Randomized Trial Comparing Resection of Primary Tumor with No Surgery in Stage IV Breast Cancer at Presentation: Protocol MF07-01.

BACKGROUND: The MF07-01 trial is a multicenter, phase III, randomized, controlled study comparing locoregional treatment (LRT) followed by systemic therapy (ST) with ST alone for treatment-naïve stage IV breast cancer (BC) patients. METHODS: At initial diagnosis, patients were randomized 1:1 to either the LRT or ST group. All the patients were given ST either immediately after randomization or after surgical resection of the intact primary tumor. RESULTS: The trial enrolled 274 patients: 138 in the LRT group and 136 in the ST group. Hazard of death was 34% lower in the LRT group than in the ST group (hazard ratio [HR], 0.66; 95% confidence interval [CI], 0.49-0.88; p = 0.005). Unplanned subgroup analyses showed that the risk of death was statistically lower in the LRT group than in the ST group with respect to estrogen receptor (ER)/progesterone receptor (PR)(+) (HR 0.64; 95% CI 0.46-0.91; p = 0.01), human epidermal growth factor 2 (HER2)/neu(-) (HR 0.64; 95% CI 0.45-0.91; p = 0.01), patients younger than 55 years (HR 0.57; 95% CI 0.38-0.86; p = 0.007), and patients with solitary bone-only metastases (HR 0.47; 95% CI 0.23-0.98; p = 0.04). CONCLUSION: In the current trial, improvement in 36-month survival was not observed with upfront surgery for stage IV breast cancer patients. However, a longer follow-up study (median, 40 months) showed statistically significant improvement in median survival. When locoregional treatment in de novo stage IV BC is discussed with the patient as an option, practitioners must consider age, performance status, comorbidities, tumor type, and metastatic disease burden.

The Comparison of Four-Port, Two-Port Without Suspension Suture and Single Port Laparoscopic Cholecystectomy Results.

BACKGROUND: Single-port surgery has recently become popular, however, many surgeons have to use additional ports during the surgery due to difficulties. OBJECTIVES: We performed two-port MCAP (with an additional port using a multi-channel device through the umbilicus) without a suspension suture in a group of patients. We compared the results of this technique to the LC and SILC techniques. MATERIAL AND METHODS: A total of 90 patients with gallbladder disease were included in the study. LC (n = 30) and SILC (n = 30) were performed in two groups. The other group underwent cholecystectomy (MCAP) by using an additional 5 mm port through the subxiphoid region with a multi-channel port through the transumblical. A transabdominal suspension suture was not used for the patients in this group. The surgery duration, estimated blood loss, length of hospitalization, visual analogue scale (VAS) score in the postoperative 1st and 7th day, need for analgesia in the postoperative period and complications, and the conversion rate were compared between the three methods. RESULTS: A total of 62 females (68.9%) and 28 males (31.1%) participated in the study. MCAP duration was significantly shorter than LC and SILC (38.1 ± 16.6, 49.4 ± 15.8, 77.8 ± 26.7 min respectively) (p < 0.05). The conversion rate was similar in all three groups. Hernia developed in the port area in two patients after SILC (6.7%). No significant difference was found between the groups for the other data we compared. CONCLUSIONS: MCAP seems to be an easier technique with a shorter operation time compared to the other two techniques. However, there is a need for other studies to evaluate the cosmetic results.

Fournier's gangrene current approaches.

Fournier's gangrene is a rare but highly mortal infectious disease characterised by fulminant necrotising fasciitis involving the genital and perineal regions. The objective of this study is to analyse the demographics, clinical feature and treatment approaches as well as outcomes of Fournier's gangrene. Data were collected retrospectively from medical records and operative notes. Patient data were analysed by demographics, aetiological factors, clinical features, treatment approaches and outcomes. Twelve patients (five female and seven male) were enrolled in this study. The most common aetiology was perianal abscess (41·6%). Wound cultures showed a mixture of microorganisms in six (50%) patients. For faecal diversion, while colostomy was performed in six cases (50%), Flexi-Seal was used in two cases (16·6%). In four patients (33·4%), no faecal diversion was performed. Negative pressure wound therapy (NPWT) system was effective in the last four patients (33·4%). The mean hospitalisation period in patients who used NPWT was 18 days, while it was 20 days in the others. NPWT in Fournier's gangrene is a safe dressing method. It promotes granulation formation. Flexi-Seal faecal management is an alternative method to colostomy and provides protection from its associated complications. The combination of two devices (Flexi-Seal and NPWT) is an effective and comfortable method in the management of Fournier's gangrene in appropriate patients.

