Predicting severity of acute appendicitis with machine learning methods: a simple and promising approach for clinicians.

BACKGROUNDS: Acute Appendicitis (AA) is one of the most common surgical emergencies worldwide. This study aims to investigate the predictive performances of 6 different Machine Learning (ML) algorithms for simple and complicated AA. METHODS: Data regarding operated AA patients between 2012 and 2022 were analyzed retrospectively. Based on operative findings, patients were evaluated under two groups: perforated AA and none-perforated AA. The features that showed statistical significance (p < 0.05) in both univariate and multivariate analysis were included in the prediction models as input features. Five different error metrics and the area under the receiver operating characteristic curve (AUC) were used for model comparison. RESULTS: A total number of 1132 patients were included in the study. Patients were divided into training (932 samples), testing (100 samples), and validation (100 samples) sets. Age, gender, neutrophil count, lymphocyte count, Neutrophil to Lymphocyte ratio, total bilirubin, C-Reactive Protein (CRP), Appendix Diameter, and PeriAppendicular Liquid Collection (PALC) were significantly different between the two groups. In the multivariate analysis, age, CRP, and PALC continued to show a significant difference in the perforated AA group. According to univariate and multivariate analysis, two data sets were used in the prediction model. K-Nearest Neighbors and Logistic Regression algorithms achieved the best prediction performance in the validation group with an accuracy of 96%. CONCLUSION: The results showed that using only three input features (age, CRP, and PALC), the severity of AA can be predicted with high accuracy. The developed prediction model can be useful in clinical practice.

Comparison of Microsatellite Instability With Clinicopathologic Data in Patients With Colon Adenocarcinoma.

Background Microsatellite instability (MSI) is a genetic condition caused by errors in DNA repair genes that cause colorectal cancer (CRC). The literature contradicts the frequency of MSI in sporadic CRCs and its effect on prognosis. This study investigated the distribution of clinicopathologic features and the relationship between MSI and survival outcomes. Methodology This is a retrospective study of 101 consecutive cases of CRC and immunohistochemical studies. All cases were retrospectively reviewed and reevaluated by histological grade, lymphovascular invasion, perineural invasion, tumor borders, dirty necrosis, tumor-infiltrating lymphocytes (TILs), Crohn's-like lymphoid reaction, mucinous and medullary differentiation, and tumoral budding from pathological slides. An immunohistochemical study was performed in appropriate blocks for using MLH-1, MSH-2, MSH-6, and PMS-2. We collected the clinical stage, pathological tumor stage, lymph node metastasis, age, sex, tumor diameter, distant metastasis, localization, and survival information from patients' clinical data. Results There was no statistically significant difference between the two groups regarding age, gender, tumor diameter, histological grade, tumor border, dirty necrosis, TILs, N and M stage, perineural and lymphovascular invasion, mucinous differentiation, medullary differentiation, and tumor budding characteristics of the patients. The MSI-H group was more frequently located in the right colon and transverse colon (p < 0.001), and the T stage was higher among them than in the MSI-L group (p = 0.014). Upon multivariate regression analysis, MSI status had no significant effect on survival time. Age and stage N and M were independent prognostic factors for colon cancer prognosis. Conclusions Our study presented the distribution of clinicopathological features and their relationship with MSI for 101 regional CRC patients. MSI status was detected by immunohistochemistry. Identifying MSI in CRCs may help personalize therapy planning. As the distribution of the features may vary from population to population, further investigations are needed on this topic.

Should we consider Systemic Inflammatory Response Index (SIRI) as a new diagnostic marker for rectal cancer?

