Stapled End-To-Side Ileocolic Anastomosis in Crohn's Disease: Old Dog, Reliable Tricks? A Retrospective Two-Center Cohort Study.

Objective: Analyze our long-term experience with a less-popularized but stalwart approach, the stapled end-to-side ileocolic anastomosis. Background: The choice of technical approach to ileocolic anastomosis after ileocecal resection for Crohn's disease affects surgical outcomes and recurrence. Yet, despite heterogeneous data from different anastomotic configurations, there remains no clear guidance as to the optimal technique. Methods: In a retrospective cohort design, patients undergoing ileocolic anastomosis in the setting of Crohn's disease between 2016 and 2021 at two institutions were identified. Patient characteristics and surgical outcomes in terms of recurrence (surgical, clinical, and endoscopic) were studied. Results: In total, 211 patients were included. Before surgery, 80% were exposed to at least 1 cycle of systemic steroids and 71% had at least 1 biologic agent; 60% exhibited penetrating disease and 38% developed an intra-abdominal abscess. After surgery, one anastomosis leaked (0.5%). Over 2.4 years of follow-up (IQR = 1.3-3.9), surgical recurrence was 0.9%. Two-year overall recurrence-free and endoscopic recurrence-free survivals were 74% and 85% (95% CI = 68-81 and 80-91), respectively. The adjusted hazard ratio of endoscopic recurrence was 3.0 (95% CI = 1.4-6.2) for males and 5.2 (1.2-22) for patients who received systemic steroids before the surgery. Conclusion: The stapled end-to-side anastomosis is an efficient, reliable, and reproducible approach to maintain bowel continuity after ileocecal resection with durable outcomes. Our outcomes demonstrate low rates of disease recurrence and stand favorably in comparison to other more technically complex or protracted anastomotic approaches. This anastomosis is an ideal reconstructive approach after ileocecal resection for Crohn's disease.

Impact of COVID-19 on operating assignments in residency training of endocrine surgery: A retrospective cohort study.

PURPOSE: Airborne pandemics illustrate a significant problem in training grounds. From the endocrine surgery point of view, we scrutinized the impact of Covid-19 on general surgery residency training in our university hospital. METHODS: The number of endocrine procedure curves was forecasted using the expert modeler in a time series model from March to September 2020 based on data from previous years. We then compared the estimation curves to actual numbers. RESULTS: There were 1340 resident participants in thyroid procedures, 405 in parathyroid procedures, 65 in other neck procedures, and 304 in adrenal procedures. In 884 of the endocrine procedures, the operating surgeon was a resident. The median experience of operating residents in endocrine procedures was 3.2 years (interquartile range 2.7-3.6) before the impact and 3.8 years (interquartile range 3.1-4.1) after it (p = 0.023). The monthly number of actual procedures with at least one resident participation in the Covid-19 period was significantly lower (8.7 ± 7.5 vs. 19.9 ± 3.7, p = 0.012) than the forecasted numbers. There were no semi-autonomous operating chief residents, although we expected a moderate level (0 actual vs. 0.5 ± 0.2 predicted, p = 0.002). CONCLUSION: This study clearly represents sustainability in surgical training and includes usual trends. Essential endocrine surgical procedures the pandemic disrupted the most were the treatment of thyroid and parathyroid diseases. Covid-19 reduced our surgical volume and resulted in delays in training. A full-scale disaster plan is necessary for possible crises threatening surgical education.

Early Onset Outlet Obstruction of a Temporary Diverting Loop Ileostomy Secondary to Urinary Retention.

A mechanical obstruction is not a physiological entity, and when it occurs within the 30-day postoperative period, it is called an early postoperative small bowel obstruction. Kinking of small bowel segments at the ileostomy outlet secondary to a distended bladder is an unusual source of early postoperative small bowel obstruction. A 36-year-old female underwent a redo J-Pouch surgery and creation of loop ileostomy after pouch failure related to recurrent small bowel obstruction and perianal fistulae. Her foley catheter was removed on postoperative day 3 and she passed a trial of void test. On postoperative day 6, the abdomen became progressively more distended. Computerized tomography (CT) imaging with IV contrast showed small bowel distension extending to the midline anterior to the urinary bladder where it demonstrated a narrowed lumen. These findings were thought to be the cause of small bowel obstruction at this level before the ileostomy. Immediately after CT, a foley catheter was applied with which 2 L of urine was removed, and consequently, gas and stool were observed in the ostomy soon thereafter. Although rare, urinary retention may cause intestinal obstruction, especially in the presence of a loop ileostomy in close proximity.

