Can the Modified Systemic Inflammation Score Predict Complicated Appendicitis?

OBJECTIVE: To differentiate between complicated and uncomplicated acute appendicitis using the modified systemic inflammation score (mSIS) preoperatively. STUDY DESIGN: Observational study. Place and Duration of the Study: The Emergency Surgery Service of General Surgery Clinic of Ankara Bilkent City Hospital, Turkey, between 2021 and 2022. METHODOLOGY: The study included 2,584 patients older than 18 years who underwent surgery with the diagnosis of acute appendicitis. Patients with malignant diseases and those younger than 18 were excluded. The patients' demographic characteristics, laboratory data, surgical notes, and pathology results were electronically obtained and analysed. According to the surgical findings and pathology records, gangrenous, perforated, and phlegmonous cases and those with any abscess focus were included in the complicated group and the remaining cases were included in the uncomplicated group. mSIS was evaluated as 0 if albumin was ≥4.0 g/dL and LMR (the lymphocyte-to-monocyte ratio) was ≥3.4, 1 if albumin <4.0 g/dL or LMR <3.4, and 2 if albumin <4.0 g/dL and LMR <3.4. RESULTS: mSIS was 0 in 868 (33.6%) cases and 1-2 in 1,716 (66.4%) cases. When the patients with mSIS values of 0 and 1-2 were compared, there was a statistically significant difference (p=0.03). mSIS 1-2 was found to have 85% sensitivity and 42% specificity in predicting complicated appendicitis. In addition, the probability of complicated appendicitis was 1.48 times higher among the patients with an mSIS of 1-2. CONCLUSION: Complicated appendicitis cases can be predicted preoperatively by simply calculating mSIS using the routine laboratory parameters. KEY WORDS: Complicated acute appendicitis, mSIS, Appendectomy.

A new, simple marker for predicting complicated appendicitis in patients with normal white blood cell count indicator; LUC.

BACKGROUND: The aim of this study was to investigate the ability of a new marker that could be easily obtained to differentiate between complicated and uncomplicated appendicitis in a patients with a white blood cell (WBC) count within the normal range. METHODS: The patients who underwent surgery with histopathologically proven acute appendicitis (AA) between January 2021 and October 2022 were evaluated retrospectively. Patients were classified into two groups as uncomplicated and complicated appendicitis, based on the surgical and histopathological findings. Groups were compared in terms of laboratory parameters at the time of hospital admission. RESULTS: During the study period, 2589 patients underwent an appendectomy, among these 612 patients who had a WBC count within the normal range at the time of admission were analyzed. Uncomplicated appendicitis was detected in 79.6% of the patients and complicated appendicitis in 20.4%. Neutrophil%, neutrophil-to-lymphocyte ratio, C-reactive protein, and total bilirubin levels were significantly higher, whereas lymphocyte%, lymphocyte count, lymphocyte-to-monocyte ratio, sodium levels, and large unstained cells (LUC)% were significantly lower in patients with complicated appendicitis. Multiple logistic regression analysis revealed that lower LUC% (Odds Ratio [OR]: 0.45; 95% Confidence Intervals [CI]: 1.08-2.09; P=0.01) and higher total bilirubin levels (OR: 1.50; 95% CI: 1.08-2.09; P=0.01) were independent risk factors for complicated appendicitis. CONCLUSION: In patients with a diagnosis of AA with a normal WBC value, LUC% obtained from the complete blood count can be used as a new parameter predicting the diagnosis of complicated appendicitis.

Applying a Silver-containing Dressing to the Incision Site and Its Effect on the Development of Surgical Site Infection After Ostomy Closure: A Prospective Randomized Clinical Pilot Study.

BACKGROUND: Surgical site infections (SSIs) can occur after colorectal surgery. Ionic silver has been used to prevent the development of SSIs. New-generation dressings, defined as total occlusive ionic silver-containing dressings, have been shown to reduce bacterial colonization in SSIs. PURPOSE: To evalute the effect of a silver hydrofiber dressing on the development of SSIs at the abdominal incision after ostomy closure. METHODS: There was a total of 37 eligible patients who underwent temporary ostomy closure. Five patients required an associated intervention during ostomy closure and were excluded. One patient was lost to follow-up. Hence, 32 patients were included in the study. Silver-containing occlusive dressings and conventional dressings were used in patients who underwent ostomy closure. In the control group (n = 16), the wound area was covered with a standard sterile gauze dressing for 24 to 48 hours, and then wound cleansing was performed with 10% povidone iodine, followed by daily dressing replacement with sterile gauze for 5 days. The patients in the study group (n = 16) were treated with a silver-containing hydrofiber dressing, which was not changed for 5 days following application in the operating room. RESULTS: At the end of the 30-day follow-up period, no SSIs were observed in the study group. When the dressing methods applied to the patient groups with and without SSIs were compared, SSIs developed at a higher rate in the control group (n = 4; 26.7%) compared with the study group (n = 0); this result was statistically significant (P = .043). CONCLUSIONS: In this study, the use of a wound care product containing ionic silver reduced the rate of SSIs related to ostomy closure. Multicenter, randomized, clinical studies involving a larger number of patients are needed. In addition, occlusive wound dressings with and without silver should be investigated in further studies.

