Pancreaticoduodenectomy in patients < 75 years versus ≥ 75 years old: a comparative study.

OBJECTIVE: This study aimed to compare the postoperative outcomes of < 75-year-old patients and ≥ 75-year-old patients who underwent pancreaticoduodenectomy (PD) for pancreatic head and periampullary region tumors. METHODS: Patients who underwent PD in our hospital between February 2019 and December 2023 were evaluated. Demographics, Eastern Cooperative Oncology Group Performance Status (ECOG-PS) scores, American Society of Anesthesiologists (ASA) scores, comorbidities, hospital stays, complications, and clinicopathological features were analyzed. Patients were divided into < 75 years (Group A) and ≥ 75 years (Group B) groups and compared. RESULTS: The median age of the entire cohort (n = 155) was 66 years (IQR = 16). There was a significant difference between Group A (n = 128) and Group B (n = 27) regarding the ECOG-PS and ASA scores. There was no significant difference between the groups regarding postoperative complications. The 30-day mortality rate was greater in Group B (p = 0.017). Group B had a cumulative median survival of 10 months, whereas Group A had a median survival of 28 months, with a statistically significant difference (p < 0.001). When age groups were stratified according to ECOG-PS, for ECOG-PS 2-3 Group A, survival was 15 months; for ECOG-PS 2-3 Group B, survival was eight months, and the difference was not statistically significant (p = 0.628). CONCLUSIONS: With the increasing aging population, patient selection for PD should not be based solely on age. This study demonstrated that PD is safe for patients older than 75 years. In older patients, performance status and the optimization of comorbidities should be considered when deciding on a candidate's suitability for surgery.

Optimal waiting period to surgical treatment after neoadjuvant chemoradiotherapy for locally advanced rectum cancer: a retrospective observational study.

BACKGROUND: The optimal waiting period after neoadjuvant treatment in patients with locally advanced rectal cancers is still controversial. The literature has different results regarding the effect of waiting periods on clinical and oncological outcomes. We aimed to investigate the effects of these different waiting periods on clinical, pathological, and oncological outcomes. METHODS: Between January 2014 and December 2018, a total of 139 consecutive patients with locally advanced rectal adenocarcinoma, who were treated in the Department of General Surgery at the Marmara University Pendik Training and Research Hospital, were enrolled in the study. The patients were split into three groups according to waiting time for surgery after neoadjuvant treatment: group 1 (n = 51) included patients that have 7 weeks and less (≤ 7 weeks) time interval, group 2 (n = 45) 8 to 10 weeks (8-10 weeks), group 3 (n = 43) 11 weeks and above (11 weeks ≤). Their database records, which were entered prospectively, were analyzed retrospectively. RESULTS: There were 83 (59.7%) males and 56 (40.3%) females. The median age was 60 years, and there was no statistical difference between the groups regarding age, gender, BMI, ASA score, ECOG performance score, tumor location, and preoperative CEA values. Also, we found no significant differences regarding operation times, intraoperative bleeding, length of hospital stay, and postoperative complications. According to the Clavien-Dindo (CD) classification, severe early postoperative complications (CD 3 and above) were observed in 9 patients. The complete pathological response (pCR, ypT0N0) was observed in 21 (15.1%) patients. The groups had no significant difference regarding 3-year disease-free and 3-year overall survival (p = 0.3, p = 0.8, respectively). Local recurrence was observed in 12 of 139 (8.6%) patients and distant metastases occurred in 30 of 139 (21.5%) patients during the follow-up period. There was no significant difference between the groups in terms of both local recurrence and distant metastasis (p = 0.98, p = 0.43, respectively). CONCLUSION: The optimal time for postoperative complications and sphincter-preserving surgery in patients with locally advanced rectal cancer is 8-10 weeks. The different waiting periods do not affect disease-free and overall survival. While long-term waiting time does not make a difference in pathological complete response rates, it negatively affects the TME quality rate.

Neuropeptide W Attenuates Oxidative Multi-Organ Injury in Rats Induced with Intra-Abdominal Sepsis.

