Is the Neutrophil-to-Lymphocyte Ratio Associated With Increased Morbidity After Colorectal Surgery?

PURPOSE: We aimed to evaluate the association between preoperative and postoperative neutrophil-to-lymphocyte ratio (NLR) and 30-day postoperative complications after colorectal surgery. METHODS: Patients undergoing elective colorectal surgery between January, 2010 and December, 2014 were identified. Patients who had preoperative and postoperative days 1 and 2 (Postoperative day [POD]-1, POD-2) NLR were included in the study. Primary study outcomes were optimal NLR cutoff values at preop, POD-1, and POD-2. RESULTS: A total of 1328 patients met the inclusion criteria. Of those, 518 (39%) patients experienced at least one postoperative complication. Sex (P<0.001), diabetes mellitus (DM) (P<0.001), diagnosis (P=0.001), operation type (P=0.03), and open surgery (P<0.001) were statistically associated with higher NLR (POD-1, P=0.02; POD2, P=0.01). DM (OR, 1.97; 95%CI, 1.27-3.08; P=0.003] and NLR on POD-2≥9.2 (OR, 1.43; 95%CI, 1.03-1.98; P=0.02) were significantly related to postoperative complications. CONCLUSIONS: NLR may provide clinicians with an additional tool for identifying patients at high risk for postoperative complications after elective colorectal surgery. Routine use of NLR may lead to early intervention and potentially improve the management of complications after colorectal surgery.

Factors associated with portomesenteric venous thrombosis after total colectomy with ileorectal anastomosis or end ileostomy.

BACKGROUND: Porto-mesenteric venous thrombosis (PMVT) is an uncommon but serious complication. Data on the risk factors for PMVT following total colectomy with ileorectal anastomosis or end ileostomy (TC/IRA or EI) is limited. This study aimed to evaluate the factors associated with PMVT after TC/IRA or EI. METHODS: Patients who underwent elective TC/IRA or EI between January 2010 and December 2014 were identified from institutional database. Patients who had CT proven PMVT within 30 days of surgery were included in the PMVT positive group. Demographics and perioperative/postoperative 30-day outcomes were compared between groups. RESULTS: Out of 832 patients, 34 patients (4.1%) were diagnosed with PMVT. PMVT positive group were younger (35.8vs.41 years, p = 0.03). Postoperative organ-space surgical site infection (17.6% vs. 4.8%, p = 0.007), deep venous thrombosis (8.8%vs.1.5%, p = 0.02), ileus (38.2%vs.20.8%, p = 0.018), and readmission (50.0%vs.12.7%, p < 0.001) were more common in patients with PMVT, who also had longer hospital stay (8.5vs.6 days, p = 0.002). CONCLUSIONS: PMVT after TC/IRA or EI may occur in non-IBD patients. PMVT should be included in differential diagnosis after TC/IRA or EI in patients with intraabdominal infection or ileus, especially in younger patients.

Laparoscopic versus open 1-stage resection of synchronous liver metastases and primary colorectal cancer.

BACKGROUND: The aim of this study is to compare the perioperative and oncologic outcomes of open and laparoscopic approaches for concomitant resection of synchronous colorectal cancer and liver metastases. METHODS: Between 2006 and 2015, all patients undergoing combined resection of primary colorectal cancer and liver metastases were included in the study (n=43). Laparoscopic and open groups were compared regarding clinical, perioperative and oncologic outcomes. RESULTS: There were 29 patients in the open group and 14 patients in the laparoscopic group. The groups were similar regarding demographics, comorbidities, histopathological characteristics of the primary tumor and liver metastases. Postoperative complication rate (44.8% vs. 7.1%, P=0.016) was higher, and hospital stay (10 vs. 6.4 days, P=0.001) longer in the open compared to the laparoscopic group. Overall survival (OS) was comparable between the groups (P=0.10); whereas, disease-free survival (DFS) was longer in laparoscopic group (P=0.02). CONCLUSIONS: According to the results, in patients, whose primary colorectal cancer and metastatic liver disease was amenable to a minimally invasive resection, a concomitant laparoscopic approach resulted in less morbidity without compromising oncologic outcomes. This suggests that a laparoscopic approach may be considered in appropriate patients by surgeons with experience in both advanced laparoscopic liver and colorectal techniques.

