six patients were included in the study with a mean age of 34 years (range 24-43). Four patients were male and two were female (male/female: 2). All six patients presented with abdominal pain, additional symptoms were nausea in five patients, and vomiting in one patient. The mean white blood cell count was 11.900/mm(3) (5850-17.400/mm(3)), while the remaining laboratory results were normal. There were no specific findings on abdominal X-ray or ultrasonography. The surgical exploration revealed an inflamed cecal diverticulitis and normal appendix in all patients. Five patients underwent appendectomy and diverticulectomy. Right hemicolectomy was performed in one patient due to suspicion of malignancy. The early postoperative period was uneventful in all patients. The mean length of hospital stay was 4.5 days with a range of 2-6 days. Histopathological examination showed acute perforated diverticulitis with underlying true diverticulum in three patients, and true diverticulum with acute diverticulitis in the remaining three patients. CONCLUSION: Pre-operative diagnosis of cecal diverticulitis is challenging due to symptoms and signs that resemble acute appendicitis. Diverticulectomy and incidental appendectomy is the treatment of choice in uncomplicated cases.