Preoperative cross-sectional imaging findings in patients with surgically complex ileocolic Crohn's disease.

PURPOSE: The aim of this study was to evaluate the diagnostic performance of preoperative cross-sectional imaging findings using the SAR-AGA definitions in Crohn's disease (CD) patients who underwent ileocolic resection (ICR) with and without surgically complex ileocolic CD (CIC-CD). METHODS: 69 CD patients [38 men; mean (± SD) age: 40.6 (16.2) years] who underwent ICR were retrospectively classified by surgical complexity by a colorectal surgeon using operative findings. CIC-CD was defined as ileal CD, not confined to the distal ileum. Two radiologists retrospectively evaluated the preoperative imaging for the presence and type of penetrating disease, stricture, or probable stricture using the SAR-AGA consensus definitions. The diagnostic performance of preoperative imaging findings was compared for patients with and without CIC-CD. Estimated blood loss (EBL), operative time (OT), conversion to open surgery, diversion, and length of hospital stay (LOS) were compared. RESULTS: 60.9% had CIC-CD and 79.7% underwent primary ICR. Penetrating disease was more common in patients with than without CIC-CD (76.2% vs. 40.7%, p = 0.0048) and similar among primary versus redo ICR (p = 0.12). Patients with CIC-CD had more complex fistulas (59.5% vs. 11.1%; p < 0.0001) and fewer simple fistulas (2.4% vs. 18.5%; p = 0.03) than those without. Mesenteric findings (abscess, inflammatory mass) were more frequent in patients with (35.7%) than without (0%) (p = 0.0002) CIC-CD. Stricture and probable stricture were similar (p = 0.59). CIC-CD patients had greater EBL (178 cc vs. 57 cc, p = 0.006), conversion rates (30% vs. 0%, p = 0.0026), and diversion (80% vs. 52%, p = 0.04). CONCLUSION: Complex fistula, mesenteric abscess, or inflammatory mass defined by the SAR-AGA guidelines suggests CIC-CD. ICR for CIC-CD had greater EBL, conversion to open surgery, and diversion.

Learning-by-teaching coming into play as a reliable trick for lower GI procedures: a learning curve analysis in 13,210 operative logs including the COVID-19 era.

After suspecting a plunge in the operative case logs in our clinic, we wanted to explore the COVID-19 impact on surgical training side of the lower gastrointestinal procedures to raise awareness of the possible cracks in the pillars of general surgery residency. Comparing the coronavirus impact to previous years starting from 2014, we examined the procedures of our residents for their roles in the operating room. We performed interrupted time-series analyses to get a sense of the magnitude and then used a new index to identify the trend of change in operator-to-first assistant rate of experience and searched for signs of learning-by-teaching motives. In total, 13,210 operative logs of residents were included; of procedures, 3483 (41%) were emergency. Both overall resident participations and learning-by-teaching dropped during first 3 months, followed by a rebound. The overall operator-to-first assistant rate of experience was 1.06 before and 0.86 after. Emergency procedures, obstruction, perforation, enterostomy closure, appendix, colon, anus and minimally invasive procedures, and COVID-19 were associated with learning-by-teaching (OR and 95% Cl were; 2.20, 1.76-2.75; 0.56, 0.36-0.85; 0.50, 0.38-0.67; 2.29, 1.44-3.63; 11.09, 8.33-14.75; 1.75, 1.32-2.32; 2.56, 2.03-3.22; 0.80, 0.65-0.99 and 1.93, 1.54-2.42, respectively) (p < 0.05). The study provided insights into a vastly underrated surgical education subject: learning-by-teaching. The training index introduced here was a valuable learning curve instrument that has the capacity of comparing different training parameters or different residency programs. The surge in learning-by-teaching after the pandemic was interpreted as a reflex, processing the teaching as a training tool.

Impact of older age on the long-term survival in living-donor liver transplantation: A propensity score matching analysis.

