Management and Morbidity of Major Pelvic Hemorrhage in Complex Abdominopelvic Surgery.

INTRODUCTION: Hemorrhage is a challenging complication of pelvic surgery. This study aimed to analyze the causes, management, and factors associated with morbidity in patients experiencing major pelvic hemorrhage during complex abdominopelvic surgery. METHODS: Patients who had major intraoperative pelvic hemorrhage during complex abdominopelvic surgery at 11 tertiary referral centers between 1997 and 2017 were included. Patient characteristics, management strategies to control bleeding, short- and long-term postoperative outcomes were evaluated retrospectively. RESULTS: There were 120 patients with a mean age of 56.6 ± 2.4 years and a mean BMI of 28.3 ± 1 kg/m2. While 104 (95%) of the patients were operated for malignancy, 16 (5%) of the patients had surgery for a benign disease. The most common bleeding site was the presacral venous plexus 90 (75%). Major pelvic hemorrhage was managed simultaneously in 114 (95%) patients. Electrocauterization 27 (23%), pelvic packing 26 (22%), suturing 7 (6%), thumbtacks application 7 (6%), muscle welding 4 (4%), use of energy devices 2 (2%), and topical hemostatic agents 2 (2%) were the management tools. Combined techniques were used in 43 (36%) patients. Short-term morbidity and mortality rates were 48 (40%) and 2 (2%), respectively. High preoperative CRP levels (p = 0.04), history of preoperative radiotherapy (p = 0.04), longer bleeding time (p = 0.006), and increased blood transfusion (p = 0.005) were the factors associated with postoperative morbidity. CONCLUSION: Postoperative morbidity related to major pelvic hemorrhage can be reduced by optimizing the risk factors. Prehabilitation prior to surgery to moderate inflammatory status and prompt action with proper technique to control major pelvic hemorrhage can prevent excessive blood loss in complex abdominopelvic surgery.

Factors affecting operative morbidity and long-term outcomes in patients undergoing surgery for presacral tumours: a multicentric cohort study from the Turkish Collaborative Group for Quality Improvement in Colorectal and Pelvic Surgery.

AIM: Data regarding the operative management of presacral tumours present various dilemmas due to their rarity and heterogeneous nature. The aim of this study was to evaluate the management strategy, factors associated with operative morbidity and long-term postoperative outcomes in a large group of patients undergoing surgery for presacral tumours. METHOD: This study was designed as a multicentre retrospective cohort study. Records of patients who underwent surgery for presacral tumours at 10 tertiary colorectal centres between 1996 and 2017 were evaluated. RESULTS: One hundred and twenty seven patients (44 men) with a mean age of 46 years and body mass index of 27 kg/m2 were included. Fifty eight per cent of the patients had low sacral lesions (below S3). The operative approaches were transabdominal (17%), transsacral (65%) and abdominosacral (17%). The postoperative morbidity was 19%. Thirty per cent of the patients had a malignant tumour. Longer duration of symptoms (p = 0.001), higher American Society of Anesthesiologists score (p = 0.01), abdominosacral operations (p = 0.0001) and presacral tumours located above S3 (p = 0.004) were associated with an increased risk of postoperative morbidity. Overall long-term postoperative recurrence and mortality were 6% and 5%, respectively, within a 3-year mean follow-up period in patients with presacral malignant tumours. CONCLUSION: Reduced physical condition, omission of symptoms prior to surgery, combined resections and high sacral tumours are the risk factors associated with postoperative complications in patients undergoing surgery for presacral tumours. Meticulous planning of the operation and intensified perioperative care may improve the outcomes in high-risk patients.

Renal autotransplantation due to iatrogenic ureter injury: A case report.