Single Port vs. Four Port Cholecystectomy--Randomized Trial on Quality of Life.

BACKGROUND: Classical laparoscopic cholecystectomy involves four ports while most novel 'single port' technique only requires one incision on the abdominal wall. This technique is thought to decrease surgical trauma and improve cosmesis although there are reports pointing out that classical laparoscopic cholecystectomy is also feasible in terms of cosmesis. OBJECTIVES: In this study we tried to determine if there are certain advantages in quality of life after single port surgery which would justify its utilization instead of classical laparoscopic cholecystectomy. MATERIAL AND METHODS: This is a prospective randomized study which enrolled 30 patients randomized either into classical laparoscopic cholecystectomy or single port surgery. The primary endpoint was patient satisfaction after surgery. This was assessed with short form 36 and gastrointestinal quality of life index (first preoperatively and then 3 months postoperatively) and a visual analogue scale on the first and seventh days. RESULTS: There was not a statistically significant difference between groups in the emotional role, social functions, mental health, vitality and general health subscales of short form 36. At the end of 12 weeks, both groups demonstrated increases in the gastrointestinal and social subscales of the gastrointestinal quality of life index. There was not a statistically significant difference between groups when the visual analogue scale scores on first and seventh days were compared. CONCLUSIONS: The equal length of hospitalization, patient quality of life and pain perception and the longer operative times, high likelihood of incisional hernia and surgical site infection call into question the utilization of single port surgery, as it does not seem to confer an advantage over classical laparoscopic cholecystectomy.

Effects of alpha lipoic acid on intra-abdominal adhesion: an experimental study in a rat model.

BACKGROUND: This study was performed to determine the effect of alpha lipoic acid, a powerful antioxidant, on intra-abdominal adhesion formation. METHODS: Twenty-four female Wistar Albino rats weighing 250-300 g were used in this study conducted on three groups consisting of the alpha lipoic acid group (Group I, n=8), control group (Group II, n=8), and sham group (Group III, n=8). After performing laparotomy with a midline incision under general anesthesia, the adhesion model was created on the antimesenteric side of the caecum in Group I and Group II. 50 mg/kg alpha-lipoic acid was administered intraperitoneally (IP) in Group I while the surgical procedure was performed but no drugs administered in Group II. Only laparotomy was performed in Group III. Rats were sacrificed at the end of the tenth day. RESULTS: Macroscopic scoring was performed, tissue samples were obtained and subjected to biochemical and histopathological evaluation. The degree of adhesion and malondialdehyde level decreased (p<0.01), and glutathione levels had increased (p<0.01) in Group I compared to Group II in macroscopic scoring. CONCLUSION: Alpha lipoic acid was found to significantly decrease (p<0.01) intra-abdominal adhesion when administered IP compared to the control group.

A comparison of single-port laparoscopic cholecystectomy and an alternative technique without a suspension suture.

OBJECTIVE: Many surgeons face difficulties during single-incision laparoscopic cholecystectomy (SILC) surgery and are forced to use an additional port. We compared the results of a technique that we developed with SILC. MATERIAL AND METHODS: Fifty-four patients who were diagnosed with chronic cholelithiasis were prospectively randomized and divided into two groups. An additional 5-mm port (MCAP: with an additional port using a multi-channel device through the umbilicus) was placed in the subxiphoid area instead of a transabdominal suspension suture in one group of patients. The other group was operated on with the SILC technique. The demographic and surgical data of the patients were compared. RESULTS: The MCAP technique shortened the surgery duration by more than half (MCAP: 35.0±12.3, SILC: 79.1±27.7 min) (p<0.05). No difference was found between the two methods in terms of estimated blood loss, length of hospitalization, postoperative day 1 and 7 visual analog scale scores, need for analgesia in the postoperative period, and rate of changing to another technique due to inadequacy of the surgical technique. CONCLUSION: MCAP is as safe as SILC for cholecystectomy and is easier for the surgeon to perform.

