Management and Morbidity of Major Pelvic Hemorrhage in Complex Abdominopelvic Surgery.

INTRODUCTION: Hemorrhage is a challenging complication of pelvic surgery. This study aimed to analyze the causes, management, and factors associated with morbidity in patients experiencing major pelvic hemorrhage during complex abdominopelvic surgery. METHODS: Patients who had major intraoperative pelvic hemorrhage during complex abdominopelvic surgery at 11 tertiary referral centers between 1997 and 2017 were included. Patient characteristics, management strategies to control bleeding, short- and long-term postoperative outcomes were evaluated retrospectively. RESULTS: There were 120 patients with a mean age of 56.6 ± 2.4 years and a mean BMI of 28.3 ± 1 kg/m2. While 104 (95%) of the patients were operated for malignancy, 16 (5%) of the patients had surgery for a benign disease. The most common bleeding site was the presacral venous plexus 90 (75%). Major pelvic hemorrhage was managed simultaneously in 114 (95%) patients. Electrocauterization 27 (23%), pelvic packing 26 (22%), suturing 7 (6%), thumbtacks application 7 (6%), muscle welding 4 (4%), use of energy devices 2 (2%), and topical hemostatic agents 2 (2%) were the management tools. Combined techniques were used in 43 (36%) patients. Short-term morbidity and mortality rates were 48 (40%) and 2 (2%), respectively. High preoperative CRP levels (p = 0.04), history of preoperative radiotherapy (p = 0.04), longer bleeding time (p = 0.006), and increased blood transfusion (p = 0.005) were the factors associated with postoperative morbidity. CONCLUSION: Postoperative morbidity related to major pelvic hemorrhage can be reduced by optimizing the risk factors. Prehabilitation prior to surgery to moderate inflammatory status and prompt action with proper technique to control major pelvic hemorrhage can prevent excessive blood loss in complex abdominopelvic surgery.

Factors affecting operative morbidity and long-term outcomes in patients undergoing surgery for presacral tumours: a multicentric cohort study from the Turkish Collaborative Group for Quality Improvement in Colorectal and Pelvic Surgery.

AIM: Data regarding the operative management of presacral tumours present various dilemmas due to their rarity and heterogeneous nature. The aim of this study was to evaluate the management strategy, factors associated with operative morbidity and long-term postoperative outcomes in a large group of patients undergoing surgery for presacral tumours. METHOD: This study was designed as a multicentre retrospective cohort study. Records of patients who underwent surgery for presacral tumours at 10 tertiary colorectal centres between 1996 and 2017 were evaluated. RESULTS: One hundred and twenty seven patients (44 men) with a mean age of 46 years and body mass index of 27 kg/m2 were included. Fifty eight per cent of the patients had low sacral lesions (below S3). The operative approaches were transabdominal (17%), transsacral (65%) and abdominosacral (17%). The postoperative morbidity was 19%. Thirty per cent of the patients had a malignant tumour. Longer duration of symptoms (p = 0.001), higher American Society of Anesthesiologists score (p = 0.01), abdominosacral operations (p = 0.0001) and presacral tumours located above S3 (p = 0.004) were associated with an increased risk of postoperative morbidity. Overall long-term postoperative recurrence and mortality were 6% and 5%, respectively, within a 3-year mean follow-up period in patients with presacral malignant tumours. CONCLUSION: Reduced physical condition, omission of symptoms prior to surgery, combined resections and high sacral tumours are the risk factors associated with postoperative complications in patients undergoing surgery for presacral tumours. Meticulous planning of the operation and intensified perioperative care may improve the outcomes in high-risk patients.

The potential prognostic role of peritumoral eosinophils within whole tumor-associated inflammatory cells and stromal histological characteristics in colorectal cancer.