BACKGROUND: Prevalence of the end-stage liver disease in the elderly patients indicating a liver transplantation (LT) has been increasing. There is no universally accepted upper age limit for LT candidates but the functional status of older patients is important in pre-LT evaluation. This study aimed to examine the impact of older age on survival after living donor liver transplantation (LDLT). METHOD: A total of 171 LDLT recipients were assessed in two groups: age ≥65 and < 65. To eliminate selection bias propensity score matching (PSM) was performed, and 56 of 171 recipients were included in this study. RESULTS: There were 20 recipients in the older group and 36 in the younger. The 1-, 3-, and 5-year survival rates were 65.0%, 60.0%, and 60.0% in group 1; 88.9%, 84.7%, and 71.4% in group 2, respectively. The 1-year survival was significantly lower in the older recipients; however, overall survival rates were similar between the groups. Of the 56 recipients, 15 (27%) deaths were observed in overall, and 11 (20%) in 1-year follow-up. The univariate regression analysis after PSM revealed that MELD score affected 1- year survival and the multivariate analysis revealed that age ≥65 years and MELD score were the predictors of 1-year survival. CONCLUSION: At first sight, before PSM, survival appeared to be worse for older recipients. However, we have shown that there were confounding effects of clinical variables in the preliminary evaluation. After the elimination of this bias with PSM, This study highlights that older recipients have similar outcomes as youngers in LDLT for long-term survival.

Safety and Threshold Analysis of Preoperative Platelets in Right Lobe Living Donors for Liver Transplantation.

BACKGROUND: Low perioperative platelet count is a powerful independent risk factor for posthepatectomy liver failure. Usually, categorical effect of thrombocytopenia was taken into account; upper thresholds were not studied in depth, exclusively in living liver donors. METHODS: Living liver donors who underwent right hepatectomy were included. Preoperative characteristics of donors were identified and examined to predict posthepatectomy liver failure. To eliminate selection bias, one-to-one propensity score matching was performed. RESULTS: There were a total of 139 living donors and 40 (29%) donors developed posthepatectomy liver failure in the aftermath of the operation. Remnant liver volume ratio and preoperative platelet count were identified as adjustable independent risk factors (OR: 0.89 and 0.99, 95% CI: 0.79-0.99 and 0.98-0.99, respectively). After propensity score matching, odds ratio of preoperative platelet count was 0.99 (95% CI: 0.98-1.00). CONCLUSIONS: Preoperative platelet count, in addition to remnant liver volume ratio, can be used as a surrogate marker to predict the risk of posthepatectomy liver failure in living liver right lobe donors. Probability curves figured out from logistic regression analysis, in this regard, provided an explicit perspective of platelets having a decisive role on liver donor safety. Thus, remaining in safer remnant liver volume ratio limits with respect to preoperative platelet count should be addressed in safe donor selection strategies.

Role of Serial Transverse Enteroplasty in the Management of Adult-Type Short Bowel Syndrome: Experience from a Single Tertiary Referral Hospital in Turkey.

BACKGROUND: There is little knowledge with regard to the management of intestinal failure in countries where home care services and dedicated intestinal rehabilitation centers are limited. This study presents a single-center experience of treating adult-type short bowel syndrome (SBS) with serial transverse enteroplasty (STEP). METHODS: Medical records were retrospectively reviewed from November 2009 to April 2018 on patients with adult-type SBS. All patients underwent STEP, and a representative quota sample of control patients treated with conventional measures were included. Clinico-demographic characteristics including baseline and post-treatment information about the orientation of bowel alignment and nutritional status were evaluated. RESULTS: The mean patient age was 51.1 ± 16.2 in the STEP group and 57.6 ± 12.7 in the control group (P = .304). The median small bowel length was 60 cm (interquartile range (IQR): 40-90) in the STEP group (before the lengthening) and 90 cm (IQR: 70-100) in the control (at the initiation of intestinal rehabilitation) (P = .035). Durations of median follow-up were 18 months (IQR: 14-58) and 10 months (IQR: 3-14), respectively (P = .019). In the STEP group, the mean increase in bowel length after STEP was 37.3 ± 11.6 cm, and at their follow-up 7 patients (64%) had successfully progressed to enteral autonomy. In the control group, only 3 patients (27%) were successful. Mean time to wean parenteral nutrition was 45 ± 54 days, and the mean increase in enteral calorie intake was 1.79 ± 1.60-fold after lengthening in the STEP group. CONCLUSIONS: STEP is an easy-to-perform procedure in the surgical rehabilitation of adult-type SBS. When performed simultaneously with reconnection surgery, it may offer a cost-effective and comprehensive solution to the treatment strategy in middle income settings.

