Spectrum of gastric histopathologies in morbidly obese Turkish patients undergoing laparoscopic sleeve gastrectomy.

OBJECTIVE: In this study, we aimed to describe the findings associated with gastric pathology and to identify the prevalence of Helicobacter pylori (H. pylori) in patients undergoing laparoscopic sleeve gastrectomy (LSG). PATIENTS AND METHODS: Gastric specimens of a total of 291 patients (225 females, 66 males; mean age: 42 years; range: 18 to 60 years) who underwent LSG for the treatment of morbid obesity were analyzed. Histopathologic diagnoses and their relation with body mass index (BMI), age and gender were evaluated. RESULTS: In the histopathological examination of sleeve specimens, 58 patients (19.93%) had chronic gastritis, 102 patients (35.05%) had chronic active gastritis, 27 patients (9.27%) had follicular gastritis, 47 patients (16.15%) had active follicular gastritis, one patient (0.34%) had a glomus tumor, and one patient (0.34%) had a gastrointestinal stromal tumor. The gastric mucosa was normal in 55 patients (18.90%). Intestinal metaplasia was detected in eight patients (2.74%). The H. pylori test result was positive in 126 patients (43.29%). There was no statistically significant difference between the pathological diagnoses and age and sex of the patient. CONCLUSIONS: Our study results suggest that the prevalence of chronic active gastritis and H. pylori positivity is high in morbidly obese Turkish patient population. No significant difference was found between the pathological diagnosis in obese patients with LSG operation in terms of age and sex.

The impact of laparoscopic sleeve gastrectomy on plasma obestatin and ghrelin levels.

OBJECTIVE: To investigate the effect of laparoscopic sleeve gastrectomy (LSG) on the levels of obestatin and ghrelin hormones and body mass index (BMI) in morbidly obese patients. PATIENTS AND METHODS: The study included 30 morbidly obese patients who had LSG. Five cc blood samples were taken from the patients preoperatively and at postoperative months 3 and 6. After serum extraction, the levels of obestatin and ghrelin hormones and the levels of fasting insulin and glucose were studied using the enzyme-linked immunosorbent assay (ELISA) method. The homeostatic model assessment of insulin resistance (HOMA-IR) score was calculated. Preoperative and postoperative 3- and 6-month BMI were calculated. Kruskal-Wallis Analysis of Variance, Bonferroni-Dunn Test, Spearman's correlation test, and Pearson's correlation test were used for statistical analysis. RESULTS: BMI of the patients were statistically significantly reduced at postoperative months 3 and 6 compared to preoperative values, and at postoperative month 3 compared to month 6 values (p < 0.001). Ghrelin values were higher at postoperative month 6 compared to the preoperative and postoperative month 3 values (p < 0.001). Obestatin values of the patients were lower at postoperative month 6 compared to the preoperative and postoperative month3 values (p < 0.001). Insulin and glucose values were statistically significantly lower at postoperative months 3 and 6 compared to preoperative values (p < 0.001), whereas there was no difference between months 3 and 6. HOMA-IR score was significantly lower at postoperative month 3 compared to preoperative values (p < 0.001). CONCLUSIONS: LSG enables effective weight loss and glucose regulation in obese patients. LSG has also effects on obestatin and ghrelin hormones, which are coded by the same gene and have opposing effects, and the associated mechanisms of which are still controversial. Obestatin produces a feeling of satiety, whereas ghrelin initiates eating by producing a feeling of hunger. The patients were observed to have increased ghrelin and reduced obestatin postoperatively due to a negative energy balance.

Nesfatin-1 hormone levels in morbidly obese patients after laparoscopic sleeve gastrectomy.