Sepsis leads to systemic hypotension, disturbed perfusion, inflammation, and tissue toxicity in vital organs. Neuropeptide W (NPW) has modulatory effects in the control of blood pressure and inflammatory processes, implicating a potential beneficial effect against sepsis-induced oxidative damage. Under anesthesia, male Sprague Dawley rats underwent cecal ligation and puncture. Immediately after surgery, either saline or TNF-alpha inhibitor (etanercept; 1 mg/kg) antibiotic (ceftriaxon; 10 mg/kg) combination or NPW (0.1, 1, or 3 µg/kg) was given subcutaneously, and injections were repeated on the 12th and 24th h. The sham-operated control group was treated with saline at the same time points. All rats were euthanized on the 25th h of surgery. Sepsis resulted in oxidative damage of the brain, heart, lung, liver, and kidney. Elevations in blood urea nitrogen and alkaline phosphatase, showing renal and hepatic dysfunction, were not evident when septic rats were treated with NPW. NPW reduced serum levels of C-reactive protein, corticosterone, and interleukin-6, while histopathologically verified tissue damage in all the studied tissues was ameliorated. NPW treatment suppressed lipid peroxidation in the heart, lung, and brain, and the depleted antioxidant GSH levels of the brain and heart were replenished by NPW. Moreover, sepsis-related neutrophil recruitment to the liver and lung was also suppressed by NPW. Although the survival rate of the rats was not significantly prolonged by NPW, most of these improvements in systemic and local inflammatory events were comparable with those reached by the etanercept and antibiotic combination, suggesting the therapeutic impact of NPW during the acute period of sepsis.

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.

Evaluation of the patients with colorectal cancer undergoing emergent curative surgery.

BACKGROUND: The aim of our study is to evaluate perioperative and mid-term oncologic outcomes of the patients with colorectal cancer, who underwent emergent curative surgery. METHODS: The study included all patients with colorectal cancer, who underwent surgery for curative intent between 1 January 2012 and 31 December 2014 in General Surgery Department of Kartal Training and Research Hospital. The patients were divided into two groups according to the type of admission (emergent or elective). The data of the patients were retrospectively collected with chart review. Demographic characteristics of the patients, ASA scores, emergent indications and surgical interventions, postoperative complications, pathological findings, oncological therapy, and follow-up findings were investigated. RESULTS: Fifty-one and 209 patients were evaluated in both groups, respectively. Rate of right sided and sigmoid/recto-sigmoid tumors were significantly higher in emergent group. Ostomy rate, early morbidity, ICU need, transfusion, and mortality rates in emergent group were significantly higher than elective group. Average length of hospital stay in emergent group was also significantly longer in elective group (11.2 ± 3.2 vs. 8.4 ± 2.4 days). The patients in emergent group had a much lower survival rate than those in elective group. CONCLUSION: In our study, emergency presentation of colorectal cancer was found associated with increased morbidity, a longer length of stay, increased in-hospital mortality, advanced pathologic stage and worsened long term survival in even same stages.

Diaphragmatic resection preserving and repairing pericardium, splenectomy and distal pancreatectomy for interval debulking surgery of ovarian cancer.

OBJECTIVE: The majority of ovarian cancer patients are initially diagnosed at an advanced-stage [1]. Upper abdominal bulky metastasis cephalad to the greater omentum reported to be present in 42% of patients [2]. Many complex surgical procedures such as splenectomy, pancreatectomy, mobilization and partial resection of liver, porta hepatis dissection, diaphragmatic peritonectomy and resection are frequently performed to achieve complete resection of metastatic disease [3]. Our aim in this surgical film is to show the resection of a left sided diaphragmatic implant located beneath the heart, with dissection from the pericardium after entrance to the pericardial cavity. Additionally, step by step splenectomy with distal pancreatectomy also presented. METHODS: A 67years-old woman referred to our clinic for interval debulking for advanced stage suboptimally debulked high grade serous ovarian carcinoma. The tumor invading distal pancreas, hilum and parenchyma of spleen is clearly seen on magnetic resonance imaging. Another implant was also visible on left side of the diaphragm. We achieved complete cytoreduction with no macroscopic disease at the end of the surgery. RESULTS: She stayed at the intensive care unit for two days and in our clinic for seven days. We did not encounter any grade 3 or 4 adverse event in post-operative period. CONCLUSION: The surgical treatment of ovarian cancer has evolved in time in favor of radical surgery. The surgical team should be highly motivated, skilled and experienced for this complex procedures, since being able to reach complete cytoreduction is the most important predictor of survival in ovarian cancer patients.

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.

Superiority of ceftriaxon to cefazolin in a rat model of obstructive jaundice: an experimental study.

OBJECTIVE: The objective of this study was to evaluate the serum and bile concentrations of cefazolin and ceftriaxone at the third and sixth hours in an experimental obstructive jaundice model and to identify the rate of excretion of these antibiotics into the bile. MATERIAL AND METHODS: Thirty-two Wistar albino rats were used in this study. The bile and serum levels of cefazolin were measured at the third hour in the A1 group and at the sixth hour in the A2 group, with cefazolin administered as 5 mg/rat; while the bile and serum levels of ceftriaxone were studied at the third hour in the B1 group and at the sixth hour in the B2 group, with ceftriaxone administered as 5 mg/rat. RESULTS: After 3 hr of cefazolin administration, the serum concentration in the A1 group reached a mean of 1.8 µg/ml, while the bile concentration was 90% of the serum concentration, with a mean of 1.6 µg/ml; whereas in the B1 group, the third-hour serum concentration of ceftriaxone was 18.6 µg/ml, while the bile concentration was found to be as high as 330% of this level, i.e., 56 µg/ml. The serum value of cefazolin decreased to 1.4 µg/ml in the A2 group and ceftriaxone decreased to 3.7 µg/ml in the B2 group at the sixth hour. CONCLUSIONS: Although the excretory level of cefazolin and ceftriaxone into the bile reaches therapeutic doses, the duration for which these levels are above those required for bactericidal activity is short. Ceftriaxone is better concentrated in the serum and bile than cefazolin.

