Upregulation of SIRT1 gene in gastric adenocarcinoma.

BACKGROUND/AIMS: SIRT1 gene overexpression is reportedly associated with cancer development, via the triggering of DNA repair impairment, and cell proliferation. The study aimed to investigate SIRT1 expression in patients with gastric cancer and its correlations with the clinical and pathological characteristics of the disease. MATERIALS AND METHODS: All patients (64 patients) who underwent gastric biopsy and were diagnosed with gastric adenocarcinoma and signet ring cell carcinoma between January 2011 and December 2013 were enrolled in the study, and patients with benign gastric biopsy were enrolled in the control group (34 patients). The previously prepared gastric tissues were collected from the pathology department, and SIRT1 gene expressions were evaluated in the gastric tissues of all study patients. Patients were subclassified according to their demographic, clinical, and pathologic features, and the patient and control groups were compared. RESULTS: Sixty-four patients were included in the study (25 females and 39 males). The mean age of the patients was 66±1 (range: 33-88) years. The SIRT1 gene 2' Average delta cycle threshold (CT) value was 0.102 in the control group, whereas it was 0.292 in the patients with gastric cancer (relative risk: 2.86; p=0.014). The SIRT1 gene was upregulated in all tumor stage subgroups except stage I, female patients, young patients (<45 years), and corpus and cardia tumor subgroups compared to the control group. CONCLUSION: SIRT1 gene overexpression is associated with gastric adenocarcinoma, and it can be argued that SIRT1 gene upregulation is associated with unfavorable gastric adenocarcinoma prognosis.

Factors affecting mortality in elderly patients who underwent surgery for gastric cancer.

AIM: The aim of this study was to determine factors affecting overall mortality in patients over 60 years of age who underwent surgery for gastric cancer in our clinic. MATERIAL AND METHODS: Data on histopathological diagnosis (tumor size, lymph node status, and number), pathological stage, serum albumin level, tumor markers, complete blood count, and demographic information of 109 patients over 60 years of age who had surgery for gastric cancer between January 2011 and July 2016 were obtained retrospectively from the patient files. In addition, the survival status of all patients were examined and recorded. Metastatic lymph node ratio (MLR), red cell distribution width platelet ratio (RPR), neutrophil-lymphocyte ratio (NLR), plateletlymphocyte ratio (PLR), and prognostic nutritional index (PNI) were calculated. RESULTS: On univariate analysis of independent parameters, pathological LN number (p = 0.001), MLR (p <0.001), T3 (p = 0.001) or T4 (p = 0,006) tumor stage according to TNM system, the presence of metastasis (p = 0.063), and male gender (p = 0.066) were found to affect overall mortality (OM). On multivariable Cox regression analysis of these results, MLR (p = 0.005) and T stage (p = 0.006) was determined to be a statistically significant and independent prognostic value. CONCLUSION: In patients over 60 years of age who underwent surgery for gastric cancer, the factors affecting mortality were determined to be the presence of metastases, number of pathological lymph nodes, and male gender. Metastatic lymph node ratio and T1&T2 stage were determined to be independent prognostic factors. KEY WORDS: Elderly, Gastric cancer, Mortality, Prognostic factor.

The Effects of Bougie Diameters on Tissue Oxygen Levels After Sleeve Gastrectomy: A Randomized Experimental Trial

Background: Staple-line leak is the most frightening complication of laparoscopic sleeve gastrectomy and several predisposing factors such as using improper staple sizes regardless of gastric wall thickness, narrower bougie diameter and ischemia of the staple line are asserted. Aims: To evaluate the effects of different bougie diameters on tissue oxygen partial pressure at the esophagogastric junction after sleeve gastrectomy. Study Design: A randomized and controlled animal experiment with 1:1:1:1 allocation ratio. Methods: Thirty-two male Wistar Albino rats were randomly divided into 4 groups of 8 each. While 12-Fr bougies were used in groups 1 and 3, 8-Fr bougies were used in groups 2 and 4. Fibrin sealant application was also carried out around the gastrectomy line after sleeve gastrectomy in groups 3 and 4. Burst pressure of gastrectomy line, tissue oxygen partial pressure and hydroxyproline levels at the esophagogastric junction were measured and compared among groups. Results: Mortality was detected in 2 out of 32 rats (6.25%) and one of them was in group 2 and the cause of this mortality was gastric leak. Gastric leak was detected in 2 out of 32 rats (6.25%). There was no significant difference in terms of burst pressures, tissue oxygen partial pressure and tissue hydroxyproline levels among the 4 groups. Conclusion: The use of narrower bougie along with fibrin sealant has not had a negative effect on tissue perfusion and wound healing.