OBJECTIVE: To investigate changes in body mass index (BMI) and nesfatin-1 levels in patients with morbid obesity who had undergone laparoscopic sleeve gastrectomy (LSG). PATIENTS AND METHODS: Blood samples were collected from, and the BMI calculated of 30 morbidly obese patients pre-surgery and at 3 and 6 months post-surgery. Nesfatin-1 hormone levels were measured using enzyme-linked immunosorbent assay (ELISA). Descriptive statistical analysis of the data was performed using Kruskal-Wallis variance analysis, one-way ANOVA, and the Bonferroni-Dunn test. The correlations between continuous variables not displaying normal distribution and those displaying normal distributions were analyzed using the Spearman correlation test and the Pearson correlation test, respectively. RESULTS: The mean age of the 30 patients was 41.23 ± 10.37 years. The mean BMI values (kg/m2) were 49.30 ± 7.92, 39,48 ± 7.32, and 34.39 ± 7.56 presurgery, three months post-surgery, and six months post-surgery, respectively (p < 0.001). Mean nesfatin-1 levels (ng/ml) were 22.80 ± 14.16, 60.23 ± 52.92, and 96.99 ± 40.20 presurgery, three months post-surgery, and six months post-surgery, respectively (p < 0.001). The postoperative months 3 and 6 BMI values were significantly lower than the preoperative BMI value and the postoperative month 6 BMI value was significantly lower than the postoperative month 3 BMI value (p < 0.001). The postoperative months 3 and 6 nesfatin-1 levels were significantly higher than the preoperative nesfatin-1 levels. A negative correlation was found between age and preoperative nesfatin-1 values (p = 0.001, r = -0.0557). CONCLUSIONS: Observation of significant increases in nesfatin-1 hormone levels in morbidly obese patients who had undergone LSG indicate that nesfatin-1 has important anorexigenic effects post-surgery and may be an important component of future obesity treatments.

The retinal nerve fiber layer, choroidal thickness, and central macular thickness in morbid obesity: an evaluation using spectral-domain optical coherence tomography.

OBJECTIVE: To assess the effect of morbid obesity on retinal nerve fiber layer (RNFL) thickness, central macular thickness (CMT), retinal ganglion cell (RGC), choroidal thickness (CT), central corneal thickness (CCT), and intraocular pressure (IOP). PATIENTS AND METHODS: Sixty-seven patients defined as having morbid or class III obesity (BMI ≥ 40; Group 1) scheduled to undergo sleeve gastrectomy surgery and 29 nonobese patients (BMI 18.50-24.99; Group 2) underwent complete ophthalmic examination for measurement of IOP, CT, RNFL thickness, CMT, RGC, and CCT. RNFL thickness, CMT, and RGC were measured using spectral-domain optical coherence tomography (SD-OCT). CT measurement was performed using the enhanced depth imaging technique of the SD-OCT. The group data were analyzed and compared using the Mann-Whitney U test and Student's t-test. The relationship between the clinical ocular variables and obesity was analyzed using the Spearman's rank correlation test. RESULTS: The mean IOP and CCT of Group 1 were found to be significantly higher (p < 0.001) and the mean RNFL, RGC, and CT significantly lower (p < 0.05) than those of Group 2. While Group 2 was found to have a slightly larger cup-to-disc ratio and Group 1 to have a thinner CMT, the differences between Groups 1 and 2 regarding these variables were not found to be statistically significant (p = 0.322 and p = 0.072, respectively). The results of Spearmen correlation analysis indicated the existence of a moderately positive correlation between IOP and BMI (p < 0.001; r = 0.5-0.6). CONCLUSIONS: We have demonstrated by SD-OCT that morbid obesity may have a significant influence on RNFL, RGC, and CT. Morbid obesity may induce inflammatory, hormonal, and metabolic changes.

Ileal J-Pouch Perforation: Case Report.

A 34-year-old male patient who had undergone total colectomy and J-pouch ileanal anastomosis subsequent to diagnosis of familial adenomatous polyposis five years previously was admitted to the emergency room with complaints of severe abdominal pain of a four-day duration. Physical examination revealed widespread tenderness throughout the abdomen, especially in the lower quadrant. Abdominal ultrasonography revealed fluid between intestinal loops and computed tomography revealed free air and fluid in the abdomen. During laparotomy to expand the ileal J-pouch to approximately 12 cm in diameter, a 2-mm perforation was detected in the blind end of the ileal J-pouch. The perforation was repaired primarily and protective ileostomy was performed. During postoperative endoscopy, neither obstruction nor stasis was observed, but pouchitis was observed in the ileal J-pouch. The patient was postoperatively discharged on the 20th day and followed endoscopically. The endoscopic findings were normal in the sixth month postsurgery.