Comparison of Short-term Outcomes After Laparoscopic Versus Open Hartmann Reversal: A Case-matched Study.

PURPOSE: The aim of this study is to compare short-term outcomes of laparoscopic versus open Hartmann reversal. MATERIALS AND METHODS: Patients who underwent Hartmann reversal between January 2005 and September 2014 were identified and matched for age, sex, body mass index, American Society of Anesthesiologists score, and creation of diverting ileostomy to open counterparts. Patient characteristics and postoperative outcomes (30 d) were evaluated. RESULTS: Eighteen patients with laparoscopic Hartmann reversal were matched to 18 open patients. There were no differences between laparoscopic versus open groups in terms of operative time (157.7±52.2 vs. 151.5±49.3 min, P>0.05) or overall complication rates [6 (33.3%) vs. 6 (33.3%) (P>0.05)]. No anastomotic leaks or mortality occurred in either group. However, the laparoscopic group was associated with significantly decreased estimated blood loss (114±103 vs. 217±125 mL, P<0.05), faster return of bowel function (3.2±0.6 vs. 4±0.6 d, P<0.05), and reduced hospital stay (5.4±3.1 vs. 8.3±4.8 d, P<0.05). CONCLUSIONS: Laparoscopic Hartmann reversal can be safely performed with better short-term outcomes in carefully selected patients.

An easily overlooked cause of mortality in trauma: rupture of diaphragm.

BACKGROUND: The purpose of our study was to share our experience in patients with traumatic diaphragmatic rupture. METHODS: Patients underwent surgery for traumatic diaphragm rupture between 2005 and 2010 were reviewed. RESULTS: There were sixty-two patients with traumatic diaphragm rupture. The mean age of the study group was 28.7 years (range 15-62 years). Diaphragmatic rupture was left sided in 43 patients (69%), right sided in 17 (28%) and bilateral in 2 (3%). Thoracotomy applied in 8 patients, laparotomy in 50, thoracoabdominal approach in 4. Mortality seen at 4 (6.4%) patients and hemorrhagic shock was the reason in two and pneumonia and sepsis in two. CONCLUSIONS: Diaphragm ruptures are infreqent injuries, however, are easily overlooked due to mask effect of accompaning visceral injuries, and it should be kept in mind at lower thoracic or upper abdominal traumas to prompt and proper management to lower the risk of mortality. KEY WORDS: Diaphragm rupture, Thoracoabdominal trauma, Treatment.

Comparing the effects of nebivolol and dexpanthenol on wound healing: an experimental study.

Wound healing is a dynamic, interactive process that is initiated in response to injury. A number of investigations and clinical studies have been performed to determine new approaches for the improvement of wound healing. The aim of this study was to compare the effects of dexpanthenol, a molecule that is widely used for improving wound healing, and nebivolol, a molecule that increases nitric oxide release, on wound healing. A total of 30 rats were divided into three equal groups (n = 10). A linear 2 cm incision was made in the rats' skin. No treatment was administered in the first (control) group. Dexpanthenol cream was administered to the rats in the second group and 5% nebivolol cream was administered to the rats in the third group. The wound areas of all of the rats were measured on certain days. On the 21(st) day, all wounds were excised and histologically evaluated. The wound healing rates of the dexpanthenol and nebivolol groups were higher than those of the control group (P < 0·05). However, the wound healing rates of the dexpanthenol and nebivolol groups were not significantly different. Nebivolol and dexpanthenol have comparable effects on wound healing.

Risk factors influencing morbidity and mortality in perforated peptic ulcer disease.