PURPOSE: The Systemic Inflammatory Response Index (SIRI), which depends on peripheral neutrophil, monocyte, and lymphocyte count, was found to be an effective prognostic indicator for various malignancies. In this study, we aimed to investigate the diagnostic value and the prognostic impact of SIRI on rectal cancer patients. METHOD: The medical records of patients underwent sphincter-sparing rectal cancer surgery at general surgery between 2017 and 2022 were examined retrospectively. Patient demographics, operation types, neoadjuvant chemo/radiotherapies, pathological results, and complications were recorded. A total number of 99 patients who operated with diagnoses other than cancer were conducted as a control group. SIRI was calculated from preoperative peripheral blood samples' neutrophil, lymphocyte, and monocyte count. The optimal cut-off value for SIRI was found to be 1.38. The clinicopathological outcomes and Overall Survival (OS) were analyzed under two groups according to the SIRI values lower or higher than 1.38. RESULTS: The number of eligible patients was 104. The median age of the entire cohort was 62 (31-89). The median follow-up time was 33 (1-62) months. The median SIRI value in the study group was significantly higher compared with the control group. The study group was examined under two groups: SIRI 1.38 and SIRI > 1.38. The male gender was significantly more frequent in the high SIRI group. The remaining patient demographics and operation types were similar between the groups. The pathological outcomes were similar between the two groups. Overall Survival rate was better in the low SIRI group than those higher. The higher group had significantly higher complication rates than the lower SIRI group (p: 0.004). CONCLUSION: SIRI may be a valuable diagnostic marker in rectal cancer patients. Higher SIRI levels were also associated with poorer prognosis and increased complication rates. Still, further prospective studies with a larger number of patients are needed.

The effect of well-known burn-related features on machine learning algorithms in burn patients' mortality prediction.

BACKGROUND: Burns is one of the most common traumas worldwide. Severely injured burn patients have an increased risk for mortality and morbidity. This study aimed to evaluate well-known risk factors for burn mortality and comparison of six machine learn-ing (ML) Algorithms' predictive performances. METHODS: The medical records of patients who had burn injuries treated at Izmir Bozyaka Training and Research Hospital's Burn Treatment Center were examined retrospectively. Patients' demographics such as age and gender, total burned surface area (TBSA), Inhalation injury (II), full-thickness burns (FTBSA), and burn types (BT) were recorded and used as input features in ML models. Pa-tients were analyzed under two groups: Survivors and Non-Survivors. Six ML algorithms, including k-Nearest Neighbor, Decision Tree, Random Forest, Support Vector Machine, Multi-Layer Perceptron, and AdaBoost (AB), were used for predicting mortality. Several different input feature combinations were evaluated for each algorithm. RESULTS: The number of eligible patients was 363. All six parameters (TBSA, Gender, FTBSA, II, Age, BT) that were included in ML algorithms showed a significant difference (p<0.001). The results show that AB algorithm using all input features had the best predic-tion performance with an accuracy of 90% and an area under the curve of 92%. CONCLUSION: ML algorithms showed strong predictive performance in burn mortality. The development of an ML algorithm with the right input features could be useful in the clinical practice. Further investigations are needed on this topic.

Gastric cancer surgery in elderly patients: promising results from a mid-western population.

BACKGROUNDS: Extended resection for gastric cancer in elderly patients is still challenging for surgeons. This study aimed to evaluate the prognosis and the postoperative outcomes of elderly patients underwent gastric cancer surgery in a high-volume center. METHODS: The medical records of patients with gastric cancer surgery at Marmara University Hospital's General Surgery Department were examined retrospectively. Patients were divided into two groups: Age ≤ 70 and Age > 70. The clinicopathological data of the patients were compared. The prognostic factors regarding gastric cancer surgery were analyzed with Cox proportional regression models. Kaplan Meier analysis and log-rank test were used to compare Overall Survival (OS) and Cancer-Specific Survival (CSS) among the groups. Competing risk regression analysis was used to examine cause-specific hazards among elderly patients. RESULTS: The number of eligible patients was 250. Age > 70 group was 68 patients, and Age ≤ 70 group was 182 patients. There is no significant difference between the patient's demographics or pathological outcomes. Neoadjuvant therapies performed less in elderly patients [40 (22%) vs. 7 (10%), p: 0.03, respectively]. There was no significant difference in severe complication (≥ Grade III) rates in both groups. Multivariate analysis showed that advanced T stage and adjacent organ invasion were the independent risk factors for OS. No significant difference was observed between the groups regarding OS (Log Rank (Mantel-Cox): 0.102). Younger patients have worse CSS than those who are older. Cause-specific hazard model demonstrated a not increased hazard ratio [HR: 1.04(0.78-1.38)] for elderly patients for OS and CSS. CONCLUSION: Gastric resections can be safely performed for elderly patients diagnosed with gastric cancer. This study showed that growing age is no longer a factor that will affect the clinician's decision in performing surgery in gastric cancer patients.