Hardy and colleagues carried out 'Renal autotransplantation' for the first time in 1963 to treat severe ureter injury and it has evolved as a method used for complex treatment of trauma, renal artery diseases or ureteral stenosis. In case of proximal ureter injury, approximately 2/3 of which is iatrogenic, if the end-to-end anastomosis is not possible, renal autotransplantation, ileal ureter interposition or nephrectomy are alternative treatments. As technology advances, the use of ureterorenoscopy (URS) increases and in parallel with this iatrogenic injuries that occur during the process have increased as well. These types of injuries are generally in form of simple perforations (2-6%), but from time to time ureter avulsions are also observed (0.3%). In this article, a case is presented where renal autotransplantation is made following development of ureter avulsion during ureterorenoscopy process carried out due to right ureteral calculi and treatment options are discussed in the light of literatures.

Conventional versus endoscopic components separation technique: New anthropometric calculation for selection of surgical approach

Background/aim: Giant ventral incisional hernias (GVIHs) are hard to manage for surgeons. This problem was resolved in 1990 with the components separation technique (CST). We aimed to compare endoscopic and conventional CST for GVIHs and find a new anthropometric calculation. Materials and methods: In this prospective nonrandomized clinical trial, 21 patients were treated with endoscopic or conventional CST between 2012 and 2016. Eight patients (38.1%) were operated endoscopically and 13 (61.9%) conventionally on the basis of preoperative tomography results, hernia surface area (HSA), number of recent abdominal operations, comorbidities, and the presence or history of ostomy. Groups in which prosthetic material was applied were also compared with groups in which it was not Results: There was no statistically significant difference between endoscopic and conventional CST groups in terms of complications. A weakly statistically significant difference (P = 0.069) was found between the components separation index (CSI) of mesh-applied and not-applied patients. HSA/body surface area (BSA) was statistically significantly different between endoscopic and conventional CST groups. Conclusion: According to our results, HSA/BSA and CSI are statistically successful for preoperative prediction of mesh placement. Furthermore, HSA/BSA preoperatively successfully predicts whether conventional or endoscopic CST should be used in patients with GVIH

Fall of another myth for colon cancer: Duration of symptoms does not differ between right- or left-sided colon cancers.

BACKGROUND/AIMS: Patients with colorectal cancer continue to present with relatively advanced tumors that are associated with poor oncological outcomes. The aim of the present study was to assess the association between localization, symptom duration, and tumor stage. MATERIALS AND METHODS: A prospective, multicenter cohort study was conducted on patients newly diagnosed with a histologically proven colorectal adenocarcinoma. Standardized questionnaire-interviews were performed. Data were collected on principal presenting symptoms, duration of symptoms (time to first presentation to a doctor and time to diagnosis) and treatment, diagnostic procedures, tumor site, and stage of the tumor (tumor, node, and metastasis (TNM)). RESULTS: A total of 1795 patients with colorectal cancer were interviewed (mean age: 60.76±13.50 years, male patients: 1057, patients aged >50 years: 1444, colon/rectal cancer: 899/850, right side/left side: 383/1250, stage 0-1-2/stage 3-4: 746/923). No statistically significant correlations were found between duration of symptoms and either tumor site or stage. Principal presenting symptoms were significantly associated with left colon cancer. Patients who had "anemia," "change in bowel habits," "anal pruritus or discharge," "weight loss," and "tumor in right colon" had a significantly longer symptom time. CONCLUSION: Symptom duration is not associated with localization, nor is the tumor stage. Diagnosis of colorectal cancer at an earlier stage may be best achieved by screening of the population.

Publication rates of abstracts presented at the annual congress of the Turkish Society of Colorectal Surgery (years 2003-2011).