We aimed to determine the prognostic role of whole tumor-associated inflammatory cells, especially eosinophils, and stromal histological characteristics in relation to other prognostic parameters in patients with colorectal carcinoma (CRC). A total of 122 patients who underwent an operation for CRC were included in this retrospective study. Conventional (tumor grade, TNM stage and venous invasion [VI]) and other histopathological (intratumoral/peritumoral budding [ITB/PTB], desmoplasia) tumor parameters were recorded and classified by density, as were the tumor-associated inflammatory parameters (intratumoral/peritumoral lymphocytes [ITL/PTL], eosinophils [IE/PTE], overall inflammation [ITI/PTI], Crohn-like inflammation [CLI]). Cancer-specific survival data were analyzed with respect to all tumor parameters. High ITB and PTB were significantly correlated with a higher rate of pT4, VI and desmoplasia (p < 0.05). An association of moderate ITL and extensive PTL with lesser likelihood of VI and metastasis; an association of extensive CLI with a significantly lower rate of metastasis and TNM stage IV; and minimal PTE with a significantly higher rate of pT4 stage, metastasis and ITB were detected (p < 0.05 for each). Our findings revealed that low score tumoral budding and an increase in tumor-related inflammation were associated with lesser likelihood of poor prognostic tumor parameters. Nonetheless, given the association of an increase in PTE with lesser likelihood of ITB, pT4, metastasis, and with non-significantly for better survival rates, our findings emphasize the potential role of peritumoral eosinophils as an additional prognostic parameter in CRC.

Outcomes of conversion from laparoscopy to open surgery in geriatric patients with colorectal cancer: a case-controlled study.

PURPOSE: To evaluate the incidence, risk factors and outcomes of conversion from laparoscopic to open surgery in geriatric patients with colorectal cancer (CRC). METHODS: All patients subjected to laparoscopic procedures for CRC between 2006 and 2018 were included. Patients older than 70 were divided into these necessitating or not necessitating conversion to open surgery (Con>70 and Lap>70 groups, respectively), and those younger than 70 requiring conversion were evaluated in Con<70 group. The results were compared between Con>70 group and the two other groups. RESULTS: Conversion was significantly more common in Con>70 group than Con<70 group (17.3 vs 9.6%, p=0.011). Although female gender and T4 tumors leading to multivisceral resection were significant risk factors for conversion in univariate analysis, multivariate analysis denied any variable as significant. Perioperative outcomes were significantly worse in Con>70 group than those in Lap>70 group. When conversion groups were compared, the rates of surgical site infection and evisceration were higher in geriatric patients. Pathological results revealed that Con>70 group had more advanced tumors than Lap>70 group regarding pT stage, number of malignant lymph nodes and perineural invasion rate. However, the numbers of harvested lymph nodes were similar in two groups. CONCLUSION: Conversion rate is higher in geriatric patients, particularly in female patients and those who necessitate multivisceral resections. Conversion worsens the perioperative outcomes in geriatric patients. Finally, since the number of harvested lymph nodes does not decrease with conversion, it probably does not threaten the quality of oncological surgery.

Prognostic Significance of Metastatic Lymph Node Ratio in Patients with pN3 Gastric Cancer Who Underwent Curative Gastrectomy.

BACKGROUND: Lymph node involvement is an important prognostic factor in patients with gastric cancer. The aim of this study was to determine the prognostic significance of metastatic lymph node ratio (MLNR) and compare it to the number of lymph node metastasis in pN3 gastric cancer. METHODS: We retrospectively analyzed 207 patients with pN3 gastric cancer who had undergone radical gastrectomy. Prognostic factors and MLNR were evaluated by univariate and multivariate analysis. RESULTS: An MLNR of 0.75 was found to be the best cut-off value to determine the prognosis of patients with pN3 gastric cancer (p = 0.001). The MLNR was significantly higher in patients with large-sized and undifferentiated tumors, vascular, lymphatic and perineural invasion, and total gastrectomy. In multivariate analysis, MLNR (p = 0.041), tumor differentiation (p = 0.046), and vascular invasion (p = 0.012) were found to be independent prognostic factors for disease-free survival, while both MLNR (p < 0.001) and pN stage (p = 0.002) were independent prognostic indicators, as was tumor size, for overall survival. There was significant difference with respect to the recurrence patterns between MLNR groups. Lymph node and peritoneal recurrences were significantly higher in patients with MLNR > 0.75 compared to the MLNR < 0.75 group (p < 0.05). However, recurrence patterns were similar between pN3a and pN3b. CONCLUSION: Our results showed that MLNR was a useful indicator to determine the prognosis and recurrence patterns of patients with radically resected gastric cancer. Moreover, MLNR is a beneficial and reliable technique for evaluating lymph node metastasis.

Gallbladder perforation during elective laparoscopic cholecystectomy: Incidence, risk factors, and outcomes.