OBJECTIVE: Peptic ulcer perforation continues to be a major surgical problem. In this study, risk factors that influence morbidity and mortality in perforated peptic ulcer disease were examined. MATERIAL AND METHODS: Files of 148 patients who were included in the study due to peptic ulcer perforation between January 2006 and December 2010 were retrospectively analyzed. Data regarding age, gender, complaints, time elapsed between onset of symptoms and hospital admission, physical examination findings, co-morbid diseases, laboratory and imaging findings, length of hospital stay, morbidity and mortality were recorded. RESULTS: The study group included 129 (87.2%) male and 19 (12.8%) female patients. The mean age was 51.7±20 (15-88) years. Forty five patients (30.4%) had at least one co-morbid disease. In the postoperative period, 30 patients (20.3%) had complications. The most common complication was wound infection. Mortality was observed in 27 patients (18.2%). The most common cause of mortality was sepsis. Multivariate analysis revealed age over 60 years, presence of co-morbidities and Mannheim peritonitis index as independent risk factors for morbidity. Age over 60 years, time to admission and Mannheim peritonitis index were detected as independent risk factors for mortality. CONCLUSION: Early diagnosis and proper treatment are important in patients presenting with peptic ulcer perforation.

The reliability of fine-needle aspiration biopsy in terms of malignancy in patients with Hashimoto thyroiditis.

The aim of this study was to analyze the presence of malignancy in patients with Hashimoto's thyroiditis and to investigate the reliability of preoperative fine-needle aspiration biopsy (FNAB). The retrospective study included 44 patients who were operated on for nodular goiter between December 2010 and October 2011. The patients underwent thyroidectomy following a cytologic analysis plus FNAB. Hashimoto's thyroiditis was confirmed on histopathology in all patients. FNAB results were defined as benign in 14 (31.8%), suspicion for malignancy in 17 (38.6%), malignant in 9 (20.5%), and inadequate in 4 (9.1%). Following the thyroidectomy, presence of papillary thyroid carcinoma and follicular variant of papillary thyroid carcinoma were detected in 10 patients (22.7%) and 1 (2.3%) patient, respectively. The FNAB results were interpreted in terms of malignancy, which revealed the sensitivity as 80%; specificity, 40%; false positives, 69.2%; false negatives, 14.3%; positive predictive value, 31.8%; negative predictive value, 85.7%; and diagnostic accuracy, 50%. The coexistence of Hashimoto's thyroiditis with papillary thyroid carcinoma is quite common. The FNAB results for such cases are hard to evaluate, and they are likely to increase the number of false positives.

Gangrenous cholecystitis: mortality and risk factors.

As a serious complication of cholelithiasis, gangrenous cholecystitis presents greater mortality than noncomplicated cholecystitis. The aim of this study was to specify the risk factors on mortality. 107 consecutive patients who underwent surgery due to gangrenous cholecystitis between January 1997 and October 2011 were investigated retrospectively. The study included 60 (56.1%) females and 47 (43.9%) males, with a mean age of 60.7 ± 16.4 (21-88) years. Cardiovascular diseases were the most frequently accompanying medical issues (24.3%). Thirty-six complications (33.6%) developed in 29 patients, and surgical site infection was proven as the most common. Longer delay time prior to hospital admission, low white blood cell count, presence of diabetes mellitus, higher blood levels of aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase and total bilirubin, pericholecystic fluid in abdominal ultrasonography, and conversion from laparoscopic surgery to open surgery were identified as risk factors affecting mortality (P < 0.001, P = 0.001, P = 0.044, P = 0.005, P = 0.049, P = 0.009, P = 0.022, P = 0.011, and P = 0.004, respectively). Longer delay time prior to hospital admission and low white blood cell count were determined as independent risk factors affecting mortality.

The effects of erythropoietin on bacterial translocation and inflammation in rats with obstructive jaundice.

INTRODUCTION: Obstruction of the common bile duct is associated with hepatic paranchymal damage and increased susceptibility to subsequent bacterial infections. Erythropoietin has antiinflammatory and cytoprotective effects and it induces antiinflammatory cytokines and suppresses the production of proinflammatory cytokines. In this study, we aimed to investigate the effect of Erythropoietin on bacterial translocation, inflammation and tissue damage in rats with obstructive jaundice. MATERIALS AND METHODS: Thirty-two Wistar albino rats (200-250 g) were divided into 4 groups as follows: Group 1 (Sham); only hepatoduodenal ligament dissection, Group 2 (Erythropoietin); hepatoduodenal ligament dissection and given 500 IU/kg Erythropoietin subcutaneously, Group 3 (Obstructive jaundice); complete hepatoduodenal ligament ligation, Group 4 (Obstructive jaundice + Erythropoietin); complete hepatoduodenal ligament ligation and given 500 IU/kg Erythropoietin subcutaneously. After 7 days, the rats were sacrificed by taking blood from the heart for biochemical analyses. Peritoneal swab culture, liver, mesenteric lymph nodes, spleen and ileum were collected for microbiological and histopathological examinations. RESULTS: Erythropoietin reduced the secretion of inflammatory cytokines, oxidative damage and bacterial translocation, prevent the formation of inflammatory changes in intestine and liver after obstructive jaundice. CONCLUSION: The treatment of EPO in rats with OJ reduces bacterial translocation, inflammation and tissue damage.