OBJECTIVE: The aim of our study is to examine the Publication Rate of Congress of Turkish Society of Colorectal Surgery meeting abstracts and determine the factors affecting publication rate. MATERIAL AND METHODS: All presentations at Congress of Turkish Society of Colorectal Surgery congresses held in 2003, 2007, 2009, 2011 were retrospectively assessed. Manuscripts indexed in Google-Scholar database were included. The meeting year, study type, presentation type, title and time to publication of studies were assessed. Actual impact factor values were assessed to introduce the scientific power of the journals. RESULTS: Among a total of 614 abstracts presented at these congresses, 139 (22.6%) presentations were published in various medical journals. The publication rate was higher in oral presentations as group compared to poster presentations (29.7% vs. 19.5%) (p<0.001). Mean time to publication period was 20.4 (±21.1) months. 78 (56.1%) of published articles were published in SCI-E journals while 61 (43.9%) were published in non-SCI-E journals. Experimental studies had a higher Publication Rate in analysis of publication rate according to study type (p<0.001). Prospective clinical studies had a higher publication rate than retrospective studies. The journals in which oral presentations had been published had greater impact factor than journals in which poster presentations had been published (p=0.02). If published; prospective clinical studies were published in journals with greater impact factor than retrospective studies (p=0.04). CONCLUSION: The quality of a meeting is correlated with the publication of abstracts accepted as presentations. Congress of Turkish Society of Colorectal Surgery congress is an efficient meeting for researchers, and have a lower PR as compared to international congresses while having a similar publication rate to equivalent scientific meetings. Being more selective during abstract acceptance should increase the Publication Rate and quality of Congress of Turkish Society of Colorectal Surgery congresses.

Urinary and sexual dysfunction rates and risk factors following rectal cancer surgery.

OBJECTIVE: The aim of this study was to express the effects of demographic characteristics, the type of the surgery, tumour characteristics and adjuvant therapy on urinary and sexual dysfunctions. MATERIALS AND METHOD: Pre-operational urinary and sexual dysfunctions of the patients were evaluated by using the surveys prepared according to International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF) in men and Index of Female Sexual Function (IFSF) in women. FINDINGS: A total of 56 patients were included in the study; 20 of them were women and 36 of them were men. The mean age was 56. Abdominoperineal resection (APR) was performed on 11 patients, and low anterior resection (LAR) was performed on 45. The post-treatment IPSS classes were worsened at a rate of 12.7 % compared to the pre-treatment. The mean post-treatment sexual dysfunction score of both men and women were decreased by 27.5 and 17.8 %, respectively. Rectal tumours located in the lower part resulted in more sexual dysfunction. CONCLUSION: The tumour in the 1/3 lower part of the rectal area was determined to be the most effective factor that caused both urinary and sexual dysfunction. Patients should be informed about the urinary and sexual dysfunctions in the pre-operative consultations.

Comparison of modified Limberg flap transposition and lateral advancement flap transposition with Burow's triangle in the treatment of pilonidal sinus disease.

BACKGROUND: Although many options exist for surgical treatment of pilonidal sinus disease (PSD), consensus has not yet been achieved, as all surgical methods have various rates of complications, postoperative infection, and recurrence. METHODS: This study was a prospective, randomized, clinical trial, and was conducted with consecutive 100 patients admitted to Ankara Military Hospital General Surgery Service for treatment of PSD from May 2013 to August 2013. This study compared two surgical treatments for PSD: modified Limberg flap transposition and lateral advancement flap transposition with Burow's triangle. The patients received surgical treatment with either modified Limberg flap transposition (n = 50) or lateral advancement flap transposition with Burow's triangle (n = 50). Clinical healing period, length of hospital stay, operative time, postoperative complications including recurrence, wound dehiscence, and surgical site infection, as noted during postoperative follow-up period; Visual Analog Scale scores for pain. RESULTS: The mean follow-up period was 12 months. No significant differences were observed between the 2 groups in length of hospital stay (P = .515), operative time (P = .175), wound dehiscence (P = .645), and Visual Analog Scale pain scores (P = .112). The mean operative times were 42.5 minutes in the modified Limberg group and 40.0 minutes in the lateral advancement group. CONCLUSIONS: Although lateral advancement flap transposition with Burow's triangle is used less often than modified Limberg flap transposition, we could not determine a parameter that was statistically different such as operative time, postoperative complication, or the length of hospital stay. Hence, the lateral advancement flap is as viable an option as other more preferable techniques in the treatment of PSD, which particularly settled on the upper segment without a deep natal cleft.

The Efficacy of Probiotic (Lactobacillus rhamnosus GG) and 5-ASA (Aminosalicylic Acid) in the Treatment of Experimental Radiation Proctitis in Rats.