Evaluation of Colonoscopic Results of Patients with Incidental Colonic FDG Uptake in PET/CT Imaging.

BACKGROUND: Colorectal cancer is a significant global health concern, ranking as the second most deadly and third most common cancer worldwide. Early detection and removal of precancerous lesions play a crucial role in preventing cancer development and reducing mortality. Since FDG uptake is not specific for malignancy, incidental increased FDG uptake in the gastrointestinal tract may be challenging to interpret and may require further colonoscopic examination. This study aimed to investigate the features associated with malignant and premalignant pathology in patients with incidental colonic FDG uptake and determine the necessity of colonoscopy for each FDG uptake. METHODS: Retrospective analysis was performed on data from patients who underwent colonoscopies between January 2016 and December 2021. Patients with FDG uptake in known colorectal malignancy regions were excluded. The study included 56 patients with incidental colonic FDG uptake. PET/CT images were visually and quantitatively analyzed, and the corresponding colonoscopy and histopathological results were recorded. Statistical analyses were conducted to evaluate the relationship between FDG uptake patterns, SUVmax values, and histopathological diagnoses. Colonoscopic findings were categorized as malignancy, polyps, and non-neoplastic lesions. RESULTS: Among the 56 patients with incidental colonic FDG uptake, 36 lesions were identified, and histopathology revealed malignancy in 10 (17.9%) patients and premalignant polyps in the 26 (46.4%) cases. Focal FDG uptake with corresponding wall thickening or soft tissue density on CT was associated with a higher likelihood of premalignant or malignant lesions. The SUVmax values demonstrated a significant difference between negative findings and polyps/malignancies. However, no significant difference was observed between malignant and premalignant lesions. A ROC curve analysis was made and assesed a cut-off value of 11.1 SUVmax (sensitivity: 83.3% and specificity: 90%) to distinguish premalignant or malignant lesions from non-malignant lesions. CONCLUSION: Incidental colonic FDG uptake with a focal pattern and corresponding CT findings were more likely to indicate premalignant or malignant lesions. SUVmax values were helpful in predicting the presence of pathological findings, but histopathological verification remains necessary for a definitive diagnosis. These findings contribute to our understanding of the clinical implications of incidental colonic FDG uptake and highlight the importance of follow-up colonoscopy for further evaluation.

Is Systemic Inflammatory Response Index (SIRI) a Reliable Tool for Prognosis of Gastric Cancer Patients Without Neoadjuvant Therapy?

BACKGROUND: The systemic inflammatory response index (SIRI), which depends on peripheral neutrophil, monocyte, and lymphocyte count, was found as an effective prognostic indicator for various malignancies. This study aims to investigate the predictive value of preoperative SIRI in the prognosis of gastric cancer patients without neoadjuvant therapy. METHODS:  The patients who underwent gastric cancer surgery in Marmara University Hospital's General Surgery Department between 2019 and 2021 were analyzed retrospectively. SIRI was calculated from preoperative peripheral blood samples' neutrophil, lymphocyte, and monocyte count. The optimal cut-off value for SIRI was calculated by the receiver operating characteristics (ROC) curve and was found to be 1.35. The clinicopathological outcomes and overall survival (OS) were analyzed under two groups according to the SIRI values lower or higher than 1.35. RESULTS:  The number of eligible patients was 199. The median follow-up time was 25 (1-56) months. The higher SIRI was associated with male gender (p = 0.044), lower serum albumin (0.002) level, and Clavien-Dindo (CD) Grade III and higher complications (p = 0.018). However, there was no significant difference between the groups regarded pathological tumor, nodes, and metastases (TNM) stages, histological grade, and Lauren Type. In addition, OS and stage-specific OS were similar between the groups. CONCLUSIONS:  SIRI may be a valuable and effective predictive indicator for postoperative morbidity. The prognostic performance of SIRI on long-term OS is still controversial. Further investigations are needed into this topic.