OBJECTIVE: This study aimed to reveal the risk factors and outcomes of gallbladder perforation (GP) during laparoscopic cholecystectomy. METHODS: Videotapes of all patients who underwent an elective cholecystectomy at our department were retrospectively analyzed, and the patients were divided into two groups based on the presence of GP. The possible risk factors and early outcomes were analyzed. RESULTS: In total, 664 patients [524 (78.9%) females, 49.7±13.4 years of age] were observed, and GP occurred in 240 (36.1%) patients, mostly while dissecting the gallbladder from its bed (n=197, 82.1%). GP was not recorded in the operation notes in 177 (73.8%) cases. Among the studied parameters, there was no significant risk factor for GP, except preoperatively elevated alanine transaminase level (p=0.005), but the sensitivity and specificity of this measure in predicting GP were 14.2% and 7.4%, respectively. The two groups had similar outcomes, but the operation time (35.4±17.5 vs 41.4±18.7 min, p=0.000) and incidence of drain use (25% vs 45.8%, p=0.000) increased in the GP group. CONCLUSION: The present study reveals that GP occurs in 36.1% of patients who undergo laparoscopic elective cholecystectomy, but it may not be recorded in most cases. We did not find any reliable risk factor that increases the possibility of GP. GP causes an increase in the operation time and incidence of drain use; however, the other outcomes were found to be similar in patients with GP and those without.

J-pouch vs. side-to-end anastomosis after hand-assisted laparoscopic low anterior resection for rectal cancer: A prospective randomized trial on short and long term outcomes including life quality and functional results.

PURPOSE: To analyze the outcomes of j-pouch and side-to-end anastomosis in rectal cancer patients treated with laparoscopic hand-assisted low anterior resection. METHODS: Prospective trial on cases randomized to have a colonic j-pouch or a side-to-end anastomosis after low anterior resection. Demographics, characteristics of disease and treatment, perioperative results, and functional outcomes and life quality were compared between the groups. RESULTS: Seventy four patients were randomized. Reservoir creation was withdrawn in 17 (23%) patients, mostly related to reach problem (n = 11, 64.7%). Anastomotic leakage rate was significantly higher in j-pouch group (8 [27.6%] vs. 0, p = 0.004). Stoma closure could not be achieved in 16 (28.1%) patients. Life quality and functional outcomes, measured 4, 8 and 12 months after the stoma reversal, were similar. CONCLUSIONS: Colonic j-pouch and side-to-end anastomosis are similar regarding perioperative measures including operation time, rates of postoperative complications, reoperation and 30-day mortality, and hospitalization period except anastomotic leak rate, which is higher in j-pouch group. Postoperative aspects are not different in patients receiving either technique including functional outcomes and life quality for the first year after stoma closure. In our opinion, both techniques may be preferred during the daily practice while performing laparoscopic surgery; but surgeons may be aware of a possibly higher anastomotic leak rate in case of a j-pouch.

Fortune of temporary ileostomies in patients treated with laparoscopic low anterior resection for rectal cancer.

PURPOSE: The current study aims to analyze the risk factors for the failure of ileostomy reversal after laparoscopic low anterior resection for rectal cancer. METHODS: All patients who underwent a laparoscopic low anterior resection for rectal cancer with a diverting ileostomy between 2007 and 2014 were abstracted. The patients who underwent and did not undergo a diverting ileostomy procedure were compared regarding patient, tumor, treatment related parameters, and survival. RESULTS: Among 160 (103 males [64.4%], mean [± standard deviation] age was 58.1 ± 11.9 years) patients, stoma reversal was achieved in 136 cases (85%). Anastomotic stricture (n = 13, 52.4%) was the most common reason for stoma reversal. These were the risk factors for the failure of stoma reversal: Male sex (P = 0.035), having complications (P = 0.01), particularly an anastomotic leak (P < 0.001), or surgical site infection (P = 0.019) especially evisceration (P = 0.011), requirement for reoperation (P = 0.003) and longer hospital stay (P = 0.004). Multivariate analysis revealed that male sex (odds ratio [OR], 7.82; P = 0.022) and additional organ resection (OR, 6.71; P = 0.027) were the risk factors. Five-year survival rates were similar (P = 0.143). CONCLUSION: Fifteen percent of patients cannot receive a stoma reversal after laparoscopic low anterior resection for rectal cancer. Anastomotic stricture is the most common reason for the failure of stoma takedown. Having complications, particularly an anastomotic leak and the necessity of reoperation, limits the stoma closure rate. Male sex and additional organ resection are the risk factors for the failure in multivariate analyses. These patients require a longer hospitalization period, but have similar survival rates as those who receive stoma closure procedure.