The aims of the study are to demonstrate the effect of probiotic use on the healing of radiation proctitis (RP) and evaluate the efficiency of fecal biomarkers at follow-up of the treatment. Thirty-two male/female rats were randomly separated into four groups of eight rats. The first group (control) was not radiated. RP was created by 17.5 Gy single dose rectal irradiation. The second group (RP) was subjected to RP, but not treated. The third group (RP+ASA) was treated with 5-aminosalicylic acid (5-ASA) 250 mg/kg daily by gastric lavage for 14 days after the irradiation, and the forth group (RP+LGG) was treated with Lactobacillus GG (LGG) 25 × 100 million CFU daily. Feces samples were taken at the 7th and 14th day of the treatment for fecal biomarkers. Rectums of the rats were resected at the 14th day by laparotomy. Samples were evaluated both macroscopically and microscopically. RP was achieved both macroscopically and microscopically. Weight loss of RP group is statistically significant (p < 0.005) than other groups. The healing ratio of RP+ASA and RP+LGG groups was significantly better than the RP group (p < 0.005) both macroscopically and microscopically. But there was no significant difference between ASA and LGG groups. Biochemically, fecal calprotectin was found to be more effective than fecal myeloperoxidase and fecal lactoferrin to show the efficacy of treatment of radiation proctitis. The results of our study demonstrate that probiotic is as effective as 5-aminosalicylic in the treatment of radiation proctitis, and fecal calprotectin is a useful biomarker in determining the response to the treatment.

Use of self-expanding covered stent and negative pressure wound therapy to manage late rectal perforation after injury from an improvised explosive device: a case report.

Blast injuries, caused by explosions accompanied by high-pressure waves, produce tissue damage in the acute period, followed in the later period by circulatory disorders due to vascular endothelial damage and related tissue necrosis. Blunt rectal perforation is rare and difficult to diagnose. In the acute period following blast pelvic injuries, the main objectives are to stop bleeding, minimise contamination and preserve the patient's life. The patient in this report had major vascular injuries, severe pelvic injury and, in the later period, rectal perforation because of vascular endothelial damage caused by the blast effect. Our aim was to treat the patient conservatively because of his poor general condition. We placed a self-expanding covered stent (SECS) into the rectum and then applied negative pressure wound therapy (NPWT; V.A.C.® Therapy, KCI) to the pelvic region and perirectal area. At the end of the treatment, the rectal perforation was closed, and the patient was discharged with healing. In this article, we discuss the novel use of an SECS with NPWT and review related literature.

The use of single port surgery for polyps located in the rectum.

Transanal endoscopic microsurgery is a minimally invasive technique for the treatment of rectal lesions which was introduced by Buess. In this report the first clinical experience of transanal endoscopic surgery was performed by a single incision laparoscopic surgical port adapted through the anal canal. In single port surgery, the single incision laparoscopic surgical port has to be stitched around anal orifice. There is no need to use a fixation apparatus. In transanal endoscopic microsurgery procedure, a rigid rectoscope 40 mm in diameter is introduced into the anus by stretching anal sphincter. A single incision laparoscopic surgical port can be disposed through the anal canal where there is no harmful cause because it is made an elastic. The dissection in the transanal endoscopic microsurgery procedure needs specific equipment to improve the surgery; however we could complete the surgical dissection using standard laparoscopic devices with articulated ones. The other factor makes single port surgery easier than transanal endoscopic microsurgery procedure is insufflation. It is easy and controlled way to be insufflated by a particular pump and cheaper than any insufflators. Furthermore, in the operating room, the patient's position on the table was not a limiting factor. As a conclusion, we report that for selected patients, single port surgery can be performed using a single incision laparoscopic surgical port as an adjusted surgical technique. It gives safe and feasible way to remove benign and malign polyps and tumors up to 20 cm in the rectum.

Single-incision laparoscopic cholecystectomy versus laparoscopic cholecystectomy: a prospective randomized study.