Surgical alternatives in the treatment of intestinal intussusceptions resulting from polyps in adults.

Adult intussusception is an uncommon disease requiring surgical intervention. The aim of this study is to discuss the surgical alternatives and share our experience in the treatment of adult patients with intussusceptions formed as a result of polyps. The retrospective study included 16 adult patients who underwent surgery after the diagnosis of intestinal invaginations resulting from polyps between the years 2000 and 2011. Sixteen patients (seven males and nine females; mean age, 48.18 years; range, 18 to 76 years) presented with intestinal intussusceptions. Although a preoperative diagnosis was carried out in 11 (68.75%) patients, the diagnosis was made intraoperatively in five patients (31.25%). Among the patients, seven (43.8%) had undergone emergency surgeries and nine (52.8) had elective surgery. The invagination in 12 patients (75%) was located in the small intestine, in two patients (12.5%) in the colon, and in a further two patients (12.5%), it was ileocecally located. Ten patients (62.5%) had segmental resection + anastomosis; three patients underwent (18.8%) segmental resection + enterostomy, and three (18.8%) received hemicolectomies. In adults, surgical treatment is always the primary option in intussusceptions resulting from polyps. Although the surgical method of choice in colonically located ones is en bloc resection without reduction, because the polyps located in the small intestine are usually of a benign nature, segmental resection with reduction should be performed in elective surgery and segmental resection without reduction should be performed in emergency cases.

The value of micro-ELISA test in the diagnosis of Fasciola hepatica infection.

OBJECTIVE: In sero-diagnosis of parasitic infection, it is essential to inspect cross-reactivity between the target parasite and other parasites in order to assess diagnostic performance. The aim of this study was to determine the cut-off value of antibody titer for diagnosis of F. hepatica (FH) infection by using the micro-ELISA and diagnostic performance of this test. METHODS: The study population consisted of the following groups: FH group (n=42), Echinococcus granulosus (EG) group (n=27) and control group (n=33). The micro-ELISA test for detection of anti-F. hepatica antibody was performed in all groups. RESULTS: The test was positive in all patients with FH, in 3 out of 27 (11%) patients with EG and in none of the control group. Mean antibody titer was significantly higher in the FH group compared to the EG group (23.8 ± 0.9 DU vs. 5.7 ± 1.2 DU; p < 0.001) and compared to the control group (23.8 ± 0.9 DU vs. 2.4 ± 0.2 DU; p < 0.001). When we used 11,5 DU as a cut-off value for sero-diagnosis of FH, the positive predictive value was 93.3%, negative predictive value was 100%, sensitivity was 100%, and specificity was 95%. CONCLUSION: Cross-reactions are an important issue in serological diagnosis of parasitic infections. The micro-ELISA test for FH antibody can not definitely discriminate fascioliasis from hydatid disease.

The impact of etiological factors on mortality in retroperitoneal hematomas.