In vitro effects of famotidine and ranitidine on lower esophageal sphincter tone in rats.

BACKGROUND/AIMS: The aim of this study was to investigate the effects of the H2 receptor antagonists famotidine and ranitidine on lower esophageal sphincter pressure in the rat isolated lower esophageal sphincter preparation contracted with carbachol. MATERIALS AND METHODS: Lower esophageal sphincter tissues of eight rats for each group were placed in a standard organ bath. After contraction with carbachol, freshly prepared famotidine and ranitidine were added directly to the tissue bath in cumulatively increasing concentrations. Activities were recorded on an online computer using the software BSL PRO v 3.7, which also analyzed the data. RESULTS: Ranitidine caused a small statistically insignificant relaxation in the contracted lower esophageal sphincter at the two applied concentrations. Although 1.5 x 10⁻5 M famotidine did not cause a significant relaxation in lower esophageal sphincter tone, this value for 4.5 x 10⁻5 M famotidine was 9.33%, and the relaxation was significant when compared with controls (p<0.05). CONCLUSIONS: Neither famotidine nor ranitidine caused any direct significant change in lower esophageal sphincter tone in the therapeutic dose range applied to the organ bath. However, the higher dose of famotidine caused a significant relaxation in the lower esophageal sphincter tone. Further in vivo human studies may affect the usage of these drugs during gastroesophageal reflux disease treatment.

Mesenteric panniculitis patients requiring emergency surgery: report of three cases.

Mesenteric panniculitis is a rare, benign disease characterized by a chronic non-specific inflammatory process of mesenteric fat tissue with unknown etiology. The small bowel mesentery is affected mostly. This process rarely involves the large intestine mesentery. Mesenteric panniculitis includes symptoms as abdominal pain, nausea and vomiting, diarrhea, constipation, and fever. In our cases, we had difficulty in the preoperative diagnosis as the clinical changes imitated an obstruction or ischemia of the small bowel. All the cases required emergency abdominal surgery and partial jejunal resection. The aim of this article was to present three cases of mesenteric panniculitis of the small bowel mesentery requiring emergency surgery together with a short review of the literature.

Repair of an extensive iatrogenic tracheal rupture with a pleural patch and a vascular graft.

Here we describe a 48-year-old woman who suffered a 7-cm rupture in the lower trachea after intubation with a double-lumen tube. We repaired the rupture with a new technique using a pleural patch reinforced by a ringed vascular graft. This technique appears to be appropriate for use in patients who have large tracheal ruptures to avoid tracheal stenosis.

Intestinal ischemia-reperfusion impairs liver regeneration after partial hepatectomy in rats.

BACKGROUND/AIMS: The deleterious effects of intestinal ischemia-reperfusion on liver are realized, but its effect on the regenerative capacity of the liver has not been studied. Our aim in this study was to determine the effect of intestinal ischemia-reperfusion on liver regeneration. METHODOLOGY: Sprague-Dawley rats were randomly divided into six groups; two sham-operated, two hepatectomy, and two hepatectomy with intestinal ischemia-reperfusion groups. To create intestinal ischemia-reperfusion, the superior mesenteric artery and collateral arteries supplying the small intestine were occluded for 20 minutes. Partial hepatectomy was performed during the period of ischemia. Ischemia-reperfusion injury in the mucosal layer of the small intestine was scored in light microscopy. Liver regeneration parameters (proliferating cell nuclear antigen labeling index for hepatocytes and liver regeneration rate), and serum levels of aspartate aminotransferase and alanine aminotransferase were studied on day 1 or 4 after operation. RESULTS: Mucosal injury score was high in the hepatectomy with intestinal ischemia-reperfusion groups. Liver regeneration rate and proliferating cell nuclear antigen labeling index were less in these groups than the hepatectomy groups on day 1 and 4. There were no differences in the serum levels of aspartate aminotransferase and alanine aminotransferase between hepatectomy and hepatectomy with intestinal ischemia-reperfusion groups. The mortality rate was higher in the hepatectomy with intestinal ischemia-reperfusion groups than the other groups. CONCLUSIONS: Ischemia and reperfusion of the small intestine impaired liver regeneration with high mortality after partial hepatectomy in the rats.