Relation between weight loss and age after laparoscopic sleeve gastrectomy.

OBJECTIVE: As a bariatric surgery; Laparoscopic Sleeve Gastrectomy (LSG) has gained popularity in recent years. In our study, we aimed to investigate the impact of age on postoperative weight loss at one year after laparoscopic sleeve gastrectomy. PATIENTS AND METHODS: In our clinic between May 2011 and July 2013, 55 patients who underwent LSG with the diagnosis of obesity were included in the study. Patients were divided into two groups below and over an age of 40. Preoperative and postoperative first year Body Mass Index (BMI), percent of Body Mass Index Lost (% BMIL) and Excess Body Mass Index Lost (% EBMIL) were recorded. RESULTS: A total of 55 patients with a mean age of 37.2 ± 8.6 years were included in the study. 37 were women. Patients divided into the age below 40 years old (group 1, n = 29) and over 40 years old (group 2, n = 26). The average age of the groups was 29.9 ± 4.63 and 45.3 ± 7.02, respectively. Characteristics of patients among groups were similar. The preoperative average BMI of groups were 49.34 ± 5.87 kg/m² and 49.73 ± 5.38 kg/m², postoperative first year mean BMI of groups were 30.05 ± 5.78 kg/m² and 36.15 ± 6.64 kg/m², respectively. Percentage loss in BMI was 19.29 ± 3.14% and 13.58 ± 2.96%, respectively; and % EBMIL was 82.95 ± 21.88% and 56.75 ± 15.90%, respectively. CONCLUSIONS: We suggest that age might be as a major determining factor for weight loss and patients over forty years old undergoing LSG for bariatric surgery should be informed about that they will have a lower weight lost.

The Comparison of Inflammatory Responses and Clinical Results After Groin Hernia Repair Using Polypropylene or Polyester Meshes.

The aim of this study was to compare the clinical results and the inflammatory responses against polypropylene and polyester meshes after groin hernia repair. Ninety patients with unilateral inguinal hernia randomly underwent Shouldice herniorrhaphy or Lichtenstein hernioplasty using polypropylene or polyester meshes. Venous blood samples were collected to evaluate serum interleukin-6 (IL-6) and C-reactive protein (CRP) levels. Postoperative acute and chronic pain and time to attain to normal activities were evaluated. IL-6 levels decreased to preoperative levels in all groups at 48th hour. CRP levels of mesh-implanted groups are significantly higher than preoperative level at 48th hour, while it reduced to preoperative level in Shouldice herniorrhaphy group. Patients treated with mesh repair had less postoperative acute pain and recovered more rapidly than those who underwent Shouldice herniorrhaphy. It was concluded that polypropylene and polyester meshes used in hernia repair caused similar inflammatory responses and that clinical results after groin hernia repair with these prostheses were not significantly different.

Is the lateralization distance important in terms in patients undergoing the modified Limberg flap procedure for treatment of pilonidal sinus?

BACKGROUND: The aim of this study was to determine whether the lateralization distance causes differences in the flattening ratio of the natal cleft, early complications, or recurrence rates in patients with sacrococcygeal pilonidal sinus disease undergoing the modified Limberg flap. METHODS: This clinical study was conducted from March 2012 to April 2013. Forty patients with sacrococcygeal pilonidal sinus disease were divided into two groups of 20 patients, each according to the lateralization distance of the lower part of the Limberg flap incision (Group I, 1 cm lateralized; Group II, 2 cm lateralized). Early wound complications, recurrence rates, and the flattening ratio of the natal cleft were evaluated. RESULTS: No statistically significant differences in operating time (mean 42.2 ± 5.7 and 42.3 ± 6.4 min, respectively; p = 0.855), drain removal time [median 3 (range 2-10) and 4 (range 2-14) days, respectively; p = 0.1], or length of hospitalization [median 1 (range 1-3) and 1 (range 1-4) days, respectively; p = 0.775] were found between the groups. The mean follow-up period was 12.8 ± 3.7 months. Recurrence was observed in only one patient of Group II. There were no statistically significant differences in the flattening ratio of the natal cleft, overall wound complications, or recurrence between the two groups. CONCLUSIONS: No statistically significant differences in early complications or recurrence rates were found between the two different lateralization distances in the modified Limberg flap procedure. Therefore, we conclude that 1-cm lateralization of the lower part of the incision is sufficient.