Laparoscopic Approach to Severe Liver Injury in a Patient With Blunt Abdominal Trauma.

With laparoscopic surgery becoming more popular in surgical practice, laparoscopic approaches in trauma patients have increased. Non-operative management is the standard treatment algorithm in patients with blunt abdominal trauma who are hemodynamically stable and have sustained a liver injury. However, laparoscopy is a safe and feasible method for exploration, irrigation, and treatment if a surgical intervention is needed in this group. In this study, we aimed to present a case of liver injury in blunt abdominal trauma and its management laparoscopically. A 22-year-old male was admitted to the Marmara University Hospital's Emergency Unit of a tertiary center following a truck accident. The patient was hemodynamically stable at admission. CT scan showed a grade IV liver laceration with hemoperitoneum. The patient was transferred to the observation room. After three hours, the patient's hemoglobin value decreased from 14.6 g/dl to 8.4 g/dl, and the mean arterial blood pressure decreased to 60 mmHg. The patient's heart rate increased to 125, and peritonitis was evident on the abdominal examination. Emergent laparoscopy was performed on the patient. Grade IV liver laceration with no active bleeding was observed. After peritoneal irrigation, surgery was terminated. With the developments in minimally invasive procedures, laparoscopic approaches were used more frequently in trauma patients. In the referral and experienced centers, laparoscopy could be an appropriate way to avoid unnecessary laparotomies.

Low anterior resection syndrome (LARS) after sphincter-sparing rectal cancer surgery. Incidence and risk factors.

BACKGROUNDS: Low anterior resection syndrome (LARS) was defined with symptoms such as frequency, incontinence, urgency, and constipation in patients who underwent Sphincter-Sparing Rectum Surgery (SSRC). In this study, LARS rates and risk factors of the patients who underwent SSRC were Investigated. MATERIAL METHOD: The medical records of patients with SSRC at general surgery department were examined retrospectively. Clinical characteristics, neo/adjuvant chemo-radiotherapies, distal resection levels, open/laparoscopic procedures, postoperative complications, and pathological outcomes were recorded. LARS scoring system defined by Emmertsen and Laurberg was used to calculate LARS scores. RESULTS: The number of eligible patients was 129. The rectal resection was performed by either low anterior resection (LAR) or very low anterior resection (VLAR). VLAR was used to specify that had anastomosis <5cm to the anal verge. The median follow-up time was 12 (1-30) months. LARS were detected in 60 (%47) patients. LARS rates were significantly higher in the patients underwent VLAR (n: 35 9% vs. 48%<0,001). In univariate analysis, the level of distal resection, open surgeries, neoadjuvant RT, and diversion with temporary stoma were significantly different in LARS group. However, in multivariate analysis, distal resection level was the only significant risk factor for LARS. CONCLUSION: Low anterior resection syndrome (LARS) was frequently seen in patients who underwent sphincter-sparing rectum surgery (SSRS). It was detected that distal resection levels were the most important risk factor for the development of LARS. This result showed that LARS should not be disregarded in patients underwent SSRS. KEY WORDS: Bowel Disfunction, Cancer, Incontinence, LARS, Rectum.

Mortality prediction models for severe burn patients: Which one is the best?

BACKGROUND: For prediction of mortality and clinical course, various scoring systems had been developed. We choose four well known burn specific scoring systems and a general scoring system that using in Intensive Care Units. The primary outcome of this study was evaluate the predictive performances of this models and define the optimal one for our patient population. METHODS: Variables analyzed were age, gender, burn type, total burned surface area (TBSA), total partial thickness burn area, total full thickness burn area, inhalation injuries, mechanical ventilation supports, blood products usage, total scores of Abbreviated Burn Severity Index (ABSI), revised Baux, Belgian Outcome in Burn Injury, Fatality by Longevity, Acute Physiology and Chronic Health Eval-uation II (APACHE II) score, Measured Extent of burn and Sex (FLAMES) and APACHE II, and their relations with mortality. RESULTS: In our study, a statistically significant relationship was found with mortality between age, TBSA, full thickness burn percent-age, inhalation injury, burn type, and it was similar to literature. Female gender was found to be a significant risk factor for mortality. CONCLUSION: We compared several burn mortality scoring systems and their predictional mortality rates. ABSI scores of patients for estimated mortality rates were similar to our mortality rate. Consequently, it was thought that ABSI was included all mortality-re-lated parameters.