Unusually located primary hydatid cysts.

The hydatid disease caused by Echinococcus granulosus is an endemic parasitic disease affecting several Mediterranean countries. Echinococcal cysts are mostly located in the liver and the lung, but the disease can be detected anywhere in the body. In this study, we present uncommon extrahepatic localizations of primary hydatid disease. Patients who were operated on for hydatid disease or cystic lesions, which were later diagnosed as hydatid disease, between 2004 and 2010 were retrieved retrospectively. Patients with lesions localized outside the liver and the lung were enrolled in the study. Eight patients with extrahepatic primary hydatid disease were treated surgically at our clinic. The cysts were located in the scapular region, spleen, pancreas, lumbosacral region and gluteal muscle. Surgical techniques were partial or total cystectomy with or without tube drainage. Splenectomy was performed for splenic hydatid disease and partial pericystectomy, Roux-en-Y cystojejunostomy, cholecystectomy and T-tube drainage for pancreatic hydatid disease. There were no complications or mortality in the postoperative period. Hydatid cyst should be considered in the differential diagnosis of cystic lesions, especially in endemic areas. Surgical technique should be planned according to the location of the cyst.

The Feasibility of Hepatic Resections Using a Bipolar Radiofrequency Device (Habib®).

The bipolar radiofrequency device (Habib®) has been recently introduced in order to reduce intraoperative bleeding for a safe hepatic resection as an alternative to the conventional tools. However, indications, perioperative findings, and outcome of the device for hepatic resections remain and deserve to be analyzed. The current study aims to analyze the feasibility of the bipolar radiofrequency device (Habib®) for hepatic resections. Information of the patients that underwent hepatic resection using with the Habib® device between 2007 and 2011 was abstracted. Patient, disease, and operation-related findings and perioperative data were investigated. A total of 71 cases (38 [53.5 %] males, mean age was 56.8 ± 11.9) were analyzed. Metastatic disease (n = 55; 77.5 %) was the leading indication followed by primary liver and biliary malignancies (n = 7; 9.9 %), hemangioma (n = 5; 7 %), hydatid disease (n = 3; 2.8 %), and hepatic gunshot trauma (n = 1; 1.4 %). Metastasectomy was the most commonly performed procedure (n = 31; 56.3 %), but in 24 (77.4 %) cases, it was performed in addition to extended resections. Other procedures in the study patients include segmentectomy in 17, bisegmentectomy in 19, trisegmentectomy in 17, right or left hepatectomy in 8, and extended right/left hepatectomy in 3. The mean (±SD) operation time was 241.7 ± 78.2 min. The median amount of bleeding was 300 cc (range 25-2500), and 23 (32.4 %) cases required perioperative transfusion. The median hospitalization period was 5 days (range 1-47). Lengthened drainage (n = 9, 12.7 %) and intraabdominal abscess (n = 8, 11.23 %) were the most common problems. Hepatic resections using the Habib® device seem to be feasible in cases with primary and metastatic hepatic lesions and benign liver masses and even those with hepatic trauma. It may lessen the amount of intraoperative hemorrhage, although lengthened drainage and intraabdominal abscess were the major postoperative problems in these cases.

Safety and feasibility of laparoscopic sigmoid colon and rectal cancer surgery in patients with previous vertical abdominal laparotomy.

INTRODUCTION: Current study aims to analyze the impact of previous vertical laparotomy on safety and feasibility of laparoscopic sigmoid colon and rectal cancer operations. METHODS: All consecutive patients who underwent a laparoscopic resection for sigmoid colon or rectal cancer were included. These aspects were abstracted and compared within no laparotomy and previous vertical laparotomy groups: demographics, perioperative aspects, pathological features and survival. RESULTS: There were 252 patients in no laparotomy group, and 25 cases with previous vertical incisions including lower (n = 12, 48%), upper (n = 7, 28%), and lower&upper (n = 2, 8%) midline and paramedian (n = 4, 16%) laparotomies. Veress insufflation and open technique were used in 19 (76%) and 6 (24%) cases, respectively, during the insertion of the first trocar in previous laparotomy group. Patients in previous laparotomy group were significantly older (59.2 ± 13.4 vs. 66.2 ± 10.1, p = 0.01), but gender, ASA scores, tumor and technique related factors were similar within the groups, including operation time (200 [70-600] vs. 200 [130-390] min, p = 0.353), blood loss (250 [100-1500] vs. 250 [0-2200] ml, p = 0.46), additional trocar insertion (10 [4%] vs. 3 [12%], p = 0.101), conversion (20 [7.9%] vs. 4 [16%], p = 0.25), postoperative complication (59 [23.4%] vs. 4 [16%], p = 0.06) and 30-day mortality (7 [2.8%] vs. 1 [4%], p = 0.536) rates. Oncological outcomes regarding pathological features and 5-year survival rates (65% vs. 73.2%, p = 0.678) were not different. CONCLUSION: The presence of a previous laparotomy does not worsen the outcomes in patients undergoing laparoscopic removal of sigmoid or rectal cancer, thus laparoscopy may be considered to be safe and feasible in these cases.