AKAP12/Gravin gene expression in colorectal cancer: clinical importance and review of the literature.

PURPOSE: : Colorectal cancer (CRC) is a common and potentially lethal disease. A number of genetic aberrations is known to take place in colorectal carcinogenesis, which leads to progressive alteration of normal mechanisms controlling cell growth. A-kinase-anchoring protein 12 (AKAP12) plays a role in cell proliferation, angiogenesis and cytoskeletal remodeling. The purpose of this study was to demonstrate the role of the AKAP12 gene expression in CRC patients and to determine its relationship (if any) with prognosis. METHODS: AKAP12 gene expression was investigated by immunohistochemistry. RESULTS: A total of 55 patients (63.6% males, 36.4% females) with histologically confirmed CRC were studied. Normal intestinal epithelium showed weak basal staining, dysplastic areas were stained mildly, whereas all of the cancer cells were stained completely with AKAP12. CONCLUSION: AKAP12 gene seems to play a role in colorectal carcinogenesis.

Prognostic significance of biological apoptosis factors in gastric cancer.

PURPOSE: Gastric cancer is a biologically heterogeneous disease containing many genetic and epigenetic alterations. In our study, the expression status of apoptosis-inducing p53 and apoptosis-inhibiting Bcl-2 in gastric cancer and their relation with prognosis, if any, was investigated. METHODS: Patients that were being followed in our clinic and had histopathologically diagnosed gastric adenocarcinoma were included in this study. The p53 and bcl-2 expressions were investigated immunohistochemically and patients were grouped according to p53 and Bcl-2 expression as follows: group A: both p53 and Bcl-2 negative; group B: p53 positive and Bcl-2 negative; group C: p53 negative and Bcl-2 positive; group D: both p53 and Bcl-2 positive. RESULTS: In 19 (51.4%) patients positive immunostaining with p53 was observed, while negative in 18 (48.6%). A significant relationship between the metastatic ability of the tumor and p53 expression was determined (p=0.004). In 78.6% of the metastatic tumors no p53 expression was observed, while in 69.6% of the non-metastatic tumors p53 expression was positive. No significant relationship was detected between p53 expression and survival. Positive immunostaining with Bcl-2 was observed in 9 (16.7%) patients, and negative in 45 (83.3%). No significant relationship was determined between the Bcl-2 expression and the depth of invasion, dissemination to lymph nodes and metastatic ability of the tumor. A borderline statistically significant relationship was determined between the Bcl-2 expression and survival (p=0.051). Group B patients showed a statistically significant survival difference compared with the other groups (p=0.022). CONCLUSION: The results of this study suggest that concurrent evaluation of p53 and Bcl-2 in patients with gastric adenocarcinoma may have prognostic importance.

Diagnostic value of thiols, paraoxonase 1, arylesterase and oxidative balance in colorectal cancer in human.

Oxidative stress has been shown to play an important role in carcinogenesis. We hypothesize that serum oxidative and anti-oxidative factors work together to influence colon and rectal cancer through an oxidative balance mechanism. Total thiol (Ttl) is considered a plasma antioxidant and high density lipoprotein (HDL)- dependent paraoxonase l (PON1) is known as a free radical scavenger. This study was undertaken to determine the activity of PON1, arylesterase (ARE) and Ttl levels and oxidative balance in colorectal cancer (CRC) patients and healthy subjects.Paraoxonase and arylesterase activities of the HDL-dependent PON1 enzyme and the level of Ttl, total oxidant status (TOS) ,total antioxidant status (TAS) in forty patients with CRC (19 female, 21 male; mean age, 56.5 ± 2.1) and thirty-nine age and sex matched healthy persons (22 female, 17 male; mean age 56 ± 1.7) were studied.PON1 and ARE activities were significantly lower in patients with CRC compared to controls (p<0.001 for each), whereas oxidant parameters (TOS and OSI) were significantly higher in CRC patients (p<0.001 for each). However, TAS and Ttl significantly decreased in patients with CRC (p=0.03 and p<0.0001, respectively). According to the ROC curve analysis, Ttl was superior to other parameters in terms of diagnostic sensitivity and specificity which were 97.5% and 92.3%, respectively, and the AUC 0.97 in CRC patients. Decreased Ttl and HDL-dependent PON 1 enzyme activities and high TOS levels imply an imbalance of the free radical system which enhances the support the hypothesis that CRC is associated with excess reactive oxygen species.These findings show that of serum oxidative imbalance was associated with an increased risk of CRC. To our knowledge, this is the first report demonstrating lower serum PON1, ARE activities in CRC patients. The mechanism behind this association needs further elucidation.