Effects of montelukast on the healing of ischemic colon anastomoses.

BACKGROUND: The aim of this study was to examine whether treatment with montelukast, a selective leukotriene antagonist, would affect anastomotic healing in a reperfused colon rat model with remote ischemia/reperfusion injury. METHODS: Rats (n = 12 per group) were intraperitoneally administered normal saline or 10 mg/kg montelukast sodium 60 minutes before and for 5 days after surgery. Ischemia was induced for 45 minutes through superior mesenteric artery occlusion. A left colon anastomosis was made. Blood and perianastomotic tissue samples were obtained on postoperative day 5. RESULTS: Mean anastomotic bursting pressures of the control and montelukast groups were 159.17 ± 29.99 and 216.67 ± 26.40, respectively (P < .001). Compared with saline, montelukast treatment increased the mean tissue hydroxyproline level (2.46 ± .30 vs 3.61 ± .33 µmol/L) and decreased tissue caspase-3 activity (36.06 ± 5.72 vs 21.78 ± 3.87) and malondialdehyde levels (3.43 ± .34 vs 2.29 ± .34 nmol/g) (P < .001 for all). Other plasma markers of injury also showed differences. CONCLUSIONS: Montelukast prevented ischemia/reperfusion-induced damage in a rat model of colonic anastomotic wound healing.

Large animal-related injuries in a rural population in northeastern Turkey.

Animal-related injury is a serious health problem for people living in rural areas. This type of injury could be of great consequence and life-threatening. There are insufficient data regarding this issue. The purpose of this study was to evaluate the causes and treatment outcomes of large animal injuries. We reviewed the medical records of 157 patients with large animal-related injuries in a State Hospital in Northeastern Turkey, between September 2004 and April 2007. Demographic and etiological characteristics of patients and injury and outcome data were analyzed. A total of 157 patients were included in the study. One hundred and thirty-two (84.1 %) of them were male and 25 (15.9 %) female. The mean age of patients was 29.1 years (range 3-83 years). One hundred and twelve patients (71.3 %) had horse-related injuries and 45 patients (28.7 %) had bovine-related injuries (P = 0.096). Twenty-one (13.4 %) patients were referred to a tertiary center due to their need for intensive care, whereas 1 (0.6 %) patient died. Large animal-related injuries constitute an important health problem for people living in rural areas. This type of injury could be serious and mortality could be observed.

Effects of hemoperitoneum on wound healing and fibrinolytic activity in colonic anastomosis.

BACKGROUND: We aimed to test whether hemoperitoneum has adverse effects on colonic anastomosis healing by increasing fibrinolytic activity. METHODS: After colonic intersection and anastomosis, 20 Wistar Albino rats received intraabdominal injections of either 25 mg/kg blood (10, Group 1) or physiologic saline (10, Group 2). Anastomotic bursting pressures were measured after sacrifice on the fifth day. Following histopathological evaluation of the anastomotic line, hydroxyproline, tissue plasminogen activator (tPA), plasminogen activator inhibitor-1 (PAI-1), and tPA/PAI-1 complex levels were determined in the omentum, lung and anastomotic colon. RESULTS: Mean anastomotic bursting pressures of Groups 1 and 2 were 224.5 mmHg and 254.4 mmHg (p=0.121), and mean hydroxyproline levels were 45.89 and 65.959 mg/g protein, respectively (p=0.257). Histopathology was insignificant. There was a significant difference between groups in omental tPA levels (0.962 ng/ml and 0.27 ng/ml, p=0.041), but not in PAI-1 and tPA/PAI-1. Anastomotic line and lung levels of tPA, PAI-1 and tPA/PAI-1 complex were not significantly different between groups. The relation between anastomotic line tPA level and bursting pressure was highly significant in Group 2 (r=0.778; p=0.008). CONCLUSION: In this first study on the effect of hemoperitoneum on colonic anastomosis, we observed no significant effect on anastomotic healing or fibrinolytic activity, except in the omentum. Further studies with different blood volumes and assessment times are needed.