A descriptive survey study to evaluate the relationship between socio-demographic factors and quality of life in patients with a permanent colostomy.

The impact of having a stoma on quality of life is increasingly recognized and studied. A descriptive survey study was conducted between January 2006 and December 2011 among 44 patients (18 women, 26 men) with a permanent stoma receiving care at the Kartal Training and Research Hospital, Istanbul, Turkey, to evaluate socio-demographic factors that may affect the quality of life in Turkish Muslim patients with an enteral stoma. A socio-demographic questionnaire, a 10- item Religious Orientation Scale (Modified Allport-Ross ROS), and the Medical Outcomes Study Short Form 36 Quality of Life survey were administered by a stoma therapy nurse at least 6 months after completion of all surgical and oncological treatments. The mean follow-up period was 15.3 ± 9.7 (range 6-44) months since completion of all treatments. Data were collected using paper/pencil instruments and entered for data analysis using Student's t-tests or one-way ANOVA univariate and multivariate analyses. No significant differences were observed for income, education level, surgical history, or religion score. Gender, geographic region, and household status were found independently related to quality of life in stoma patients. Female patients had significantly lower scores than males in general health perception (P = 0.049), role emotion (P = 0.02), mental health perception (P = 0.026), and mental component (P = 0.007). Patients living in a village (four) had significantly lower scores than patients living in a big city (33) in all scales (P <0.05 for all comparisons). Village-dwelling patents also had significantly lower scores than patients living in a town (seven) in physical function (P = 0.001), vitality (P = 0.012), social function (P = 0.003), and mental component scores (P = 0.021). Patients living alone (seven) had significantly lower scores than patients living with a partner (11) in three of eight scales (physical functioning [P <0.001], role-physical [P = 0.047], and bodily pain [P = 0.015]) and physical component scores (P <0.001); they also had significantly lower scores than patients living with their families (26) in four of eight scales (physical functioning [P <0.001], role-physical [P = 0.032], bodily pain [P = 0.02], and general health perception [P=0.036]) and physical component scores (P <0.001). Although these findings provide evidence for the relationship between some socio-demographic factors on quality of life of patients with a stoma, the results of the study should be interpreted with caution; multicenter, prospective, controlled studies are needed to substantiate and clarify the relationships among these variables.

Stereotactic excision of additional lesions detected with intraoperative ultrasound examination during radiofrequency dissecting sealar (habib®) assisted hepatic metastasectomy: report of 4 cases.

Intraoperative ultrasound has been using to achieve a proper resection strategy in patients undergoing a hepatic colorectal metastasectomy. This study aims to describe and reveal the place of stereotactic metastasectomy in nonpalpable colorectal liver metastases (CLM). A chart review was initiated for all patients underwent resection for CLM between 2006 and 2011. The data concerning perioperative data and intraoperative strategy were abstracted. Among the 58 patients, who underwent a resection for CLM, 4 (6.9 %) (all men, median age 65.5, range 49-72, years) necessitated a stereotactic metastasectomy. Preoperative evaluations showed 1 (n = 1), 2 (n = 2), or 3 (n = 1) lesions, and intraoperative ultrasound (IUS) found an additional lesion in a case. Stereotactic marking was performed for nonpalpable lesions located in segments IVA, II, and VI and at the junction of segments V and VI. The margins were negative for all lesions both resected with conventional and stereotactic techniques. The examinations of the stereotactic resection materials revealed metastatic adenocarcinoma (patients n = 2), focal nodular hyperplasia (n = 1), and abnormal benign liver histology probably induced by chemotherapy (n = 1). The median (range) operation and hospitalization periods were 217.5 (150-310) minutes and 5.5 (2-9) days. No complications were observed except biliary fistula in a case, which spontaneously disappeared within 2 weeks. A patient died due to systemic disease including hepatic metastases 33 months after the liver surgery. Stereotactic metastasectomy may be feasible for the removal of nonpalpable CLM. Further evaluations are necessitated to understand the accurate place of this novel technique.