This prospective randomized study compared single-incision laparoscopic cholecystectomy (SILC) and laparoscopic cholecystectomy (LC) with respect to estimated blood loss, operative time, postoperative pain levels, and complications. Thirty-four study patients were divided into 2 groups: 17 patients underwent SILC and 17 underwent LC. Operative time was longer for SILC than for LC, and the difference was statistically significant (P<0.001). There was no statistically significant difference in the relationship of body mass index with operative time between SILC and LC (P=0.613, P=0.983, respectively). The 2 groups had no statistically significant differences with respect to visual analog scale scores, estimated blood loss, shoulder pain, or complications (P>0.05). SILC can be the treatment of choice for gallbladder disease. Although the surgeon's first several attempts at SILC require a longer operative time compared with LC, there are no differences in hospital length of stay, blood loss, complication rates, or pain scores between SILC and LC.

Use of vacuum-assisted closure (VAC™) in high-energy complicated perineal injuries: analysis of nine cases.

Our study reviewed nine patients who were treated with the VAC™ Abdominal Dressing System after suffering pelvic fractures and soft tissue loss after high-energy pelvic trauma. Between March 2008 and August 2009, our clinic treated nine patients with complicated perineal injuries from high-energy pelvic trauma with multiple irrigation and debridement procedures and broad-spectrum antibiotics. Protective ostomies were created for all nine patients. Required interventions were made for associated injuries, and VAC™ application was started. All patients were male, with an average age of 24·3 (range 21-32) years, and a mean injury severity score of 36·4 (range 16-59). Wound diameters ranged from 15 to 30 cm, and wound depths ranged from 5 to 25 cm. The injuries included one traumatic bilateral hemipelvectomy, and three unilateral and two bilateral lower extremity amputations. Intensive care unit length of stay averaged 12 (6-19) days, and average hospital length of stay was 44·12 (31-64) days. Beginning at an average of day 17 (±5·9 days) post-injury, wound cultures detected no bacterial colonisation. One patient died on the sixth day after injury from septic complications. Two patients' wounds were closed by primary closure, and six patients' wounds were closed by split thickness grafts after an average of 31·4 (17-50) days. Optimal treatment of high-energy perineal injuries requires early and extensive debridement and rich irrigation. The application of the VAC™ system as temporary coverage of large complex wounds in the pelvic region enhances wound healing and facilitates an early grafting process.

A new method for hepatic resection and hemostasis: absorbable plaque and suture.

OBJECTIVE: Blunt and penetrating hepatic injuries are conditions that are frequently encountered in emergency surgeries, and they involve high mortality morbidity. In the handling of such injuries, methods ranging from the application of simple cauterization and suturing for hemostasis to hepatic lobectomies, which might involve the removal of the greater part of the organ, have been defined. Due to the organ's fragility and susceptibility to bleeding, elective hepatic resections necessitate both surgical experience and technological equipment. Therefore, the demand still exists for an affordable and easy-to-use-method that could be applied by all centers. MATERIALS AND METHODS: To meet this demand, we have developed a method of hemorrhage control via sutures supported by absorbable plaques that provide effective compression and prevent the suture from cutting the tissue during the application of the sutures in the treatment of such fragile organs as the liver. In our method, we have achieved hemostasis by bilaterally compressing the tissue through strong ties after placing, on the part of the tissue on which the sutures are applied, absorbable and flexible plaques that prevent the suture from cutting the tissue during the application of a polyglactin suture to the solid organ. To prevent dislocation of the plaques, we have fastened the sutures by reeving them through the holes made in the plaques. RESULTS: We have demonstrated the success and the practicality of our method by applying it on four pigs; we experimentally inflicted hepatic injuries on two pigs, and we performed resection on the other two pigs. The hepatic hemorrhages we developed in both of the animals were successfully restrained by the use of our method. On the other hand, two resections were performed on the right and left lobes of the other two animals. There were no hemorrhages during the surgery, and the procedure took 45 minutes in total. No postoperative complications occurred. While the liver function test values were high on the seventh day, due to the operation, they were observed to be normal on the thirtieth day. After the laparotomies, performed six months later, we observed that the plaques as well as the sutures were absorbed and that the injured tissues were completely healed. Additionally, it was observed during the pathological examination that the tissues beneath the area of application were healed through fibrosis and that the liver had no other pathologies. CONCLUSIONS: In conclusion, we believe that the method can be safely used in hepatic resections or traumatic hemorrhages in the proper locations.