The impact of preoperative immunonutrition and other nutrition models on tumor infiltrative lymphocytes in colorectal cancer patients.

AIM: The importance of the alteration of tumor infiltrative lymphocytes (CD4(+), CD8(+), CD16(+), and CD56(+)) in colorectal cancer prognosis is well known. In this study, we analyzed the effect of preoperative immunonutrition and different nutritional models on the clinical condition of colorectal cancer patients. METHODS: Twenty-eight colorectal cancer patients were grouped into 4 groups according to their nutrition regimens randomly and were given immunonutrition (IMN), standard enteral (SE), total parental nutrition (TPN), and normal nutrition (NN) regimens, all of which contained the same calorie-nitrogen content within a 7-day preoperative period. All patients had an endoscopic biopsy before and after the regimen, and the lymphocyte population infiltrating mucosal parts of the resected tumor tissue were evaluated. Immunohistochemical analysis of the tissue specimens was performed by staining with antihuman CD4(+), CD8(+), CD16(+), and CD56(+) antibodies. RESULTS: After nutrition, there were significant increases in each of the 4 groups of CD4(+) and CD8(+) cells within the tumor. Comparing the rates of augmentation, the increased rates of the CD8(+) cells infiltrating the tumor after nutrition in the patients who were fed with IMN were significantly more than the ones in other groups (P = .01). CD16(+) cell infiltration was significantly higher in all groups except the SE and IMN groups. The SE group had increased CD56(+) cell infiltration compared with the other groups. CONCLUSIONS: In the colorectal cancer patients who had nutrition in the 7-day preoperative period, except for the SE nutrition group, there were significant increases of infiltration of CD56(+) cells at the mucosal part of the tumor tissue within the CD4(+) and CD8(+) cell population. When postnutrition values were compared, there was a marked increase of CD8(+) cells in the IMN group.

Prevention of adhesion to prosthetic mesh: comparison of oxidized generated cellulose, polyethylene glycol and hylan G-F 20.

BACKGROUND: The aim of this study was to investigate the impact of oxidized generated cellulose, polyethylene glycol and hylan G-F 20 on adhesion formation, fibrosis and inflammation after repair of abdominal wall defect with polypropylene mesh in an animal model. METHODS: Forty rats were divided into four groups and abdominal wall defect was established. The defect was repaired with polypropylene mesh alone (control group), polypropylene mesh and hylan G-F 20 as adhesion barrier, polypropylene mesh and oxidized generated cellulose as adhesion barrier, or polypropylene mesh and polyethylene glycol as adhesion barrier in Groups I, II, III, and IV, respectively. Rats were sacrificed on the 14th day in all groups. RESULTS: A comparison of the groups in terms of macroscopic adhesion scores revealed statistically significant differences between the groups using an adhesion barrier and the control group. Severe fibroblast proliferation was seen in the control group and mild fibroblast proliferation was seen in polyethylene glycol group. CONCLUSION: Polyethylene glycol is an effective adhesion prevention barrier. Laparoscopic surgery has become the standard method in most of the surgical field. With its laparoscopic apparatus, polyethylene glycol allows easy application on the damaged surface.

Left gastric and right hepatic artery anomalies in a patient with gastric cancer: images for surgeons.