Breast Cancer in Turkey; An Analysis of 20.000 Patients with Breast Cancer.

OBJECTIVE: Breast cancer is the most common type of cancer and the leading cause of cancer-related deaths in women in Turkey. This study presents the characteristics of patients registered in National Breast Cancer Registry Program of Turkish Federation of Breast Diseases Societies. MATERIALS AND METHODS: The registry contains 242 variables under 10 categories and 699 questions. Patients were recorded (online and offline) from nationwide breast centers around Turkey. RESULTS: Twenty-thousand patients were registered between May 2005 and April 2017 at 36 centers. After data cleaning, 19,503 women were included in the study. The median age at diagnosis was 51 [14-97]; 17.2% were younger than 40 and 37.2% were premenopausal; 13.6% were nulliparous. Breast conserving surgery rate was 39.3%. Histopathology was invasive ductal cancer in 77%. Majority of patients had stage II cancer (48.3%). Estrogen, progesterone and HER-2 receptor positivity rates in invasive breast cancer were 72.5%, 62.5% and 21.8%, respectively. The mean tumor diameter was 2.5±1.7 cm. During the mean 51.6 months of follow-up, the local/regional and systemic recurrence rates were 3.7% and 5.2%, respectively; five and 10-year overall survival rates were 86% and 76%. CONCLUSION: Despite increasing number of screening centers and free-of-charge mammography (ages 40 to 69) and mobile screening systems in recent years, a significant portion of patients were diagnosed at advanced stage due to lack of breast cancer awareness. In contrast with the study published 5 years ago, there was a decrease in the rate of pre-menopausal women and an increase in the breast conserving surgery.

Oncoplastic approach to excisional breast biopsies: a randomized controlled, phase 2a trial.

BACKGROUND: Oncoplastic surgery has been used in breast cancer patients for better cosmetic outcome over the last decades. The aim of this prospective randomized study is to show its place in excisional breast biopsy. METHODS: An oncoplastic approach excision was compared with conventional excisional breast biopsies. The study included 80 patients, of whom half received oncoplastic intervention and half received the conventional. The primary endpoint was the cosmetic result. Patient, surgeon and independent observers rated the results on a four-point scale. Scores other than self-perceived were based on third-month medical photographs. RESULTS: Between May 20, 2015 and April 27, 2016, 40 patients were randomly assigned to oncoplastic biopsy and 40 patients were assigned to conventional excisional biopsy. Median follow-up was 5.6 months (IQR 3.0-6.0). Self-perceived perfect scoring for general cosmetic outcome was found significantly higher after oncoplastic biopsy (73 0.5%) comparing with control group (32.4%) (p = 0.001). This impact did not change after adjusting patients for potential confounders. Margin clearance rates in malignant cases were comparable in both arms (p = 0.999); four patients in oncoplastic biopsy group (40%) and three patients in control group (33%) had positive margins. CONCLUSIONS: The oncoplastic biopsy achieved better cosmetic results with similar surgical margin positivity rates when compared with conventional breast biopsy. It may be a better biopsy option used for patients requiring excisional breast biopsy.

An unusual case of primary colonic dedifferentiated liposarcoma.

INTRODUCTION: In this paper, we present a rare case of primary dedifferantiated liposarcoma (DDLS) of the colon, management of which is unclear and difficult to cope with. PRESENTATION OF CASE: 71 year old female patient with complaints of abdominal pain and swelling was referred to our clinic with the diagnosis of intraabdominal mass. 23cm×19cm×18cm tumor starting from the neighborhood of left liver lobe and extending toward pelvic floor was detected on computed tomography. At laparotomy, a multilobulated, soft and yellowish mass was arising from transvers colon and invading greater curvature of stomach. En-bloc removal of the tumor including segmental colon and gastric wedge resection was performed. Postoperative histopathological diagnosis was consistent with dedifferentiated liposarcoma. DISCUSSION: Liposarcomas are rarely encountered in the gastrointestinal tract. Previously, only ten cases of primary liposarcoma of the colon have been reported worldwide and to our knowledge DDLS of transverse colon is the first case reported in the literature. DDLS is a high-grade aggressive tumor carrying the ability to metastasize. Despite complete removal of tumor recurrence is common in DDLS. CONCLUSION: The constellation of findings in our patient demonstrates that liposarcomas which histologically exhibit dedifferentiation are associated with a poor clinical prognosis and advocating surgery alone is not recommended.