Hospital experience, body image, and cosmesis after laparoscopic or open splenectomy.

BACKGROUND: Laparoscopic splenectomy (LS) is becoming the "gold standard" technique for splenectomy. The aim of this study was to evaluate the hospital experience, body image, and cosmesis after LS or open splenectomy (OS). METHODS: Patients who underwent LS or OS were invited to fill out questionnaires evaluating their hospital experience, body image, and cosmetic results. A total of 72 patients (34 LS and 38 OS) agreed to participate in the study. RESULTS: No significant difference was observed between the groups in terms of age, sex, body mass index, or indication for splenectomy. Mean spleen weight and postoperative complications were slightly higher (P>0.05) and the postoperative hospital stay was significantly longer (P<0.05) in the OS group compared with the LS group. Scores from the modified Body Image, Hospital Experience, and Photo Series Questionnaires were higher (favorable) in the LS group compared with the OS group (P<0.01, P<0.001, and P<0.001, respectively). CONCLUSIONS: LS is the procedure of choice for most indications of splenectomy, which has comparable or better perioperative outcomes and complication rate as well as the advantages of better body image, cosmesis, and hospital experience compared with OS. Our results presenting improved outcomes with LS will contribute to the widespread application of laparoscopy for splenectomy.

A novel laparoscopic suction device for applying precise aspiration during laparoscopic surgery: sponge-tip suction tube.

Aspiration of the intra-abdominal fluid and debris is usually needed during different stages of the operation. This is necessary to protect the intra-abdominal space from contamination and/or to remove blood or tissue fluids occurring during the operation. It is also essential for obtaining a clean surgical area. Aspiration of the intra-abdominal fluid is relatively more difficult in laparoscopic surgery because of the suctioning of the omentum and intestine with the aspirator. In this paper, we report on a new suction device (sponge tip suction tube; STST), which allows the surgeon easier suctioning of intra-abdominal fluid. STST has an additional sponge tip and air channel, which prevents the device from suctioning intra-abdominal organs, such as the intestine and omentum. We tested the efficacy of STST in a simulated intra-abdominal space, such as a large transparent plastic bag with fresh sheep intestine-omentum and with 2000 cc of physiologic saline solution and 14 mm Hg of air pressure. Whereas the suctioning of all the fluid was difficult and time consuming when the conventional suction unit was used, all of the saline solution was easily and quickly suctioned when STST was used. In conclusion, STST provides a safe, fast, and complete fluid extraction.

Prognostic importance of increased cyclooxygenase-2 levels in colorectal carcinomas: a 5-year single-institution study.

OBJECTIVE: COX-2-selective inhibitors are used in the prevention and management of colorectal carcinogenesis. Our objective was to investigate if COX-2 levels have prognostic value in patients diagnosed with colorectal carcinoma. MATERIALS AND METHODS: This is a retrospective study of 112 patients diagnosed with colorectal carcinoma between 2000-2004 from the General Surgery Department at Haydarpasa Training Hospital, Gulhane Military Medical Academy. Patients were assessed according to age, gender, localization of the tumor, stage of the tumor, remote metastasis status, patient survival, COX-2 levels and grade of differentiation. RESULTS: COX-2 levels significantly affect the duration of survival (P=0.026) and overall survival (P=0.013). The COX-2 significance value showed a tendency to change from negative to positive while a statistically meaningful decrease was observed in the survival value (r=-0.25; P=0.007) in groups related with the survival duration of cases (r=-0.24; P=0.01). The median survival was 36 (26.35-45.65) months. During the examination of survival statuses of cases, a statistically meaningful difference was determined between patients whom were alive and dead (P=0.01). CONCLUSION: We conclude that COX-2 levels are a negative predictor of survival.