Does transverse colon cancer spread to the extramesocolic lymph node stations?

BACKGROUND: Transverse colon cancers show behavioral differences in terms of the involvement of extramesocolic lymph nodes since they are closely related to all three embryological planes. These tumors have also been observed in the gastroepiploic-omental (GEOM) region, outside their usual regional areas. We will evaluate this new metastatic route in our own cases. METHODS: Thirty-four patients (16 female, 18 male) that presented to our clinic with hepatic flexure, transverse colon, and splenic flexure cancer between October 2011 and May 2017 were included in the study. Type of surgery, histopathology, and factors causing metastasis, morbidity, and mortality were evaluated. RESULTS: Cancer was located in the transverse colon in 20 patients (58.8%), hepatic flexure in 10 (29.4%), and splenic flexure in four (11.7%). Lymph node positivity in the GEOM region was present in four patients: in the infrapyloric region and pancreatic head, close to the hepatic flexure in three patients; and the midline of GEOM, close to the inferior body of the pancreas in one patient. Perineural invasion (p < .05) and N stage (p < .05) were associated with GEOM region metastasis. Tumor localization and age significantly increased pleural effusion. CONCLUSIONS: In transverse colon and both flexural tumors, we recommend planning the surgery according to the localization of the tumor and including the GEOM, infrapyloric and infrapancreatic areas. It is possible to discuss whether to perform extended excision for all or only selected patients. The best approach seems to be to evaluate the co-factors to manage these patients.

Clinical course of percutaneous cholecystostomies: A cross-sectional study.

BACKGROUND: Although cholecystectomy is the standard treatment modality, it has been shown that perioperative mortality is approaching 19% in critical and elderly patients. Percutaneous cholecystostomy (PC) can be considered as a safer option with a significantly lower complication rate in these patients. AIM: To assess the clinical course of acute cholecystitis (AC) in patients we treated with PC. METHODS: The study included 82 patients with Grade I, II or III AC according to the Tokyo Guidelines 2018 (TG18) and treated with PC. The patients' demographic and clinical features, laboratory parameters, and radiological findings were retrospectively obtained from their medical records. RESULTS: Eighty-two patients, 45 (54.9%) were male, and the median age was 76 (35-98) years. According to TG18, 25 patients (30.5%) had Grade I, 34 (41.5%) Grade II, and 23 (28%) Grade III AC. The American Society of Anesthesiologists (ASA) physical status score was III or more in 78 patients (95.1%). The patients, who had been treated with PC, were divided into two groups: discharged patients and those who died in hospital. The groups statistically significantly differed only concerning the ASA score (P = 0.0001) and WBCC (P = 0.025). Two months after discharge, two patients (3%) were readmitted with AC, and the intervention was repeated. Nine of the discharged patients (13.6%) underwent interval open cholecystectomy or laparoscopic cholecystectomy (8/1) within six to eight weeks after PC. The median follow-up time of these patients was 128 (12-365) wk, and their median lifetime was 36 (1-332) wk. CONCLUSION: For high clinical success in AC treatment, PC is recommended for high-risk patients with moderate-severe AC according to TG18, elderly patients, and especially those with ASA scores of ≥ III. According to our results, PC, a safe, effective and minimally invasive treatment, should be preferred in cases suffering from AC with high risk of mortality associated with cholecystectomy.

Small bowel and cecal Involvement: Unusual metastasis sites from adenoid cystic carcinoma of the minor salivary gland.

