Management of granulomatous lobular mastitis: an international multidisciplinary consensus (2021 edition).

Granulomatous lobular mastitis (GLM) is a rare and chronic benign inflammatory disease of the breast. Difficulties exist in the management of GLM for many front-line surgeons and medical specialists who care for patients with inflammatory disorders of the breast. This consensus is summarized to establish evidence-based recommendations for the management of GLM. Literature was reviewed using PubMed from January 1, 1971 to July 31, 2020. Sixty-six international experienced multidisciplinary experts from 11 countries or regions were invited to review the evidence. Levels of evidence were determined using the American College of Physicians grading system, and recommendations were discussed until consensus. Experts discussed and concluded 30 recommendations on historical definitions, etiology and predisposing factors, diagnosis criteria, treatment, clinical stages, relapse and recurrence of GLM. GLM was recommended as a widely accepted definition. In addition, this consensus introduced a new clinical stages and management algorithm for GLM to provide individual treatment strategies. In conclusion, diagnosis of GLM depends on a combination of history, clinical manifestations, imaging examinations, laboratory examinations and pathology. The approach to treatment of GLM should be applied according to the different clinical stage of GLM. This evidence-based consensus would be valuable to assist front-line surgeons and medical specialists in the optimal management of GLM.

Association of CDH1 -160 C → A and -347 G→ GA polymorphisms and expression of E-cadherin and gastric cancer: A case-control study.

OBJECTIVES: The loss of function of the E-cadherin (CDH1) gene with -160 C→A and -347 G→GA polymorphisms is regarded as a critical step for gastric cancer. It was aimed to investigate possible association of these polymorphisms and immunoexpression of E-cadherin with gastric cancer. MATERIAL AND METHODS: Gastric adenocarcinoma patients and individuals with benign gastric pathologies were included in this case-control study. Demographic data and pathological findings were recorded. Immunohistochemical staining of E-cadherin expression and analysis of -160 C→A and -347 G→GA polymorphisms were done. Differences between allele frequencies of -160 C→A and -347 G→GA polymorphisms and expression of E-cadherin were the primary outcomes. RESULTS: There were 78 gastric cancer patients (Group A) and 113 individuals with benign gastric pathologies (Group B). The number of male patients and mean age were higher in Group A (p <0.001). -160 C→A and 347 G→GA polymorphisms and their allelic distributions showed no difference between the groups (p> 0.05 for all). There was a significant association between -160 C→A polymorphism and grade of E-cadherin expression (p= 0.013). There were no significant differences between survival rates with -160 C→A, 347 G→GA and intensity of E-cadherin expression (p> 0.05 for all). There was no significant association between -160 C→A and -347 G→GA polymorphisms and gastric cancer. CONCLUSION: There was no impact of E-cadherin expression on tumoral features and survival in gastric cancer. -160 C→A polymorphism may influence the expression of E-cadherin in gastric cancer.

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.

Hand-assisted Laparoscopic Left Donor Nephrectomy Without a Hand-assisted Device: Is it Possible?

BACKGROUND: Live donor nephrectomy is an important donor source. Donor nephrectomy can be performed by laparoscopy or hand-assisted laparoscopy. Different types of hand port devices can be used for assistance. In the literature there are few studies about hand-assisted laparoscopy without a hand port. In this study, we aimed to evaluate the impact of not using a hand port for hand-assisted laparoscopic donor nephrectomy for kidney transplantation. METHODS: Patients who were operated on for kidney donation between January 2011 and June 2018 evaluated retrospectively. The patients were divided into 2 groups: group A, on whom a hand port was used, and group B, whose surgeries did not involve a hand port. The groups were compared for sex, age, body mass index, amount of intraoperative bleeding, warm ischemia time, duration of surgery, perioperative complications, duration of hospital stay, and postoperative complications. RESULTS: There were 159 patients in group A and 146 patients in group B. There was no difference between the groups considering intraoperative bleeding, warm ischemia time, duration of surgery and postoperative early complications (P > .05 for all). CONCLUSION: Hand-assisted laparoscopic donor nephrectomy without a hand port can be considered an easy and effective method of laparoscopic nephrectomy.

Prospective multi-center study of surgeon's assessment of the gallbladder compared to histopathological examination to detect incidental malignancy.