BACKGROUND: Surgical resection remains the principal treatment for advanced gastric cancer, but one of the difficulties in a curative or extended gastrectomy is the identification of the vascular supply of the stomach. METHODS: A patient had gastric cancer hospitalized for planning and performing his surgical therapy. A multidetector-row computed tomography scan showed us a large tumor mass and numerous lymph nodes invading perigastric and second tiers of stomach and revealed a left gastric artery and right hepatic artery in which branched directly from aorta. A 3-dimensional construction showed a demonstrative vascular anomaly as well during operation. RESULT: We were able to perform total gastrectomy and D2 lymph node dissection as surgical therapy for patient. The patient's postoperative clinical course was uneventful, and after postoperative 36 months, there was no evidence of recurrence. CONCLUSION: We recommend that a multidetector-row computed tomography scan is very useful for the preoperative staging in gastric cancer patients because of its diagnostic value for showing any vascular anomaly and aiding in decision making on the appropriate surgical strategy.

Effect of pentoxifylline and vinpocetine on the healing of ischemic colon anastomosis: an experimental study.

BACKGROUND: In the current study, we aimed to investigate the influences of pentoxifylline, which increases the flexibility, deformability and viscosity of the erythrocytes while reducing the aggregation abilities of the platelets, and vinpocetine, which has neuroprotective and antioxidant effects, on healing of colonic anastomoses. METHODS: We used 30 Albino Wistar rats. Subjects were divided into three groups of 10 rats each. Colonic ischemia was established in all the groups. Following colonic transection, anastomosis was performed. Group A received intraperitoneal saline, whereas Group B and Group C received pentoxifylline and vinpocetine, respectively. The subjects were sacrificed on the postoperative 5th day by ether anesthesia, and their colonic bursting pressures were measured. The anastomotic area was excised for hydroxyproline assay and histopathologic examination. RESULTS: According to intergroup comparisons, colonic bursting pressure was found to be higher in the treatment groups than in the control group; however, the difference was not statistically significant. Intergroup comparisons regarding tissue hydroxyproline levels showed statistically significant differences between Groups A and B, Groups A and C and Groups B and C. CONCLUSION: Similar to pentoxifylline, vinpocetine was also shown to have a beneficial effect over ischemic colon anastomoses.

The role of computerized tomography in the diagnosis of acute appendicitis in patients with negative ultrasonography findings and a low Alvarado score.

BACKGROUND: We aimed to identify the role of computerized tomography (CT) in the differential diagnosis of acute appendicitis in patients with a low Alvarado score and negative ultrasonography findings. METHODS: Fifty-two cases who underwent appendectomy (December 2004-September 2008) were included. All patients had an Alvarado score of 4-6 together with negative ultrasonography findings; preoperative abdominal CT examination results were available in all patients. CT results were compared with intraoperative and pathological findings. RESULTS: The mean age of the cases was 31±4 years (range 11 to 71 years). The mean Alvarado score was 4.9. CT results were in favor of acute appendicitis in 34 of 52 cases. Of these 34 patients, acute appendicitis was confirmed by pathological findings in 31, whereas acute appendicitis could not be confirmed in the remaining three cases (8.2%). In 15 of 18 cases without CT findings of appendicitis, intraoperative and pathological findings were also in agreement; however, the remaining three cases had acute appendicitis. Based on the results of the recent studies, sensitivity and specificity of CT in the diagnosis of acute appendicitis were 91.2% and 83.3%, respectively. CONCLUSION: To avoid unnecessary appendectomies in suspected acute appendicitis cases with a low Alvarado score and negative ultrasonography findings, CT may be used as a complementary diagnostic tool.

Diagnostic process and management of diaphragmatic injuries: approach in patients with blunt and penetrating trauma.

BACKGROUND: Diaphragmatic rupture is one of the most commonly missed injuries in trauma cases. Traditionally, laparotomy or thoracotomy has been the treatment of choice for this condition. We aimed to evaluate the diagnostic process in patients with diaphragmatic injuries (DIs) who were diagnosed with diaphragm rupture during the preoperative or intraoperative course together with morbidity and mortality rates. METHODS: Sixteen patients with DIs were admitted to our department during the last seven-year period. Surgical procedure, accompanying injuries, duration of hospital stay, transfusion necessity, and morbidity and mortality rates were analyzed retrospectively. RESULTS: In seven years, 16 patients were treated and followed-up for DI. Female/male ratio was 2/14. Fifteen patients were operated and one was treated conservatively. The mortality rate was 2/16. CONCLUSION: DIs are being seen with increasing frequency in recent years. In patients with high Injury Severity Score (ISS), probability of DI should be taken into consideration.