Adenoid cystic carcinoma (ACC) is a rare neoplasm and the most frequent pathology occurring in the minor salivary glands. Lung, bone, liver, and brain are the most frequent metastasis sites in ACC cases. To our knowledge, cecal and ileum metastasis from ACC has not been previously reported in literature. Herein, we reported a case of cecal and small bowel metastasis (ileum) in a patient with ACC. A 41-year-old male patient with ACC developed iron and Vitamin B12 deficiency anemia during further controls. Lower gastrointestinal (GI) endoscopy detected an ulcerated polypoid lesion with raised margins in cecum. Pathological evaluation of polyp biopsy was consistent with metastasis from ACC. The patient underwent surgery of right hemicolectomy. Pathological examinations revealed an ACC of cecum and small bowel (ileum) showing positive staining with CD117, CK7, and panCK. We aimed to emphasize that performing GI stromal screening in ACC patients presenting with iron deficiency is important for early diagnosis of metastasis.

Prognostic efficacy of inflammation-based markers in patients with curative colorectal cancer resection.

AIM: To evaluate the prognostic significance of neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), and prognostic nutritional index (PNI) and other clinicopathological factors in patients undergoing curative resection of colon cancer. METHODS: 183 patients with histologically proven colorectal cancer who had undergone potentially curative resection between 2010 and 2016 at Ankara Numune Training and Research Hospital were retrospectively analyzed and clinicopathological characteristics included age, sex, tumor type, grade, size and localization, the number of metastatic and total number of lymph nodes removed, vascular and perineural invasion of the tumor, TNM stages, tumor marker levels (CEA, CA19-9, AFP, CA-125, CA15-3), complete blood counts, albumin levels, overall survival (months), NLR, PLR, LMR and PNI ratios were retrospectively reviewed and analyzed from the electronic database. The primary outcome measure was overall survival. RESULTS: Regarding overall survival, on univariate analysis the following variables were significantly associated with poor outcome following resection: T-stage (P = 0.037), lymph node invasion (P = 0.037), cancer stage (P = 0.034), CEA (P = 0.042), CA19-9 (P = 0.004), and PNI (P = 0.001). To evaluate the independent prognostic value, multivariate Cox proportional hazard analysis to control for other prognostic factors was used. Using cancer-specific death as an end point for NLR, PLR, LMR, PNI and CA19-9 the optimal cut off values were calculated by ROC analysis. Regarding overall survival, on multivariate analysis high CA19-9 (HR = 1.001, 95%CI: 1.00-1.002, P = 0.012) and low PNI (HR = 0.938, 95%CI: 0.891-0.987, P = 0.014) were the only variables independently associated with shortened overall survival. Patients with a PNI < 35 had a median OS of 52.25 mo. In contrast, patients with an PNI > 35 had a median OS of 66 mo. Patients with a CA 19-9 < 17 had a median OS of 66 mo and in patients with a CA19-9 > 17 had a median OS of 53.76 mo. CONCLUSION: This study shows that decrease in the PNI and increase in CA 19-9 is associated with poor survival in patients with resectable colon cancer.

Does the preoperative prognostic nutritional index predict postoperative complications in patients with colorectal cancer who underwent curative resection?

AIM: Malnutrition is a common and very important issue in colorectal cancer patients.The immunological and nutritional status of these patients have been reported to be correlated with the postoperative complications.The prognostic nutritional index (PNI) is an effective and simple parameter, initially created to evaluate preoperative surgical risks. The aim of this study was to evaluate the predictive value of PNI in patients with colorectal cancer who underwent surgery. METHODS: One hundred eighty patients who underwent curative colorectal resections for colorectal cancer were included in this retrospective study. Demographic characteristics of the patients, biochemical parameters, intra-operative findings, operation type, postoperative surgical complications, and PNI values were collected Results:The median PNI value was 44,4(range 19-60,5).Receiver Operating Characteristics demonstrated that a value below 39,75 was the optimal cut-off value for the prediction of major complications. The median PNI values were significantly lower in patients with major complications (Clavien-Dindo grade 3 to 5). CONCLUSION: The PNI can predict severe complications in patients with colorectal cancer who are undergoing primary tumor resection. Investigation of the nutritional status by using the PNI could be a useful approach for clinical follow-up. KEY WORDS: Colorectal, Nutritional index, Postoperative complications.

Small Intestinal and Mesenteric Multiple Gastrointestinal Stromal Tumors Causing Occult Bleeding.

Gastrointestinal stromal tumors are the meseancymal neoplasms which may involve any part of gastrointestinal tract. C-Kit and platelet derived factor receptor alpha polypeptide are believed to be responsible for the genetic basis. This case presentation aimed to discuss the diagnostic and therapeutic modality of multiple small intestinal, omental, and mesenteric GISTs with different sizes which caused occult bleeding in a 43-year-old male patient.

