Management of Nonocclusive Mesenteric Ischemia in Patients with Cardiac Failure.

AIM: This study aimed to evaluate the surgical procedures, outcomes, and prognostic factors in patients with ischemic heart disease who were operated on due to nonocclusive mesenteric ischemia (NOMI). MATERIAL AND METHODS: This research contains all patients diagnosed with congestive heart failure and NOMI between January 2011 to January 2020. The patients who had angiography or CT that showed occlusion of more than 50% in any of the main branches of the mesenteric artery or patients who presented with symptoms in correlation with a total occlusion were excluded from the study. Patients who underwent coronary heart surgery but were not diagnosed with congestive heart failure and those with atrial fibrillation also were excluded from the study. Patients divided into two groups, according to a medical database. RESULTS: A significant difference was found between the surviving and non-survivor groups in minutes, in terms of median time to segmenter intestinal resection (P = 0.042). CONCLUSION: An early diagnosis and surgical segmental intestinal resection before peritonitis worsens can be the key to better prognosis for NOMI patients.

Usefulness of Endoscopic Tattooing Before Neoadjuvant Therapy in Patients with Clinical Complete Response in Locally Advanced Rectal Cancer for Providing a Safe Distal Surgical Margin.

Background: Endoscopic tattooing of colorectal tumors enables tumor localization and determination of appropriate surgical margins. It becomes very difficult to detect the distal surgical margins (DSMs) of rectal tumors in patients who obtain clinical complete response (cCR) after neoadjuvant therapy. In this study, our aim is to examine the benefits of endoscopic tattooing of the tumor before neoadjuvant therapy in patients with locally advanced rectal cancer in accurate localization of the previous tumor and in providing appropriate DSMs in cases with cCR. Patients and Methods: The patients who were diagnosed with locally advanced rectal cancer, received neoadjuvant therapy and subsequently achieved cCR, and underwent surgery between January 2015 and October 2020 were included in the study. The patients were divided into two groups according to whether they were endoscopically tattooed before neoadjuvant chemoradiotherapy. Results: A total of 49 cases were included in the study. Significantly better DSMs were observed especially in female gender in the tattooed group. DSMs were found to be closer to the resection margins in the nontattooed group. It was found that endoscopic tattooing had a significant effect on the DSM in the regression analysis (P = .06, R2 = 0.47). It was determined that laparoscopy or open surgery alone did not differ in terms of DSMs but open surgery together with tattooing was found to be strongly effective in providing larger DSMs. Conclusion: In locally advanced rectal cancer, endoscopic tattooing of the distal margin of the tumor before neoadjuvant therapy is a reliable and effective method for obtaining a safe DSM and not leaving the residual tumor at the lower end of anastomosis, especially in cases of cCR.

Emergency computed tomography for the diagnosis of acute appendicitis: How effectively we use it?

BACKGROUND: Technological developments support using ultrasonography (US) in all patients, if available, and advanced diagnostic methods such as abdominal computed tomography (CT) in case of clinical suspicion during diagnostic process of acute appendicitis. We aimed to investigate whether CT was appropriately and efficiently used in the diagnosis of acute appendicitis. METHODS: Between May 2013 and February 2016, 811 patients who underwent appendectomy were retrospectively reviewed from an IRB-approved database, and those who underwent a preoperative CT were enrolled into the study. Results of Alvarado scores and US were recorded in addition to which clinic requested the CT (general surgery or emergency department). RESULTS: The frequency of CT use in the diagnostic process was 25% (n=208/811). Ultrasound was negative for appendicitis in 53% of these patients. The mean Alvarado score was 5±1.5 (range: 3-8). General surgeons requested 57% of CTs. Alvarado scores were significantly higher in patients whose CT was requested by general surgery than in those whose CT was requested by the emergency clinic (5.6 vs. 4.7, p=0.013). Regarding histopathological results, age and Alvarado scores were significantly lower (p=0.015 and 0.037, respectively), whereas the frequency of negative CT was significantly higher (p=0.042) in those with negative appendectomy (n=29, 14%). CONCLUSION: Most patients who underwent CT in the diagnostic process had an Alvarado score between 5 and 8 and negative ultrasound for appendicitis preoperatively. These findings may provide efficient use of CT in the diagnosis of appendicitis with an acceptable rate of 25% compared with the findings in current literature. However, further research is needed to ensure more efficient use of CT because negative appendectomy has been a concern in our series despite promising results of this study.