AIM: Retroperitoneal hematomas (RPH) mostly occur after blunt and penetrating traumas. However, these hematomas may develop spontaneously in the elderly and the patients who use anticoagulants. Between January 2006 and December 2011, 31 patients with RPH were evaluated retropectively. The patients were allocated into three groups according to the underlying etiological factor: Group I; spontaneous RPH, group II; RPH caused by penetrating trauma, group III; RPH caused by blunt trauma. RESULTS: There were 22 (71%) male and 9 (29%) female patients with a mean age of 35.7 ± 18.7 (range: 15-88 years). Spontaneous RPH was diagnosed in eight patients (25.8%) while RPH caused by penetrating trauma in 13 patients (41.9%) and RPH induced by blunt trauma in 10 (32.3%) patients. Retroperitoneal hematomas were located at zone I in 2 patients (6.5%) whereas zone II in 19 patients (61.3%) and zone III in 9 patients (29%). On the other hand, RPH was regarded to be at zone II-III in 1 patient (3.2%). Additional organ injury was defined in 18 patients (58.1%). Twenty patients (65%) were treated surgically. The morbidity rates were 12.5%, 7.7% and 20% and the mortality rates were denoted as 12.5%, 15.4% and 50%, for group I, group II and group III, respectively. DISCUSSION: Additional organ injury, massive blood transfusion, the route of injury and the need for surgery are defined as the most significant factors associated with increased mortality.

Percutaneous cholecystostomy in high-risk elderly patients with acute cholecystitis: a lifesaving option.

PURPOSE: To analyze the results of percutaneous cholecystostomy in in high-risk elderly patients with acute cholecystitis. MATERIALS AND METHODS: Between June 2010 and May 2011, 11 patients aged over 60 who had at least 1 systemic disease and underwent percutaneous cholecystostomy were reviewed retrospectively. RESULTS: The procedure was technically successful in 10 (90.9%) patients. Clinical improvement was achieved in 81.8% of patients within 72 hours. Two patients received emergency surgery while elective cholecystostomy was performed in 5 patients. Percutaneous cholecystostomy was performed singly in 4 (36.4%) patients. Early complication rate was 18.2%. Two (18.2%) patients died. CONCLUSION: Percutaneous cholecystostomy can be performed with low mortality and morbidity. Cholecystectomy should be performed in all patients with suitable general conditions due to the high recurrence rates of percutaneous cholecystostomy.

Pilonidal sinus disease: risk factors for postoperative complications and recurrence.

The aim of this study is to analyze the risk factors for complications and recurrence in pilonidal sinus disease. The prospective study consisted of 144 patients with pilonidal sinus disease who were operated on at Dicle University Medical Faculty, Department of General Surgery, between February 2008 and December 2010. Patients receiving the Limberg flap totaled 106 (73.6%), while 38 (26.4%) had primary closure. Postoperative complications developed in 42 subjects (29.2%), and recurrence occurred in 19 (13.2%). The Limberg flap method was statistically considered as a risk factor for postoperative complications (P  =  0.039). Regarding recurrence, family tendency (P  =  0.011), sinus number (P  =  0.005), cavity diameter (P  =  0.002), and primary closure (P  =  0.001) were found to be risk factors. Postoperative complication rate is higher in the Limberg flap method than primary closure method. The risk of recurrence is related to family tendency, sinus number, cavity diameter and anesthesia type and is also higher in primary closure.

Spontaneous intraperitoneal rupture of a hepatic hydatid cyst.

Hydatid cysts, which are endemic to certain areas, typically are found in the liver. Spontaneous intraperitoneal rupture, which can be life threatening, is rare. This article presents a case of spontaneous rupture of a hydatid cyst in a 69-year-old woman who was admitted to the emergency department. The patient had no history of trauma. Abdominal ultrasonography and computed tomography suggested rupture of a hydatid cyst. The patient underwent a partial cystectomy, and the cystic area was washed with hypertonic saline and the peritoneal cavity was washed with isotonic saline and drained. Postoperatively, the patient was treated with albendazole for 3 months. No additional pathology was observed at the 3-, 6-, and 9-month follow-ups. Although rare, a ruptured hydatid cyst should be considered in the differential diagnosis of the acute abdomen in a patient residing in an endemic area.

Thymoquinone ameliorates bacterial translocation and inflammatory response in rats with intestinal obstruction.