Role of self expandable stents in management of colorectal cancers.

Acute malignant colorectal obstruction is a complication of colorectal cancer that can occur in 7%-29% of patients. Self-expanding metallic stent placement for malignant colorectal obstruction has gained popularity as a safe and effective procedure for relieving obstruction. This technique can be used in the palliation of malignant colorectal obstruction, as a bridge to elective surgery for resectable colorectal cancers, palliation of extracolonic malignant obstruction, and for nonmalignant etiologies such as anastomotic strictures, Crohn's disease, radiation therapy, and diverticular diseases. Self-expanding metallic stent has its own advantages and disadvantages over the surgery in these indications. During the insertion of the self-expanding metallic stent, and in the follow-up, short term and long term morbidities should be kept in mind. The most important complications of the stents are perforation, stent obstruction, stent migration, and bleeding. Additionally, given the high risk of perforation, if a patient is treated or being considered fortreatmentwith antiangiogenic agents such as bevacizumab, it is not recommended to use self-expanding metallic stent as a palliative treatment for obstruction. Therefore, there is a need for careful clinical evaluation for each patient who is a candidate for this procedure. The purpose of this review was to evaluate self-expanding metallic stent in the management of the obstruction of the colon due to the colorectal and extracolonic obstruction.

High serum cancer antigen 125 level indicates perforation in acute appendicitis.

BACKGROUND: The diagnosis of acute appendicitis is sometimes challenging, and prompt evaluation is required because of the risk of complications if not treated appropriately. AIM: We aimed to evaluate whether cancer antigen 125 (CA-125) has diagnositic accuracy and predictor of the severity in acute appendicitis. RESULTS: Sixty patients with acute appendicitis were recruited prospectively in this study between May 2014 and March 2015. Blood samples were obtained to measure CA-125 levels before appendectomy. Of the 57 patients, 10 had perforated or gangrenous appendicitis intraoperatively. The CA-125 levels were significantly higher in patients with perforated or gangrenous appendicitis than patients with uncomplicated appendicitis (49.9 vs 10.5 U/mL, P=.000). CONCLUSIONS: Cancer antigen 125 levels in patients with highly suspected or confirmed appendicitis could help clinicians determine the severity of the disease.

Effects of intra-abdominal pressure on adrenal gland function and morphology in rats.

Intra-abdominal hypertension and abdominal compartment syndrome (IAH/ACS) are life-threatening conditions and caused by several clinical status. Although there is insufficient data regarding its effects on adrenal glands. This study aimed to identify whether elevated intra-abdominal pressure (IAP) caused any alteration on the morphology and function of adrenal glands in a rat model. Twenty four Sprague-Dawley male rats were included in the study. Animals were allocated into 4 groups. IAP was elevated to 15 mmHg for one hour and four hours in group 2 and 4. Group 1 and 3 were sham groups. Blood samples were taken for the assessment of plasma adrenaline, noradrenaline, and corticosterone levels and adrenalectomies were performed to evaluate apoptosis. Blood adrenaline, noradrenaline and corticosterone levels were significantly higher in the study groups compared with the sham groups. However, there were no significant changes in apoptotic index scores in the study groups as compared to sham groups. These results support that increased IAH leads to discharge of catecholamine and corticosterone from the adrenal glands. Failure to demonstrate similar changes in apoptotic index score may be concluded as apoptosis is not a leading pathway for impairment of adrenal glands during IAH period.

Red cell distribution width to platelet ratio: new and promising prognostic marker in acute pancreatitis.

AIM: To evaluate the accuracy of red cell distribution width (RDW) to platelet ratio (RPR) to predict in-hospital mortality in acute pancreatitis (AP). METHODS: Between January 2010 and June 2012, 102 patients with AP were recruited to the study. In this retrospective cohort study, for all subjects, demographic data on hospital admission, AP etiology, co-morbid diseases, organ failure assessment, laboratory parameters and length of hospital stay were examined. Additionally, we used a non-invasive prediction method in addition to the RPR to evaluate the disease severity. Multivariate logistic regression analyses were used to evaluate the impact of RPR on hospital admission to predict mortality. RESULTS: The male-female ratio (59/43) was 1.37 with a median age of 56.5 years (17-89 years). In both univariate and multivariate analyses, RDW and RPR were presented as independent and significant variables on admission to predict mortality. The RPR obtained on hospital admission was persistently higher among non-survivors than among survivors (P < 0.0001). The median RPR was 0.000087 in the non-survivor group and 0.000058 in the survivor group. RPR with a cutoff value of 0.000067 presented an area under the curve of 0.783 (95%CI: 0.688-0.878) in receiver operating characteristic curves and could predict the mortality of approximately 80% of the patients. CONCLUSION: We identified RPR as a valuable, novel laboratory test to predict mortality in AP.