PURPOSE: Routine histopathological examination after cholecystectomy for gallstones is performed despite the low rates of incidental findings of malignancy. The aim of this study was to assess predictive values of macroscopic examination of cholecystectomy specimens by surgeons in gallstone disease. METHODS: A prospective multi-center diagnostic study was carried out between December 2015 and March 2017 at four different centers. All patients undergoing cholecystectomy for gallstone disease were consecutively screened for eligibility. Patients whose ages are 18 to 80 years, and preoperative imaging findings without any pathology except cholelithiasis were included. The gallbladder was first evaluated macroscopically ex situ by two operating surgeons and rated as macroscopically benign (group S1), suspicious for a benign diagnosis (group S2), and suspicious for malignancy (group S3). Thereafter, a pathologist made a final histopathological examination whose results are grouped as chronic cholecystitis (group P1), benign or precancerous lesions in which only cholecystectomy is the adequate treatment modality (group P2), and carcinoma (group P3). Diagnostic accuracy of the surgeon's assessment to the histopathological examination was evaluated using sensitivity, specificity, positive and negative predictive values, and accuracy, and correlated by a kappa agreement coefficient. RESULTS: A total of 1112 patients were included in this trial. The specificity rates were 96.5%, 100%, and 98.7% for group S1-group S2, group S1-group S3, and group S2-group S3, respectively. Accuracy rates to detect malignancy were 100% and 95. 2% for group S1 and group S2, respectively. Kappa coefficient values were 1.0 and 0.64 for group S1-group S3 and group S2-group S3, respectively (p < 0.001 for both). CONCLUSION: Assessment of the gallbladder specimen and selective histopathological examination may be adequate after cholecystectomy for gallstone diseases. Such a procedure would have the potential to reduce costs and prevent unnecessary loss of labor productivity without affecting patients' safety. However, higher number of patients in more centers is needed to confirm this hypothesis.

Nonclosure of the Peritoneum during Appendectomy May Cause Less Postoperative Pain: A Randomized, Double-Blind Study.

Objective: We aim to evaluate the effect of peritoneal closure on postoperative pain and life quality associated with open appendectomy operations. Methods: This is a single-center, prospective, randomized, and double-blinded study. Here, 18-65-year-old patients who underwent open appendectomy for acute appendicitis were included. Demographic data of the patients, operation time, length of hospital stay, pain scores using a 10 cm visual analogue scale (VAS) on the first postoperative day, quality of life assessment using the EuroQol-5D-5L questionnaire on postoperative 10th day, deep wound dehiscence, bowel obstruction, and mortality data were recorded. Results: In total, 112 patients were included in the study. The demographic data showed no significant difference between the groups. The median VAS score was lower in the group with open peritoneum, but this difference was not statistically significant (3 vs. 4, p=0.134). The duration of surgery was significantly shorter in the peritoneal nonclosure group (31.0 ± 15.1 vs. 38.5 ± 17.5 minutes, p=0.016). Overall complication rates and life quality test (EuroQol-5D-5L) results were similar between groups. Conclusion: Nonclosure of the peritoneum seems to shorten the duration of surgery without increasing complications during open appendectomy. Postoperative pain and life quality measures were not affected by nonclosure of the peritoneum. This trial is registered with NCT02803463.

Comparison of Laparoscopic and Conventional Cystotomy/Partial Cystectomy in Treatment of Liver Hydatidosis.

INTRODUCTION: Hydatidosis is a zoonotic infection and treatment is mandatory to avoid complications. Surgery remains the first choice in the treatment especially for CE2-CE3b cysts. Open or laparoscopic approaches are available. However, comparative studies are limited. MATERIALS AND METHODS: Data of patients who underwent cystotomy/partial cystectomy for liver hydatidosis between January 2012 and September 2016 (n=77) were evaluated retrospectively. Recurrent cases and the patients with previous hepatobiliary surgery were excluded. 23 patients were operated upon laparoscopically and named as Group 1. 48 patients operated conventionally named as Group 2. Demographics, cyst characteristics, operative time, length of hospital stay, recurrences, and surgery related complications were evaluated. RESULTS: Groups were similar in terms of demographics, cyst characteristics, and operative time. The length of hospital stay was 3.4 days in Group 1 and 4.7 days in Group 2 (p=0,007). The mean follow-up period was 17.8 months and 21.7 months, respectively (p=0.170). Overall complication rates were similar in two groups (p=0.764). Three conversion cases occurred (13%). One mortality was seen in Group 2. Four recurrences occurred in each group (17% versus 8.3%, respectively) (p=0.258). CONCLUSIONS: Laparoscopy is a safe and feasible approach for surgical treatment of liver hydatidosis. Recurrence may be prevented by selection of appropriate cases in which exposure of cysts does not pose an intraoperative difficulty.

Is it beneficial to use clinical scoring systems for acute appendicitis in adults?