The effects of drainage on the rates of early wound complications and recurrences after Limberg flap reconstruction in patients with pilonidal disease.

BACKGROUND: Cavity drainage has been used routinely in Limberg flap repair for pilonidal disease but there have been few controlled studies on the rationale for routine usage of drains. The aim of this study was to determine whether routine cavity drainage affects the rates of early wound complications and recurrences after rhomboid excision with Limberg flap repair for pilonidal disease. METHODS: Sixty patients with pilonidal disease in the sacrococcygeal region were randomized sequentially into 2 groups as drained or non-drained. All of them underwent rhomboid excision and Limberg flap reconstruction. The patients were followed up by physical examination at 2 and 4 weeks after the operation and every 6 months thereafter. RESULTS: Two patients in the drained group and 3 patients in the non-drained group were excluded from the study because of non-attendance at the follow-up physical examinations. The average length of hospital stay was 3.1 ± 0.9 and 3.3 ± 0.8 days in the drained and non-drained groups, respectively. There were 5 seromas, 2 wound dehiscences and 1 hematoma in the non-drained group, while 3 seromas and 2 wound dehiscences developed in the drained group. The complication rates of groups were similar (29.6% in the non-drained group vs. 17.8% in the drained group). Pilonidal disease recurred in 2 patients in the drained group who had wound dehiscence and in 3 patients in the non-drained group who had wound dehiscence or seroma. CONCLUSIONS: Routine usage of drains for Limberg flap reconstruction in the sacrococcygeal region did not affect wound-related complications and recurrence rates.

Hemobilia.

BACKGROUND: Laparoscopic procedures are safe and effective treatment methods in experienced hands. However, complications have been reported for laparoscopic procedures. One of the complications of laparoscopic cholecystectomy is vascular injuries. Hepatic and cystic artery injuries may occur alone or in association with bile duct injury. Bleeding from arterial injury may be seen during operation or in the late postoperative period. One of the most significant pathologies leading to this rare phenomenon is hemobilia. METHODS: We present a case of a 62-year-old woman who underwent routine laparoscopic cholecystectomy for cholelithiasis at another hospital. She presented 6 months later with the clinical feature of upper gastrointestinal bleeding. RESULTS: There was a 42 x 40 x 11 mm anechoic lesion and an echoic pattern compatible with a metallic object was found in the subhepatic region using abdominal ultrasonography. In the endoscopic examination, fresh blood was found in the stomach. The source of hemorrhage could not be identified. Bulbus duodeni was normal but a fresh clot on the papilla of Vateri was seen on gastroduodenoscopic examination. Laparotomy was performed and the provisional diagnosis of hemobilia was reached. The injured hepatic artery and pseudoaneurysmatic structure were repaired. CONCLUSION: Hemobilia is a late complication of laparoscopic cholecystectomy. We believe that it is important to take into consideration that bile duct injuries may be accompanied by arterial pathology.

The effects of melatonin and prostaglandin E1 analogue on experimental hepatic ischaemia reperfusion damage.