Gastric Cancer Surgery During the Pandemic: What It Costs?

BACKGROUND: From the early days of 2020, the COVID-19 pandemic continues to change whole life all around the world. Oncological patients are the most affected populations since these days. Because of decreasing numbers in surgery and endoscopy, gastric cancer patients had difficulties in treatment and diagnoses. Therefore, the early and long-term results may be affected during the pandemic. In this study, we aimed to evaluate pandemia effects on gastric cancer surgery in a single center. PATIENTS-METHODS: Patients were categorized as the COVID group and the Pre-COVID group. Patients who received neoadjuvant chemotherapy were excluded from the study. In the COVID period, 50 patients underwent gastric cancer surgery, while 64 were operated on in the pre-COVID period. Patients' demographics and clinical and pathological outcomes were evaluated. RESULTS: There was no statistically significant difference in both periods among patient characteristics such as age, gender, and body mass index. Pre-operative laboratory results were similar between two groups. Although there was no difference in operation types, an increase was detected in Clavien-Dindo grade 3 and higher complications during the COVID period. During the pandemic, there was a significant difference in the pathological outcomes. Peritoneal cytology-positive patients were higher in the COVID group. More lymphovascular invasions were also detected in the COVID period. Finally, it resulted stage differences between two groups. CONCLUSION: Because of COVID-19's heavy burden on healthcare system, delays in the diagnosis and treatment of oncological patients may occur. Therefore, this may be affected pathological and survival outcomes of cancer patients. Finally, further investigations are needed.

A laparoscopic approach to gastric foreign bodies. A video case presentation.

INTRODUCTION: Foreign body ingestions are one of the common reasons for Emergency Department applications. Although it is mostly seen in the pediatric age group, adult patients could be more complicated. The majority of swallowed foreign bodies could pass through the digestive system spontaneously. Only %1 of them needs surgical interventions. In this study, we present a case that swallowed his denture and needs surgical treatment. CASE PRESENTATION: A 59-year-old male patient was admitted to Emergency Department for swallowing his dental prosthesis accidentally. He had the feeling of being stuck in his chest while swallowing, and there were no additional symptoms. On the chest x-ray, it was detected in the middle part of esophagus. Upper Gastrointestinal System Endoscopy was performed to remove it. Foreign body was detected in the stomach during the endoscopy. However, it was not suitable for endoscopic extraction. Surgery was performed, and the foreign body was removed from the stomach laparoscopically. The patient was discharged from the hospital uneventfully on the fifth day after surgery. CONCLUSION: Although they have seemed in many cases, a small percentage of foreign body ingestions needs surgical treatment. Developments in recent years have increased the frequency of using minimally invasive techniques in emergency surgeries. Because of advantages such as fast recovery and small scars, laparoscopic surgery is recommended as an option that can be used safely in emergency cases. KEY WORDS: Foreign Body, Gastric, Laparoscopy, Surgery.

Negative-pressure Wound Therapy in Chronic Inflammatory Breast Diseases.

Mastitis is inflammation of breast tissue that may or may not originate from an infection. Two different forms of mastitis have been described, lactational and non-lactational. Lactational mastitis is the most common type and generally conservative therapy that includes milk removal and physical therapy provides symptomatic relief, but antibiotic therapy is also needed. Common types of non-lactational mastitis are periductal mastitis and idiopathic granulomatous mastitis. Treatment includes antibiotics, drainage, and surgery, but usually this is a chronic process and a therapeutic management algorithm for chronic breast inflammation is unclear and has no consensus. Negative-pressure wound therapy is commonly used for various types of wounds but is limited for breast wounds. In this report, we present and discuss two patients with chronic breast inflammation who underwent surgery and were successfully treated using negative-pressure wound therapy to minimize wide tissue defects and cosmetic problems after surgery. Use of negative-pressure wound therapy for breast wounds might be benefical as it is with other wounds but there is scarce information in the literature.