Evaluation and Comparison of Charcot's Triad and Tokyo Guidelines for the Diagnosis of Acute Cholangitis.

Reliability of Charcot's triad has long been questioned. Tokyo Guidelines committee published Tokyo Guidelines in 2007 and 2013. The aim of this study was to retrospectively examine the patients who had been treated with the diagnosis of acute cholangitis and evaluate 2007-2013 Tokyo criteria and Charcot's triad. The files of the patients with acute cholangitis in a referral center were examined retrospectively. All patients were classified and evaluated according to 2007 and 2013 Tokyo criteria and Charcot's triad; and results were compared. It was detected that 51.7 % of patients who did not meet Charcot's triad were in definitive diagnosis group of both Tokyo criteria. Kappa value was calculated as 0.404 in the analysis of consistency between two Tokyo criteria. Two patients who had features sufficient to objectively make the diagnosis of acute cholangitis failed to meet the Tokyo criteria 2007 or 2013. Charcot's triad is not sensitive and specific enough in the diagnosis of acute cholangitis. Revision of Tokyo 2007 criteria caused a change in the diagnostic status of 15 % of the patients. It is remarkable that kappa value can hardly be considered as a sign of moderate agreement between two Tokyo guidelines. Tokyo criteria should be supported and updated.

Questions from and answers to a patient with groin hernia.

Inguinal hernia surgical treatment are the most commonly performed operations in general surgery practice. There is a need for detailed anatomical knowledge and surgical skills to satisfactorily treat this disease. In this review, we aimed to present up-to-date information and approaches on basic diagnosis, treatment, complications and management of inguinal hernias in our institution. KEY WORDS: Chronic pain, Groin hernia, Inguinal hernia, Recurrence, Surgery.

The evaluation of the complications observed in patients with bilateral total and bilateral near total thyroidectomy.

AIM: The objective was to compare the recurrent laryngeal nerve (RLN) and superior laryngeal nerve (SLN) injuries in patients with bilateral total thyroidectomy (BTT) and bilateral near total thyroidectomy (BNTT) with the frequency of the hypocalcemic complications regarding the operation procedures. MATERIALS AND METHODS: Patients, who underwent BTT and BNTT in our clinic between January 1999 and January 2011, were included in this retrospective clinical study. Patients' files are evaluated. Demographic information, pre-operative complete blood cell count and biochemical analysis, thyroid function tests, ultrasonographic results, results of the fine needle aspiration biopsy, implemented operative procedures (BTT or BNTT), vocal cord investigation, post-operative calcium levels, postoperative complications were analyzed. RESULTS: In 328 of 408 (80.4%) patients BTT was the preferred method and 80 underwent BNTT (19.6 %). Postoperative hypocalcemia was observed in 59 patients in the BTT group (17.9 %) and in 11 patients in the BNTT group (13.7 %) . Hypocalcemia persisted in 8 patients in BTT group (2.4 %) and in 6 patients in BNTT group (7.5%). Unilateral RLN paralysis was observed in 22 patients in BTT group (6.7 %) and in 13 patients in the BNTT group (16.2 %). CONCLUSION: In this study, the likelihood of the temporary RLN paralysis and permanent hypoparathyroidism is found to be higher in the patients with BNTT compared to the patients with BTT. BNTT may be the preferred choice of treatment in suitable patients. KEY WORDS: Complication, Hypocalcemia, Nervus laryngealis recurrens, Nervus laryngealis superior, Thyroidectomy.

Expression of nestin and chromogranin in regeneration zones of rat pancreas.