The effects of antioxidant melatonin and a prostaglandin E1 analogue (PGE1) on hepatic ischaemia reperfusion damage were investigated. Fifty rats were divided into five equal groups: sham, control, melatonin, PGE1 and combined treatment. No procedures were applied to the sham group. In the control and treatment groups, the hepatic hilus was clamped at the level of the hepatic artery and portal vein for 60 min and reperfusion was provided for two hours. In the treatment and combined treatment groups, melatonin was administered intramuscularly at a dose of 20 mg/kg 15 mins before reperfusion, and PGE1 was administered intravenously at a dose of 25 mg/kg 1 min before reperfusion. Blood samples for SGOT, SGPT, GSH-Px, SOD and MDA measurements and hepatic tissue samples were taken. The decrease in the plasma MDA levels was statistically significant in the melatonin and combined treatment groups, but not in the PGE1 group (p > 0.025). A significant decrease was found in the tissue MDA levels of the treatment groups (p < 0.025). The decrease in SGOT and SGPT levels in the PGE1 group was significant (p < 0.025), but the decreases in the melatonin and combined treatment groups were not significant (p>0.025). Melatonin and PGE1 were found to be effective in reducing the hepatic ischaemia reperfusion damage in rats. However, the damage could not be reversed. Combined treatment was found not to be superior to melatonin or PGE1 alone.

Nonspecific ulcerated jejunitis as an unusual complication of laparoscopic cholecystectomy: report of a case.

We describe herein the case of a 65-year-old man in whom a lower gastrointestinal hemorrhage developed a few days after he underwent an elective laparoscopic cholecystectomy. A laparotomy was performed on postoperative day 16 and a jejunal segment containing mucosal changes and oozing ulcers was resected. Pathologic examination of the specimen revealed "nonspecific ulcerated jejunitis." There is no explanation for the etiopathogenesis of this pathology; however, we concluded that this clinical picture may be attributed to ischemia-reperfusion injury that occurred following an ischemic period caused by the pneumoperitoneum during laparoscopic surgery.

Effect of levamisole on intestinal anastomoses in transfused guinea pigs.

In this experimental study, the effects of an antihelminthic and immunostimulating agent (levamisole) on anastomosis recovery in transfused and normal guinea pigs were investigated. A total of 56 animals were divided into four groups of 14 each; an additional 10 were employed for blood transfusion (BT). Intestinal anastomoses were performed on all animals; the following postoperative treatments were administered: none (control group); BT; intra-abdominal (IA) levamisole; and BT + levamisole. After recording the mortality of each group, a relaparotomy was performed on one-half of the animals on the 3rd postoperative day and on the remaining half on the 7th postoperative day. Findings of IA sepsis, resistance of the anastomosis, bursting pressure, and hydroxyproline values were evaluated. Statistical comparison of the groups was accomplished by analysis of variance. In the transfused group an increase in sepsis was determined and the bursting pressure was significantly lower than in the control group. IA levamisole application following BT reduced the mortality by diminishing IA sepsis and anastomotic abscess formation and increased anastomotic pressure and recovery (P < 0.01). Histopathologic recovery in levamisole groups was better than in the group that received BT only. Levamisole application without BT resulted in equal mortality and morbidity to that of the control group. We conclude that clinical use of levamisole should be considered only in intestinal anastomoses in which BT is inevitable.

Fascioperitoneal graft with T-tube drainage for patching bile duct defects.

Reconstruction of choledochal wall defects in an experimental dog model by T-tube plus fascioperitoneal graft and an evaluation of the short-term results were the aims of this study. Twelve randomly selected mongrel dogs of both sexes, having an average weight of 22.15 +/- 1.85 kg, were anaesthetized with ketamine HCI and xylazine and underwent laparatomy. The front wall of choledoch canal were excised with its all layers 0.5 cm in diameter at the distal part of the cystic duct junctions. These defects were repaired by using grafts prepared of the same diameter from the dorsal fascias of rectus muscles and peritoneum. T-tubes were introduced into the common ducts on the proximal part of the grafts. One of the animals died in the postoperative period due to evantration. T-tube cholangiograms on the twelfth day did not indicate any extravasation or stricture. Histopathological examination of the graft regions on the sixtieth day revealed that the epithelialization had commenced on the border between the bile epithelium and grafts. Based on these early findings, it was suggested that if supported by further studies it may be thought of as a clinical method.