BACKGROUND: Clinical scoring systems have been used to reduce negative appendectomy rate for several decades. However, the use of these systems has been questioned due to differences in their diagnostic accuracies. The aim of this prospective study was to develop a new clinical scoring system using a combination of all previously described variables for the diagnosis of acute appendicitis (AA). METHODS: Consecutive patients who underwent emergency appendectomy for AA between December 2016 and April 2017 were prospectively included in the study. During admission, a prepared questionnaire including variables obtained from the previously used clinical scoring systems was administered. Histopathological analysis was regarded as the main outcome. Patients with no histopathological evidence of AA were defined as negative appendectomy. All variables were analyzed separately to assess their association with AA. A receiver operating characteristic curve with area under curve analysis was performed to obtain the cut-off values for numerical variables. RESULTS: There were 200 patients with a mean age of 30.8±12.8 years with a negative appendectomy rate of 5.5%. There was no significant association between the variables and the detection of histologically proven AA except increased white blood cell count >11.05/mm3 and proportion of the polymorphonuclear leukocytes >71.2% (p=0.003 and p=0.015, respectively). CONCLUSION: The present study shows that the development and/or use of scoring systems does not significantly improve the diagnostic accuracy of AA.

Use of peritoneal washing cytology for the detection of free peritoneal cancer cells before and after surgical treatment of gastric adenocarcinoma.

AIM: Cytological detection of peritoneal-free gastric cancer cells is considered as the gold standard with variable sensitivity. Seeding of cancer cells after radical surgery for gastric cancer is a controversial issue. In this study, it was aimed to detect the rate of positive peritoneal washing cytology and the incidence of spreading of tumor cells after radical surgery. MATERIALS AND METHODS: Patients with pathologically proven and surgically treated gastric adenocarcinoma were enrolled. Three peritoneal washing samples were examined cytologically: at the beginning, after completion of resection, and before closure of the abdomen. Identification of peritoneal-free gastric cancer cells was regarded as the main outcome. RESULTS: Thirty-four patients with a mean age of 60.7 ± 12 years were enrolled. T3 and N0 were the most common stages seen in 16 (47%) and 12 patients (35.3%), respectively. There were two positive results (5.9%) as the first peritoneal sample. Considering T3- or N-positive patients, the incidence increased to 9.1%. There was no conversion of negative to positive cytology. Cytological positivity remained only in one case (2.9%) after the second and the third peritoneal samples. CONCLUSION: Rate of positive peritoneal washing cytology in patients with gastric cancer is influenced by clinicopathological findings and the technique used. Use of cytology alone is thought to be failed to detect free cancers cells within the peritoneal cavity.

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.

Use of Imaging for the Diagnosis of Idiopathic Granulomatous Mastitis: A Clinician's Perspective.

Idiopathic granulomatous mastitis (IGM) is an inflammatory breast disease with unknown etiology and nonspecific symptoms. Differentiation of breast cancer from granulomatous disease is a diagnostic and clinical challenge. Imaging features and decision of the surgeon, based on these findings, may be important steps during diagnosis and follow-up period. Articles in association with imaging of IGM were evaluated using a PubMed search in August, 2017. Hypo-echoic or heterogeneous mass/es with or without tubular extensions were the most common ultrasonographic findings. Focal asymmetric density with or without skin thickening and parenchymal distortion were detected in most of the patients during mammography. Magnetic resonance imaging most commonly revealed focal or diffuse asymmetrical signal intensity changes without significant mass effect. Although a specified and standardised criteria list for each type of the imaging modality has been lacking, the most commonly detected imaging findings, especially in cases of multiple lesions in accordance with the decision of the surgeon and/or clinician, can be used for the diagnosis and follow-up of IGM with acceptable safety margins. However, in the presence of any suspicious findings during imaging or clinical examination, histopathological analysis should be performed.

The impact of a percutaneous cholecystostomy catheter in situ until the time of cholecystectomy on the development of recurrent acute cholecystitis: a historical cohort study

Background: the optimal duration of percutaneous cholecystostomy in patients with acute cholecystitis is unknown. Methods: this study was a retrospective analysis of patients (age ≥ 18 years) who underwent percutaneous cholecystostomy due to acute calculous cholecystitis. Patients were grouped according to treatment modality: percutaneous cholecystostomy as a definitive treatment (group 1), subsequent surgical treatment after the removal of the catheter (group 2) and those remaining in situ (group 3). The development of gallstone-related complications was the main outcome. Results: there were 24 females (43.6%) and 31 males (56.4%) included in the study with a mean age of 64.8 ± 15.9 years. There were 16 (29.1%), 19 (34.5%) and 20 (36.4%) patients in groups 1, 2, and 3, respectively. The catheter withdrawal time for group 1 and group 2 was 18.2 ± 6.9 and 20.7 ± 13.4 days, respectively. Surgical treatment was performed after a mean of 85.4 ± 93.5 days following catheter removal in group 2 and a mean of 64 ± 32.5 days while the PC tube was in place in group 3. There were one (6.3%) and two cases of a recurrence (10.5%) in groups 1 and 2, respectively. Two patients developed choledocholithiasis (10%) in group 3. Conclusion: maintaining percutaneous cholecystostomy tubes in place until the time of surgery in surgically fit patients may help to prevent a recurrence after acute calculous cholecystitis

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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.