Role of surgery in colorectal cancer liver metastases.

Colorectal carcinoma (CRC) is the third most common cancer, and approximately 35%-55% of patients with CRC will develop hepatic metastases during the course of their disease. Surgical resection represents the only chance of long-term survival. The goal of surgery should be to resect all metastases with negative histological margins while preserving sufficient functional hepatic parenchyma. Although resection remains the only chance of long-term survival, management strategies should be tailored for each case. For patients with extensive metastatic disease who would otherwise be unresectable, the combination of advances in medical therapy, such as systemic chemotherapy (CTX), and the improvement in surgical techniques for metastatic disease, have enhanced prognosis with prolongation of the median survival rate and cure. The use of portal vein embolization and preoperative CTX may also increase the number of patients suitable for surgical treatment. Despite current treatment options, many patients still experience a recurrence after hepatic resection. More active systemic CTX agents are being used increasingly as adjuvant therapy either before or after surgery. Local tumor ablative therapies, such as microwave coagulation therapy and radiofrequency ablation therapy, should be considered as an adjunct to hepatic resection, in which resection cannot deal with all of the tumor lesions. Formulation of an individualized plan, which combines surgery with systemic CTX, is a necessary task of the multidisciplinary team. The aim of this paper is to discuss different approaches for patients that are treated due to CRC liver metastasis.

Effect of irinotecan on liver regeneration: an experimental study in rats.

BACKGROUND/AIMS: The aim of this study was to determine the histopathological changes caused by irinotecan and show the effect of these changes on liver regeneration. METHODOLOGY: In this experimental study 96 Winstar-Albino breed female rats were used. The animals were divided into two groups. Study group received intraperitoneal irinotecan weekly for four weeks. Control group received normal saline. One week after the last injection all animals had undergone 70% hepatectomy. Following 70% hepatectomy rats were sacrificed and liver tissue samples were obtained at 0, 24, 48, 72, 96 and 120 hours. Specimens were evaluated for steatosis, lobular inflammation and cellular swelling with hematoxylin and eosin staining. Liver regeneration was evaluated im munohistochemically using proliferating cell nuclear antigen activity index. RESULTS: Hepatic steatosis was significantly more in the irinotecan group. Although lobular inflammation and cellular swelling were more prominent in the irinotecan group these values were not statistically significant. In both groups, regeneration reached to peak at 48th hour and returned to baseline at 120th hour. Liver regeneration indices were not different between the groups. CONCLUSION: It was shown that irinotecan did not affect the liver regeneration adversely. In order to show the effects of irinotecan on liver regeneration in humans further clinical studies are needed.

Diagnostic significance of serum eotaxin-1 level in gastric cancer patients.

INTRODUCTION: Gastric cancer is the second cause of cancer-related deaths worldwide. Delayed diagnosis leads to high mortality rates. Eotaxin-1 was originally discovered as an eosinophil-selective chemoattractant and may play a role in a number of chronic inflammatory diseases, cancer, and other gastrointestinal disorders. The aim of this study was to analyse diagnostic and prognostic significance of serum eotaxin-1 (s-eotaxin-1) levels in gastric cancer. METHODS: Sixty gastric cancer patients and 69 healthy subjects were included into the study. S-eotaxin-1 levels were compared with clinicopathological features and outcomes in gastric cancer. RESULTS: Serum levels of eotaxin-1 in gastric cancer patients were significantly higher than controls (74.51 ± 16.65 pg/mL versus 16.79 ± 5.52 pg/mL, respectively (P < 0.001)). The s-eotaxin-1 levels did not differ significantly with histopathological grade, tumor-node-metastasis (TNM) stage, tumor localization, lymph node metastases, positive lymph node ratio, size, perineural and perivascular invasion. So there is no relationship found between s-eotaxin-1 level and prognosis. CONCLUSION: S-eotaxin-1 levels may be used as an easily available biomarker for gastric cancer risk and may alert physicians for early diagnosis. Due to the limited number of patients included in this study, larger cohort studies are warranted to validate the diagnostic value of s-eotaxin-1 level in gastric cancer.