BACKGROUND: Intestinal obstructions might cause mucosal disruption, motility dysfunction, increasing intestinal volume, and intestinal bacterial overgrowth; it might also result in bacterial translocation. Thymoquinone is a bioactive substance that might affect antioxidant, anticancer, antimicrobial, anti-inflammatory, and immunomodulatory activities. In this study, we aimed to investigate the effectiveness of thymoquinone against bacterial translocation and inflammatory response induced by mechanical intestinal obstruction. METHODS: Thirty Wistar albino rats (200-250 g) were divided into three groups, as follows: Group 1 (sham), with only ileocaecal junction dissection; Group 2 (intestinal obstruction), with complete ileal ligation; Group 3 (intestinal obstruction+thymoquinone), with complete ileal ligation and given 10 mg/kg thymoquinone intraperitoneally. After 24 h, the rats were sacrificed by taking blood from the heart for biochemical analyses. Peritoneal swab cultures and the liver, mesenteric lymph nodes, spleen, and ileum were collected for microbiological and histopathological examinations. RESULTS: Thymoquinone reduced the secretion of inflammatory cytokines, oxidative damage, and bacterial translocation, and prevented inflammatory changes in intestine and liver; it also significantly ameliorated intestinal mucosal damage after intestinal obstruction (P<0.05). CONCLUSIONS: Thymoquinone was found effective in successfully controlling bacterial translocation and improving intestinal barrier function.

The protective effects of curcumin on intestine and remote organs against mesenteric ischemia/reperfusion injury.

BACKGROUND/AIMS: Mesenteric ischemia/reperfusion injury induces a systemic response and releases harmful substances that may affect distant organs such as the lung, liver and kidney. We designed this study to determine if curcumin has protective effects against mesenteric ischemia/reperfusion injury and mesenteric ischemia/reperfusion-induced intestinal and distant organ injury. METHODS: Forty Wistar-Albino rats were divided into four groups as: sham, control, ischemia/reperfusion, and ischemia/reperfusion+curcumin. The ischemia/reperfusion and ischemia/reperfusion+curcumin groups were subjected to mesenteric arterial ischemia for 30 minutes and reperfusion for 1 hour. The control and ischemia/reperfusion+curcumin groups were administered curcumin (200 mg/kg, single dose) via oral gavage 15 min before the injury insult. Blood and pulmonary, hepatic and kidney tissue specimens were obtained to measure serum malondialdehyde and total antioxidant capacity, tissue levels of total antioxidant capacity, total oxidative status, and oxidative stress index. In addition, intestine, pulmonary, hepatic, and kidney tissue specimens were obtained for the evaluation of histopathological changes. RESULTS: The histopathological injury scores of the intestine and distant organs were significantly higher in the ischemia/reperfusion group; these injuries were prevented by curcumin in the ischemia/reperfusion+curcumin group. In the ischemia/reperfusion group, a significant increase in serum malondialdehyde levels was determined, which was prevented with curcumin pretreatment in the ischemia/reperfusion+curcumin group. Total antioxidant capacity levels were significantly supported by curcumin pretreatment in the control and ischemia/reperfusion+curcumin groups. CONCLUSIONS: This study demonstrated that curcumin ameliorates histopathological damage in the intestine and distant organs against mesenteric ischemia/reperfusion injury.

Are Breast Masses in Teenagers Always Benign? Undifferentiated Mesenchymal Sarcoma in a 14-Year-Old Girl.

BACKGROUND: This article is concerned with the evaluation of an adolescent breast mass using imaging methods. CASE REPORT: A 14-year-old girl presented with progressive asymmetric enlargement of the left breast. She had felt a breast lump about 4 months earlier, and over the last 2 months it had been growing progressively. Tumor markers, including AFP, CEA, CA15-3, and CA125, were all normal. Ultrasonography showed a hypoechoichyperechoic, solid mass. Magnetic resonance imaging of the breast revealed a well marginated mass with hypointensity on T1-weighted images and mild hyperintensity on T2-weighted images, which showed mild contrast uptake. Biopsy revealed an undifferentiated malignant mesenchymal sarcoma. The patient underwent mastectomy with axillary lymph node sampling. After the operation, she received 3 cycles of chemotherapy and radiotherapy. CONCLUSION: Due to the rarity of breast sarcoma and inadequate imaging methods to establish an exact diagnosis, radiologists and clinicians may misdiagnose and merely follow these tumors. As in our case, the histology of the patient may be the leading factor in the management of these tumors. Even in very young patients, progressively growing breast masses should alert the clinician to check for malignancy verified by biopsy.