Risk factors for early postoperative morbidity and mortality in patients underwent radical surgery for gastric carcinoma: a single center experience.

BACKGROUND: Aim of this study is to analyze the incidence and risk factors for early postoperative morbidity and mortality that occur after gastric carcinoma surgery. MATERIALS AND METHODS: All consecutive patients with gastric adenocarcinoma resected with curative intent between 2005 and 2011 were included to a retrospective analysis. Patient, disease and operation related parameters were questioned as risk factors for postoperative morbidity and mortality. RESULTS: A total of 160 patients (103 [64.8%] male and the average age was 62.4 ± 11.5) were abstracted. Early postoperative morbidity, operation related morbidity and mortality were observed in 46 (28.7%), 31 (19.4%) and 19 (11.9%) cases, respectively. No other factors but ASA score was found to be a risk factor for overall morbidity (p = 0.021 and 0.033 in univariate and multivariate analyses, respectively). The incidence of anastomotic leak was increasing in patients who received a D2 dissection in univariate analysis (p = 0.039), but not in multivariate calculation. There were no factors effecting surgical site infection risk. Although univariate analysis revealed that age over 70 (p = 0.008), ASA score (p = 0.018), operation time (p = 0.032), D2 dissection (p = 0.026) and type of anastomosis (p = 0.023) were effecting the risk for early mortality, multivariate analysis showed that age was the only risk factor (p = 0.005). CONCLUSION: Current study has revealed that early morbidity and mortality are not rare after gastric cancer surgery with curative intent. Since multivariate analyses have revealed that ASA score and older age may be only risk factors for postoperative morbidity and 30-day mortality, respectively; it may be logical to consider these factors during the preoperative decision making in patients with gastric cancer.

Ramadan fasting in patients with a stoma: a prospective study of quality of life and nutritional status.

Ramadan fasting is an Islamic obligation for healthy Muslims after the age of puberty. Persons with an acute or chronic disease may be excused from this obligation; the degree of the disease is an important parameter for not fasting. Little is known about the effect of fasting on persons with a stoma. A prospective study was conducted among 56 patients with a cancer-related fecal stoma (33 [58.9%] male, mean age 55.9 ± 13.1 years) over two periods of Ramadan to analyze the effect of fasting 15 to 16 hours on nutritional and metabolic status and quality of life. Eligible patients were divided into two groups: fasting (n = 14) and nonfasting (n = 42). Demographic and stoma information, as well as disease and treatmentrelated variables, were evaluated. Participants completed cancer patient and colorectal cancer patient quality-of-life instruments and rated their religious orientation. Laboratory tests (blood urea nitrogen, creatinin, cholesterol, prealbumin, albumin, and transferrin) were performed 1 to 3 weeks before Ramadan, and questionnaires and tests were repeated 1 to 3 weeks after Ramadan in people who fasted. Demographic parameters, including religious orientation scale scores, were similar between fasting and nonfasting groups. Patients in the fasting group had significantly higher albumin levels (4.6 ± 0.2 versus 4.1 ± 0.4, P = 0.001), prealbumin levels (27.6 ± 7.4 versus 21.3 ± 8.5, P = 0.018), and global health status scores (81.5 ± 16.7 versus 68.3 ± 20.1, P = 0.030) than patients in the nonfasting group. Patients who fasted also had their stoma for a longer period of time than patients in the nonfasting group (average 9 months [range 3-87 months] in the fasting versus 4.5 months [range 3-36 months] in the nonfasting group, P = 0.084), and the proportion of patients with a permanent stoma was higher in the fasting group than in the nonfasting group (P = 0.051). Ramadan fasting had almost no influence on quality of life. Fasting lowered prealbumin levels (27.6 ± 7.4 versus 21.2 ± 4.4; P = 0.046), but did not adversely affect other nutritional or global health status variables. Most patients in the fasting group (13, 92.9%) stated they would feel sad if they were not fasting. The results of this study suggest that although fasting may decrease prealbumin levels, persons with a stoma and good nutritional status may decide for themselves whether to fast.