AIM: The particular signals that start and orchestrate the regeneration process in pancreas are not well understood yet. We aimed to investigate the expression of nestin and chromogranin A in pancreatic regeneration zones and a secondary objective, we assessed the efficiency of pancreatic duct ligation method in creation of a pancreatic regeneration model in rats. MATERIALS AND METHODS: Partial (90%) pancreatectomy and pancreatic duct ligation were performed in Wistar rats, in order to create pancreatic regeneration models. Pancreatic tissues were examined histologically. Expression profiles were investigated by immunohistochemistry for nestin and chromogranin A. RESULTS: Nestin and chromogranin A expressions were observed in regeneration zones. Pancreatic regenerations zones were seen in pancreatic duct ligation group samples as well as partial pancreatectomy group. Nestin was expressed prominently in acinoductular metaplasia cells in regeneration zones. This was best demonstrated in the samples of pancreatic duct ligation group. In the subsequent sections of nestin positive sites, cytoplasmic positivity with chromogranin A was observed. CONCLUSION: This study confirms that nestin and chromogranin A can be detected in neogenesis-evoked pancreatic tissue, particularly in the acinoductular epithelium. Nestin and chromogranin A may be important markers to identify pancreatic stem cells. Pancreatic duct ligation can be used for creating pancreatic regeneration model in rats. KEY WORDS: Chromogranin A, Nestin, Pancreas, Regeneration, Stem cells.

Factors Affecting Mortality After Major Nontraumatic Lower Extremity Amputation.

Our aim was to evaluate the factors affecting the mortality of patients who underwent nontraumatic major lower limb amputation due to ischemic and/or diabetic causes. A total of 100 patients were included in the study. Among these patients, 70 (70%) underwent below-knee amputation, whereas 30 (30%) underwent above-knee amputation. Eleven (15.7%) of the 70 patients who underwent below-knee amputation and 12 (40%) of the 30 patients who underwent above-knee amputation (P = .008) were deceased. After multivariable Poisson regression analysis, female gender (risk ratio [RR] = 2.00, 95% CI = 1.07-3.74) and a neutrophil lymphocyte ratio (NLR) less than 6.8 (RR = 5.12, 95% CI = 1.86-14.08) were found to be independent risk factors for mortality. The value of 6.8 was used as a cutoff point for the NLR (area under the curve = 0.73, 95% CI = 0.62-0.85), with a sensitivity, specificity, positive predictive value, and negative predictive value of 83%, 66%, 57%, and 92%, respectively. The NLR and female gender were found to be independent factors that are related to increased mortality in patients who underwent lower limb amputation due to diabetic and/or ischemic causes. The coexistence of congestive heart failure and the amputation level (above knee) were found to be predictors of mortality in univariable analysis, but significance could not be demonstrated in multivariable analysis.

Diagnostic value of the femoral vein flow pattern for the detection of an iliocaval venous obstruction.

OBJECTIVE: Identification of iliocaval obstructions has traditionally been difficult due to the lack of a reliable noninvasive screening technique. Although femoral vein flow patterns have been used to detect outflow obstructions, the diagnostic accuracy of indirect Doppler parameters has not yet been fully elucidated. The purpose of this study was to establish the diagnostic value of the femoral vein waveform in detecting chronic iliocaval venous lesions. METHODS: Medical records of consecutive patients with chronic venous disease classified as Clinical, Etiologic, Anatomic, and Pathophysiologic (CEAP) C3-6 between March 2011 and December 2012 were assessed retrospectively. The results of common femoral vein duplex ultrasound examinations, based on the presence or absence of respiratory variation in the femoral flow as well as its response to the Valsalva maneuver, were compared with contrast venography and intravascular ultrasound imaging of the inferior vena cava and the bilateral common and external iliac veins. Three types of flow patterns in the common femoral vein were identified with duplex ultrasound examination: phasic flow correlated with respiration, minimally phasic flow (showing some phasicity but no cessation with respiration), and monophasic flow (continuous flattened flow). In addition, three types of responses to the Valsalva maneuver were recorded: complete cessation of flow, reversal of flow, and continuation of flow. RESULTS: The study evaluated 86 patients (63 men, 23 women) with a mean age 40.3 ± 1.5 years. Contrast venography and intravascular ultrasound imaging were used to detect venous obstructions in the inferior vena cava and the right and left iliac veins in 16.3%, 32.6%, and 80.2% of patients, respectively. When various flow parameters were evaluated, the combination of common femoral vein monophasic flow at rest and continuous flow during the Valsalva maneuver had the highest diagnostic value for iliocaval venous obstructions. The sensitivity, specificity, positive predictive value, and negative predictive value of the combination of monophasic flow at rest and unceasing forward flow during the Valsalva maneuver for the diagnosis of any degree of iliac venous obstruction were 38.1%, 100%, 100%, and 55.8%, respectively. The sensitivity and negative predictive value of these diagnostic parameters increased as the degree of obstruction increased. CONCLUSIONS: An iliocaval venous obstruction is a frequent feature of chronic venous disease. Doppler examination of the common femoral vein can be used as a screening test for iliocaval venous obstructions. The monophasic flow of the common femoral vein is a reliable diagnostic tool for the detection of possible iliac vein obstructions.