Unusual locations of hydatid disease: diagnostic and surgical management of a case series.

BACKGROUND: Hydatid disease is endemic in many areas of the world, where it is an important public health problem. The aim of this study was to describe a series of patients with atypically located primary hydatid disease, accompanied by a literature review. METHODS: Six male and four female patients with atypically located hydatid cysts who presented to the Kars State Hospital between September 2004 and March 2008 were evaluated. The mean age was 42.5 years (range 17-72 years). Hydatid cysts were identified by using a combination of serology tests, ultrasonography, and computed tomography (CT). RESULTS: Six of the patients underwent surgical treatment. Three patients (two with pericardial hydatid involvement and one with pancreatic involvement) were sent to a tertiary medical center for surgery, and one patient died from cardiac and renal failure two days after diagnosis. CONCLUSIONS: Although this disease is seen most often in the liver and lungs, it can be found in any part of the body. Hydatid disease must be considered in the differential diagnosis of cystic lesions, especially in patients who have spent time in endemic areas.

Gastric duplication cyst in an adult.

Gastric duplication cyst which is a rare anomaly can also be observed in adulthood. Abdominal pain is the most common complaint in adults and most cases are discovered incidentally by radiological examination or gastric endoscopy. Preoperative diagnosis of gastric duplication is difficult and definitive diagnosis requires findings on laparatomy together with histopathological examination of the lesion. Gastric duplication cyst is primarily managed by complete excision. Gastric duplication cyst was suspected on gastric endoscopy and magnetic resonance imaging (MRI) of the abdomen in a 52-year-old woman presented with abdominal pain. She was treated by complete excision of the cyst and the diagnosis was confirmed with the operative findings and histopathological examination of the removed specimen.

Impact of herniorraphy technique on testicular perfusion: results of a prospective study.

BACKGROUND: Inguinal hernia repair is one of the most frequently performed operations. The Lichtenstein hernia repair is the most popular hernia repair technique in general surgical practice. However, totally extraperitoneal-preperitoneal hernia repair technique has been frequently used technique recently. The aim of this prospective, randomized, clinical study was to evaluate testicular perfusion after these 2 procedures. METHODS: In our prospective randomized study, 32 male patients, aged 33 to 72 years who fulfilled the inclusion criteria underwent elective herniorraphy for groin hernia. The patients were randomly assigned into either Lichtenstein hernia repair (n=16) or totally extraperitoneal-preperitoneal hernia repair (n=16) group according to their admittance. Color Doppler ultrasonography of the testes was performed on all patients 1 day before the operation, 3 days and 6 months after the operation. RESULTS: The results of the resistive index of the both groups; Lichtenstein hernia repair and totally extraperitoneal-preperitoneal hernia repair are statistically insignificant in all preoperative, early and late postoperative periods (P>0.05). CONCLUSIONS: Either Lichtenstein hernia repair or totally extraperitoneal-preperitoneal hernia repair does not effect the testicular perfusion.

Ectopic breast carcinoma.

A 47-year-old premenopausal woman had a swelling in right axilla which had been diagnosed as "ectopic breast tissue" with an incisional biopsy. A subcutaneous nodule appeared two years ago. The ectopic breast containing the mass was excised with axillary dissection. It was an invasive ductal carcinoma and metastasis was detected in one lymph node. She received local radiotherapy after 6 cycles of chemotherapy and has now been taking hormonotherapy. Ectopic breast tissue has potential for malignant transformation. As its carcinoma has a worse prognosis and a higher incidence of metastasis because of delayed diagnosis, prophylactic excision may be recommended.