The effect of fibrin glue on the intensity of colonic anastomosis in the presence and absence of peritonitis: an experimental randomized controlled trial on rats.

Aim. Anastomotic leakage after colon anastomosis is the most frequent and most feared complication with its highest mortality rate. In this study, we aimed to expose the impact of performing fibrin glue on sutured colocolic anastomosis, in the presence of experimental peritonitis, on anastomosis safety. Method. In this experimental study, the rats were divided into two groups as control group (Groups 1 and 3) and experimental group (Groups 2 and 4). They were also divided as clean abdomen (Groups 1 and 2) and infected abdomen (3 and 4) groups. Full-thickness incisions were made on the proximal colon of both groups of rats. The control group's anastomoses were conducted only with sutures, whereas in experimental group, fibrin glue was applied over the sutures. The samples were taken on the 10th day. Results. Highest values for average levels of hydroxyproline in the tissues and anastomotic bursting pressures were detected when fibrin glue was applied on sutured anastomosis in clean abdomen. In the histopathological staging performed in line with Ehrlich-Hunt model, lowest values were detected during the presence of peritonitis. Conclusion. As a result, it has been established that the use of fibrin glue over sutured colocolic anastomosis, both in clean abdomen and in the presence of peritonitis, had increased anastomosis safety.

Laparoscopic and conventional resections for low rectal cancers: a retrospective analysis on perioperative outcomes, sphincter preservation, and oncological results.

BACKGROUND: This study aims to compare the results of laparoscopic and conventional techniques in patients with low rectal cancers. SUBJECTS AND METHODS: A retrospective data analysis was initiated in patients underwent laparoscopic or conventional surgery for cancers located in the low (<6 cm) rectum. Patient and tumor-related information, outcomes of operations, and survival were compared between the groups. RESULTS: Among 142 patietns (91 men [64.1%]; mean±standard deviation age, 57.7±14.6 years) who had tumors located <6 cm from the dentate line, 92 (64.8%) were operated on with the laparoscopic technique. Demographics, tumor stage, and localization (2.9±2.0 versus 2.9±2.1 cm from the dentate line in laparoscopic and conventional arms, respectively; P=.968) were similar. However, there were more patients in the laparoscopic group who received neoadjuvant chemoradiation therapy (92.4% versus 80.0%; P=.03), since there were significantly fewer cases with stage I tumors in this group (3.3% versus 14%; P=.33). The conversion rate was 14.1% (n=13). The amount of bleeding and the requirement for transfusion decreased (P<.05 for both), and the possibility of sphincter-saving procedures (66.3% versus 34.0%; P<.001) increased, in the laparoscopy group. Other parameters were identical. In the laparoscopy group, the number of harvested lymph nodes (10.2±5.4 versus 12.4±6.0; P=.025) and the rate of vascular invasion (27.5% versus 47.8%; P=.021) were less, and Kaplan-Meier analysis revealed an improved survival (P=.042), although the follow-up period was significantly shorter in this group (P<.001). CONCLUSIONS: Laparoscopic surgery for low rectal cancers may be technically feasible and oncologically safe. Laparoscopy may increase the possibility of sphincter preservation.

Complete versus partial mobilization of splenic flexure during laparoscopic low anterior resection for rectal tumors: a comparative study.

BACKGROUND: The aim of the current study is to compare the results after partial and complete splenic flexure mobilization (SFM). SUBJECTS AND METHODS: The records of laparoscopic and hand-assisted laparoscopic procedures for primary rectal tumor patients were abstracted from a prospectively designed database. The phrenicocolic and splenocolic ligaments were divided via a four-trocar technique in the partial SFM group, and dissection was continued with the separation of gastrocolic and pancreaticomesocolic attachments via a five-trocar procedure in the complete SFM group. The following data were compared between the groups: Demographics, intra- and postoperative information, and pathological features. RESULTS: In total, 122 cases (77 [63.1%] male, 58.2±13.2 years old) who underwent a partial (n=36, 29.5%) or a complete (n=86, 70.5%) SFM were included. Reservoir creation (48.8% versus 19.4%, P=.003) was more common and conversion (8.1% versus 22.2%, P=.039) was less frequent in the complete SFM group, but there were significantly more T4 tumors in the partial group (16.7% versus 2.3%, P=.008). Demographics, other intra- and postoperative parameters, and pathological features were identical. CONCLUSIONS: In our study, complete SFM decreased conversion rates, but this finding may be related to the higher rate of T4 tumors in the partial SFM group. Complete SFM assures an increase in reservoir creation in patients receiving a low anterior resection. Because other parameters are identical, the decision for the level of SFM is better left to the surgeon in cases undergoing a low anterior resection, but complete SFM may be preferred in cases who are candidates for a reservoir formation.