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.

Surgical Management of Liver Hydatid Cyst Related Non-traumatic Emergencies: Single Center Experience.

BACKGROUND: Vast majority of complaints and physical examination findings of hydatid disease are common in emergency room patients. Different emergency presentations of hydatid cyst disease and their treatment are evaluated. We studied preoperative laboratory findings of these patients to identify any parameters to predict hydatid cyst-biliary system communication. METHODS: We reviewed the files of patients who underwent emergency surgery due to liver hydatid cysts and related conditions between March 2010 and March 2014 in Ankara Numune Research and Training Hospital, Turkey, retrospectively. Patients were grouped, regarding to the presence of biliary system involvement. RESULTS: Twelve patients (9 males, 3 females) were included. We identified two groups. Biliary system involved group (n=9) had significantly higher pre-operative gamma glutamine transferase and alkaline phosphatase levels (P=0.036). No significant difference was noted regarding other pre-operative laboratory findings. Mortality rate was 17%. CONCLUSION: Medical literature lacks sufficient information about hydatid disease related non-traumatic emergency surgeries. Preoperative elevated gamma glutamyl transferase and alkaline phosphatase levels may be questioned as a warning about cyst-biliary communication in hydatid cyst patients with abdominal pain in the emergency room. Future studies with larger sample sizes are needed. In addition, prolongation of the time before diagnosis in these patients may result in life threatening complications.

Late Onset Traumatic Diaphragmatic Herniation Leading to Intestinal Obstruction and Pancreatitis: Two Separate Cases.

Although diaphragmatic injuries caused by blunt or penetrating trauma are rare entities, they are the most commonly misdiagnosed injuries in trauma patients and occur in approximately 3-7% of all abdominal or thoracic traumas. Acute pancreatitis secondary to late presenting diaphragmatic hernia is very rare. Here we present two separate cases: one with acute bowel obstruction and the other with acute pancreatitis secondary to late onset traumatic diaphragmatic hernia (three and twenty-eight years after chest trauma, resp.).

Postoperative fluid management.

Postoperative care units are run by an anesthesiologist or a surgeon, or a team formed of both. Management of postoperative fluid therapy should be done considering both patients' status and intraoperative events. Types of the fluids, amount of the fluid given and timing of the administration are the main topics that determine the fluid management strategy. The main goal of fluid resuscitation is to provide adequate tissue perfusion without harming the patient. The endothelial glycocalyx dysfunction and fluid shift to extracellular compartment should be considered wisely. Fluid management must be done based on patient's body fluid status. Patients who are responsive to fluids can benefit from fluid resuscitation, whereas patients who are not fluid responsive are more likely to suffer complications of over-hydration. Therefore, common use of central venous pressure measurement, which is proved to be inefficient to predict fluid responsiveness, should be avoided. Goal directed strategy is the most rational approach to assess the patient and maintain optimum fluid balance. However, accessible and applicable monitoring tools for determining patient's actual fluid need should be further studied and universalized. The debate around colloids and crystalloids should also be considered with goal directed therapies. Advantages and disadvantages of each solution must be evaluated with the patient's specific condition.

Spontaneous Rectus Sheath Hematoma: an Overview of 4-Year Single Center Experience.