Delaying surgery after neoadjuvant chemoradiotherapy improves prognosis of rectal cancer.

AIM: To investigate the prognostic effect of a delayed interval between neoadjuvant chemoradiotherapy (CRT) and surgery in locally advanced rectal cancer. METHODS: We evaluated 87 patients with locally advanced mid- or distal rectal cancer undergoing total mesorectal excision following an interval period after neoadjuvant CRT at Sisli Hamidiye Etfal Training and Research Hospital, Istanbul between January 2009 and January 2014. Patients were divided into two groups according to the interval before surgery: < 8 wk (group I) and ≥ 8 wk (group II). Data related to patients, cancer characteristics and pathological examination were collected and analyzed. RESULTS: When the distribution of timing between group I (n = 45) and group II (n = 42) was viewed, comparison of interval periods (median ± SD) of groups showed a significant difference of as 5 ± 1.28 wk in group I and 10.1 ± 2.2 wk in group II (P < 0.001). The median follow-up period for all patients was 34.5 (9.9-81) mo. group II had significantly higher rates of pathological complete response (pCR) than group I had (19% vs 8.9%, P = 0.002). Rate of tumor regression grade (TRG) poor response was 44.4% in group I and 9.5% in group II (P < 0.002). A poor pathological response was associated with worse disease-free survival (P = 0.009). The interval time did not show any association with local recurrence (P = 0.79). CONCLUSION: Delaying the neoadjuvant CRT-surgery interval may provide nodal down-staging, improve pCR rate, and decrease the rate of TRG poor response.

Ostomy in Nontraumatic Conditions: Our Experience and Review of the Literature.

A number of nontraumatic acute abdomen can result in peritonitis leading to sepsis. In emergent conditions, various procedures like segmentary colectomy and/or subtotal colectomy with anastomosis, Hartmann's procedure, transverse colectomy, and/or expandable metallic stent (SEMS) placement can be performed, considering the status of the patient and the facilitaties of the institution. In our study, we examined the cases diagnosed as acute abdomen without the history of trauma, which had lead to a procedure requiring colostomy. We retrospectively analysed 105 cases of nontraumatic acute abdomen, resulted in a procedure requiring colostomy. American Society of Anesthesiologists (ASA) scoring and Mannheim Peritonitis Index (MPI) were used in the evaluation of the risk of mortality and morbidity. There were colonic perforations of rectosigmoid tumor in 66 cases (62.8 %), sigmoid volvulus in 10 cases (9.5 %), colonic anastomotic leakage in 9 cases (8.5 %), intestinal adhesions in 8 cases (7.6 %), mesenteric ischemia in 5 cases (4.7 %), gynecological diseases in 3 cases (2.85 %), strangulated hernias in 3 (2.85 %), and Ogilvie syndrome in 1 case (0.95 %). Rate of morbidity was found to be 25.7 %, while mortality occurred in 2.8 % of the cases. Cases with mortality and morbidity had ASA scores above two and MPI scores above 23. Anastomotic leakage was the only reason of mortality. In nontraumatic occasions, the management and prognosis of cases with peritonitis, general status of the patients play major roles. The prognosis rates of morbidity and mortality can be highly predicted when ASA and MPI scores are evaluated together.

Single Incision Laparoscopic Cholecystectomy for Gallbladder Duplication.

Duplication of the gallbladder is a rare congenital anomaly of the gallbladder, with an estimated prevalence of 1-3 per 3800 individuals. Unless properly diagnosed preoperatively, it can lead to biliary tract injuries and postoperative complications which may require reoperative surgeries. While previously reported cases have been treated with conventional laparoscopic cholecystectomy (LC), treatment with single incision laparoscopic surgery (SILS) has not been reported yet. We herein present the case of a 58-year-old female with gallbladder duplication who was successfully treated with SILS cholecystectomy.

Prediction of the grade of acute cholecystitis by plasma level of C-reactive protein.