Safety and effectiveness of 5-mm and 10-mm electrothermal bipolar vessel sealers (LigaSure) in laparoscopic resections for sigmoid colon and rectal cancers.

BACKGROUND: LigaSure™ (Covidien, Mansfield, MA) has been used in cases undergoing laparoscopic colon and rectal resections. This study aims to analyze the efficacy and safety of the 5-mm and 10-mm devices. SUBJECTS AND METHODS: Patients who received a laparoscopic or hand-assisted laparoscopic operation for a tumor located in the sigmoid colon or rectum since 2006 were abstracted from a prospectively designed database, and findings were analyzed in two groups based on size of the device used during the procedure. The videotapes of the procedures were watched, and operation reports were read to obtain further information on specific intra- and postoperative complications. Demographics, tumor and operation-related information, and postoperative data were compared. RESULTS: Among 215 (128 [59.5%] males; median age, 59.5±13.8 years) patients, data obtained from the 5-mm (n=32) and 10-mm (n=183) groups were identical regarding demographics and data related to tumor (localization and stage) and operation (number of harvested lymph nodes, conversion rates, operation time, intraoperative bleeding, transfusion requirement, reoperation rates, complications, 30-day mortality, and length of hospital stay). However, more patients underwent an anterior resection in the 10-mm group than in the 5-mm group (31.7% versus 15.6%, P<.05). Further analyses found device-related bleeding in 8 (3.7%) cases (2 [6.3%] versus 6 [3.3%] in the 5-mm versus 10-mm group, respectively, P>.05), requiring further attempts for hemorrhage control (n=6), conversion to open surgery (n=1), or relaparotomy (n=1). CONCLUSIONS: The 5-mm and 10-mm LigaSure devices are similarly effective and safe during laparoscopic sigmoid colon and rectal resections. Severe bleeding from larger vessels may be observed, requiring conversion to open surgery or relaparotomy.

Results after multivisceral resections of locally advanced colorectal cancers: an analysis on clinical and pathological t4 tumors.

BACKGROUND: Locally advanced colorectal cancers are best treated with multivisceral resections. The aim of this study is to evaluate early and late results after multivisceral resections. METHODS: All patients operated for primary colorectal cancer between 2001 and 2010 were -reviewed. These were compared within the patients underwent single organ and multivisceral resections: demographics, tumor and procedure related parameters, perioperative results, early oncological outcomes and 5-year survival. RESULTS: A total of 354 patients (59.6 ± 13.8 years old, 210 [59.3%] males) were abstracted. Ninety (25.4%) patients underwent multivisceral resections for clinical T4 tumors and en-bloc R0 resection was achieved in 82 (91.1%). Only 31 (34.4% and 8.8% of clinical T4 and all cancers, respectively) cases had actual adjacent organ invasions (pT4). Males (20%) had lower risk for locally advanced tumors than females (33.3%) (p < 0.05). PT4 cancers were more common, if the clinical T4 tumor is located in the colon (48.8% vs 21.3%; p < 0.01). Laparoscopy was seldom initiated and the risk of conversion was higher in clinical T4 tumors (p < 0.05). The rates of sphincter-saving procedures were not different. Operation time, bleeding and transfusion requirements increased when multivisceral resections were necessitated (p < 0.05), but hospital stay, complications and 30-day mortality rates were similar. The 5-year survival rates were identical (p > 0.05). CONCLUSIONS: Clinical T4 tumors are not rare and more common in women. An actual invasion (pT4) may be observed in one third of all clinical T4 tumors, and more frequent in colon cancers. An en-bloc, R0, multivisceral resection may be achieved in most cases. Multivisceral resections do not alter the rates of sphincter-saving procedures, morbidity and 30-day mortality; do not worsen survival but increase operation time, intraoperative bleeding and perioperative transfusion requirements.