Rectus sheath hematoma is a clinical entity characterized by the presence of blood within rectus abdominis muscle sheath. The aim of this study was to analyze clinical characteristics, diagnostic approach, treatment strategy, and outcomes of patients with rectus sheath hematoma. Patients diagnosed and treated for spontaneous rectus sheath hematoma between March 2010 and March 2014 were included in the study. A total of 10 patients were diagnosed as spontaneous rectus sheath hematoma. The mean age was 66.5 ± 16.9 years, and the mean hospital stay was 4.4 ± 1.8 days. There was no mortality. Six patients were using anticoagulant or antiplatelet agents. Eight patients recovered after conservative treatment. Two patients underwent surgery. Spontaneous rectus sheath hematoma is associated with anticoagulant therapy. Cases with abdominal pain and a non-pulsatile abdominal mass particularly in elderly women should be kept in mind. Treatment is mostly based on supportive care to preserve hemodynamic stability.

Fournier's Gangrene as a Postoperative Complication of Inguinal Hernia Repair.

Fournier's gangrene is the necrotizing fasciitis of perianal, genitourinary, and perineal regions. Herein, we present a case of scrotal Fournier's gangrene as a postoperative complication of inguinal hernia repair. A 51-year-old male with giant indirect hernia is presented. Patient underwent inguinal hernia repair, and after an unproblematic recovery period, he was discharged. He applied to our outpatient clinic on the fifth day with swollen and painful scrotum and it turned out to be Fournier's gangrene. Polypropylene mesh was not infected. Patient recovered and was discharged after repeated debridements. Basic principles in treatment of Fournier's gangrene are comprised of initial resuscitation, broad-spectrum antibiotics therapy, and early aggressive debridement. In the management of presented case, aggressive debridement was made right after diagnosis and broad-spectrum antibiotics were given to the hemodynamically stable patient. In these circumstances, the important question is whether we could prevent occurrence of Fournier's gangrene.

Gastric metastasis of ectopic breast cancer mimicking axillary metastasis of primary gastric cancer.

Ectopic breast tissue has the ability to undergo all the pathological changes of the normal breast, including breast cancer. Gastrointestinal metastasis of breast cancer is rarely observed and it is very difficult to differentiate gastric metastases from primary gastric cancer. We present a case of 52-year-old female, who suffered from abdominal pain. Physical examination showed a palpable mass in the left anterior axilla and computerized tomography revealed gastric wall thickening with linitis plastica. When gastroscopic biopsy showed no signs of malignancy, excisional biopsy was performed in the left axilla. Histological examination revealed invasive lobular carcinoma of the breast, consistent with ectopic breast cancer. Further gastroscopic submucosal biopsies and immunohistochemical studies revealed gastric metastases of invasive lobular carcinoma. Axillary ectopic breast tissue carcinomas can mimic axillary lymphadenopathies. Additionally, gastric metastasis of breast cancer is an uncommon but possible condition. To the best of our knowledge, this is the first report of ectopic breast cancer with gastric metastasis.

Thyroid nodules with atypia or follicular lesions of undetermined significance (AUS/FLUS): analysis of variables associated with outcome.

BACKGROUND: The Bethesda System for Reporting Thyroid Cytopathology is one of the main classification systems for thyroid nodules. It expects that 7% of all fine needle aspiration biopsies will be reported as atypia or follicular lesions of undetermined significance, and 5-15% of these undetermined nodules are malignant. Our study is a retrospective analysis of variables that may be associated with outcome in patients with indeterminate thyroid nodules. MATERIALS AND METHODS: Patients who underwent thyroidectomy in our institution between 2010 and 2014 were retrieved from the institutional records database. Patient demographics and medical histories were recorded. All ultrasonography reports were examined for nodule features and biochemical blood levels, hormone levels and complete blood counts were recorded. RESULTS: A total of 103 patient cytopathology reports were regarded as belonging to the undetermined category. Some 35% of patients had malignant nodules. Median preoperative red cell distribution width (RDW) level was 13.6 inthe benign group, while it was 14.3 in patients with malignancy, demonstrating a significant correlation (p=0.003). Only calcification presence was significantly different between benign and malignant groups on ultrasonography (p=0.034). CONCLUSIONS: Ultrasonography is one of the primary tools for this matter. RDW levels may become another promising tool to predict malignancy.