BACKGROUND: Acute cholecystitis is the most common complication of gallbladder stones. Today, Tokyo guidelines criteria are recommended for diagnosis, grading, and management of acute cholecystitis. OBJECTIVES: We aimed to evaluate the levels of C-reactive protein (CRP) at different cut-off values to predict the severity of the disease and its possible role in grading the disease with regard to the guideline. PATIENTS AND METHODS: This is a retrospective study, analyzing 682 cases out of consecutive 892 patients with acute cholecystitis admitted to two different general surgery clinics in Istanbul, Turkey. Records of patients diagnosed with acute cholecystitis were screened retrospectively from the hospital computer database between January 2011 and July 2014. A total of 210 patients with concomitant diseases causing high CRP levels were excluded from the study. The criteria of Tokyo guidelines were used in grading the severity of acute cholecystitis, and patients were divided into 3 groups. CRP values at the time of admission were analyzed and compared among the groups. RESULTS: Mean CRP levels of groups were found to be significantly different, 18.96 mg/L in Group I, 133.51 mg/L in Group II, and 237.23 mg/L in Group III (P < 0.001). Having examined CRP values among the groups, they were found to be highly and significantly correlated with the disease grade (P < 0.0001). After evaluating CRP levels according to the grade of the disease, group 2 was distinguished from group 1 with a cut-off CRP level of 70.65 mg/L, and from group 3 with a value of 198.95 mg/L. Those results were found to be statistically significant (P < 0.001). CONCLUSIONS: CRP, a well-known acute phase reactant that increases rapidly in various inflammatory processes, can be accepted as a strong predictor in classifying different grades of the disease, and treatment can be reliably planned according to this classification.

Minimal invasive management of anastomosis leakage after colon resection.

The gold standard of surgical treatment of colorectal anastomotic leak is abdominal drainage of collected fluid and stoma formation. Conventional laparotomy has been the preferred approach for treatment. However, both laparoscopic surgical techniquesand endoscopic stenting have gained popularity over the past years as minimal invasive approaches, especially in the management and treatment of perforations of the gastrointestinal system. We present here a successful treatment with a minimal invasive management of anastomosis leak in the early postoperative period after colon resection in a 62-year-old female patient who had undergone urgent laparoscopic intra-abdominal lavage and drainage followed by endoscopic stenting.

Cardiopulmonary safety of propofol versus midazolam/meperidine sedation for colonoscopy: a prospective, randomized, double-blinded study.

BACKGROUND: Different levels of pharmacological sedation ranging from minimal to general anesthesia are often used to increase patient tolerance for a successful colonoscopy. However, sedation increases the risk of respiratory depression and cardiovascular complications during colonoscopy. OBJECTIVES: We aimed to compare the propofol and midazolam/meperidine sedation methods for colonoscopy procedures with respect to cardiopulmonary safety, procedure-related times, and patient satisfaction. PATIENTS AND METHODS: This was a prospective, randomized, double-blinded study, in which 124 consecutive patients undergoing elective outpatient diagnostic colonoscopies were divided into propofol and midazolam/meperidine sedation groups (n: 62, m/f ratio: 26/36, mean age: 46 ± 15 for the propofol group; n: 62, m/f ratio: 28/34, mean age: 49 ± 15 for the midazolam/meperidine group) by computer-generated randomization. The frequency of cardiopulmonary events (hypotension, bradycardia, hypoxemia), procedure-related times (duration of colonoscopy, time to cecal intubation, time to ileal intubation, awakening time, and time to hospital discharge) and patients' evaluation results (pain assessment, quality of sedation, and recollection of procedure) were compared between the groups. RESULTS: There were no statistically significant differences between the two groups with respect to demographic and clinical characteristics of the patients, the frequency of hypotension, hypoxemia or bradycardia, cecal and ileal intubation times, and the duration of colonoscopy. The logistic regression analysis indicated that the development of cardiopulmonary events was not associated with the sedative agent used or the characteristics of the patients. The time required for the patient to be fully awake and the time to hospital discharge was significantly longer in the propofol group (11 ± 8 and 37 ± 11 minutes, respectively) than the midazolam/meperidine group (8 ± 6 and 29 ± 12 minutes, respectively) (P = 0.009 and P < 0.001, respectively). The patient satisfaction rates were not significantly different between the groups; however, patients in the propofol group experienced more pain than patients in the midazolam/meperidine group (VAS score: 0.31 ± 0.76 vs. 0 ± 0; P = 0.002). CONCLUSIONS: Midazolam/meperidine and propofol sedation for colonoscopy have similar cardiopulmonary safety profiles and patient satisfaction levels. Midazolam/meperidine can be preferred to propofol sedation due to a shorter hospital length of stay and better analgesic activity.