The impact of a percutaneous cholecystostomy catheter in situ until the time of cholecystectomy on the development of recurrent acute cholecystitis: a historical cohort study.

BACKGROUND: the optimal duration of percutaneous cholecystostomy in patients with acute cholecystitis is unknown. METHODS: this study was a retrospective analysis of patients (age ≥ 18 years) who underwent percutaneous cholecystostomy due to acute calculous cholecystitis. Patients were grouped according to treatment modality: percutaneous cholecystostomy as a definitive treatment (group 1), subsequent surgical treatment after the removal of the catheter (group 2) and those remaining in situ (group 3). The development of gallstone-related complications was the main outcome. RESULTS: there were 24 females (43.6%) and 31 males (56.4%) included in the study with a mean age of 64.8 ± 15.9 years. There were 16 (29.1%), 19 (34.5%) and 20 (36.4%) patients in groups 1, 2, and 3, respectively. The catheter withdrawal time for group 1 and group 2 was 18.2 ± 6.9 and 20.7 ± 13.4 days, respectively. Surgical treatment was performed after a mean of 85.4 ± 93.5 days following catheter removal in group 2 and a mean of 64 ± 32.5 days while the PC tube was in place in group 3. There were one (6.3%) and two cases of a recurrence (10.5%) in groups 1 and 2, respectively. Two patients developed choledocholithiasis (10%) in group 3. CONCLUSION: maintaining percutaneous cholecystostomy tubes in place until the time of surgery in surgically fit patients may help to prevent a recurrence after acute calculous cholecystitis.

Partial Cecum Necrosis as a Rare Cause of Acute Abdominal Pain in an Elderly Patient.

Partial necrosis of the cecum is a rare form of ischemic colitis with unknown etiology. A 68-year female patient was admitted due to a severe pain in the right lower quadrant of the abdomen for one week. One month ago, she had coronary artery bypass graft surgery with carotid endarterectomy. During physical examination, tenderness and rebound tenderness at the right lower quadrant were detected. Computed tomography showed a 7-mm tubular structure extending from the back of the cecum to the lower border of the liver. Laparoscopic appendectomy was planned with a preoperative diagnosis of acute appendicitis. During laparoscopy, a 3x3 cm necrotic area was noticed on the lateral wall of the cecum. After conversion to open surgery, partial cecum resection and ileocolostomy with appendectomy were performed. She was discharged on the 6th postoperative day, uneventfully. An isolated non-occlusive mesenteric ischemic event should be thought as a differential diagnosis in elderly patients who have right lower quadrant pain with atypical presentation, if there is chronic cardiac or renal failure.

The Role of C-Reactive Protein in the Early Prediction of Serious Pancreatic Fistula Development after Pancreaticoduodenectomy.

INTRODUCTION: Despite recent advances in surgical techniques, pancreatic fistulas are common. We aimed to determine the role of C-reactive protein in the prediction of clinically relevant fistula development. MATERIALS AND METHODS: Data from patients who underwent pancreaticoduodenectomy between 2012 and 2015 is collected. Postoperative 1st, 3rd, and 5th day (POD1, POD3, and POD5) C-reactive protein (CRP) levels, postoperative pancreatic fistula (POPF) development, other complications, length of hospital stay, and mortality were recorded. RESULTS: Of 117 patients, 43 patients (36.8%) developed complications (including fistulas). Of the patients developing fistulas, 21 (17.9%) had POPF A, 2 (1.7%) had POPF B, and 7 (6.0%) had POPF C. POD5 CRP and POD3 CRP were shown to be significantly correlated with mortality and development of clinically relevant POPF (p = 0.001 and p = 0.0001, resp.) and with mortality (p = 0.017), respectively. The development of clinically relevant POPFs (B and C) could be predicted with 90% sensitivity and 82.2% specificity by POD5 CRP cut-off level of 19 mg/dL and with 100% sensitivity and 63.6% specificity by the difference between POD5 and POD1 CRP cut-off level of >2.5 mg/dL. CONCLUSION: CRP levels can effectively predict the development of clinically relevant pancreatic fistulas.

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.