Do tumor localization, microsatellite instability and mismatch repair deficiency have an impact on the prognosis of colorectal cancer?

BACKGROUND: Recent reports have shown that left-and right-sided colon cancers display different clinical and biological features. Chromosomal instability, epigenetic alterations, and defects in the deoxyribonucleic acid (DNA) mismatch repair (MMR) system may lead to the development of colorectal cancer (CRC). Besides microsatellite instability (MSI) caused by DNA MMR activity degradation increases the risk for CRC. AIM: We aimed to show the differences between CRCs in different locations, to research the cause of these differences, to present whether there is a relation between MMR and MSI, and to evaluate their effects on prognosis. PATIENTS AND METHODS: 641 CRC cases were divided into three groups: Group 1 (right-sided), Group 2 (left-sided), and Group 3 (rectum). Demographics, cancer stages, location of the tumors, number of the lymph nodes removed, MMR deficiency or proficiency, MSI status, and survival were assessed by retrospective review of the patients. RESULTS: Among 641 patients, 64.9% were males. Group 1, 2, and 3 comprised 31.2%, 45.7%, and 23.1% of all the cases, respectively. There was a significant difference in terms of survival and location only in stage II tumors. Stage II left colon cancer (LCCs) had a statistically significant lower survival rate. There was no significant difference in survival between both MSI and MMR statuses. In addition, cases were also stratified by stages. According to this data, 10.1, 45.7, and 44.2% of the patients had stages I, II, and III disease, respectively. CONCLUSIONS: Although it was not statistically significant, tumors with MMR deficiency (dMMR) and high microsatellite instability (MSI-H) are more common in right-sided colon tumors.

Comparative efficacy of medical treatment versus surgical sphincterotomy in the treatment of chronic anal fissure.

BACKGROUND: Anal fissure which is defined as a longitudinal tear in anoderm below the dentate line is one of the most common benign diseases of anorectal area. Severe pain during the defecation and emotional stress that it causes may reduce people's quality of life. AIMS: In this randomized clinical trial, we aimed to compare the efficiency of the topical ointment with medical treatment and surgical lateral internal sphincterotomy. METHOD: This is a randomized clinical trial of 550 patients who were treated for chronic anal fissure. Patients were randomly divided into 4 groups according to the treatment type they received. RESULTS: In a vast majority of the patients, the primary complaint was pain (92.3%) and bleeding during defecation (62%). Both pain relief and healing of the fissure, which are the components of response to treatment, had not been observed in 56 (37.3%) patients of topical nitroglycerin ointment group until the second month. Among the recalcitrant patients in both topical nitroglycerin (56) and topical diltiazem ointment (47) groups, 27 (48.2%), and 36 (76.5%) patients underwent surgery, respectively. The best response to treatment was also obtained in lateral internal sphincterotomy group. CONCLUSION: LIS is still the gold standard for the treatment of chronic anal fissure when the physicians would like to avoid recurrence and obtain the best pain relief.

Spindle epithelial tumour with thymus-like differentiation: report of two cases.

Spindle epithelial tumour with thymus-like differentiation (SETTLE) is a very rare neck malignancy arising from thymic tissue or branchial pouch, mostly seen in the early decades of life. SETTLE is thought to be a low-grade neoplasm but distant metastases have been reported. Fewer than 50 cases have been reported in the PubMed database. We report on the four-year follow-up for a 13-year-old boy, with no signs of recurrence or distant metastasis. In addition, a 45-year-old woman was admitted to hospital with neck mass. Fine-needle aspiration biopsy was compatible with medullary thyroid carcinoma but serum levels of calcitonin were normal. Total thyroidectomy and central compartment lymph node dissection was planned with an initial diagnosis of medullary thyroid carcinoma. At surgery, frozen section analysis converted our diagnosis to SETTLE and the intraoperative strategy was changed. SETTLE should be considered in a patient with normal serum calcitonin levels in the presence of suspicious medullary thyroid carcinoma at fine-needle aspiration biopsy. Frozen section analysis may help to manage the intraoperative strategy. This report describes the first case of SETTLE successfully diagnosed by frozen section analysis.

Intraoperative nerve monitoring during thyroidectomy: evaluation of signal loss, prognostic value and surgical strategy.

INTRODUCTION: Intraoperative neural monitoring of the recurrent laryngeal nerve has been widely used to avoid nerve injury during thyroidectomy. We discuss the results of the change in surgical strategy after unilateral signal loss surgeries using intermittent intraoperative neural monitoring in a high-volume referral centre. MATERIALS AND METHODS: Details of consecutive patients who underwent thyroidectomy with intermittent intraoperative neural monitoring between January 2014 and December 2017 were prospectively recorded and retrospectively reviewed. Loss of signal was defined as recurrent laryngeal nerve amplitude level lower than 100 µV during surgery. The rate of loss of signal and change in surgical strategy during the operation were evaluated. RESULTS: Loss of signal was detected in 25 (5.4%) of 456 patients for whom intermittent intraoperative neural monitoring was performed. Four patients had anatomic nerve disruption and surgery was completed by an experienced endocrine surgeon making use of intraoperative neural monitoring with continuous vagal stimulation. Staged thyroidectomy was performed on 16 patients with unilateral loss of signal in whom the nerves were intact visually. Postoperative vocal cord paralysis was encountered in 18 of 21 (85.7%) patients with loss of signal, and 16 of 18 (88.8%) were improved during the follow-up period. Patients' voices were subjectively normal to the surgeon postoperatively in 9 of 21 (42.8%) patients who were found to have loss of signal with intact nerves. CONCLUSIONS: Intraoperative neural monitoring can be used safely in thyroid surgery to avoid recurrent laryngeal nerve injury. It enables the surgeon to diagnose recurrent laryngeal nerve injury intraoperatively to estimate the postoperative nerve function and to modify the surgical strategy to avoid bilateral vocal cord paralysis.

Comparison of different scoring systems in patients undergoing colorectal cancer surgery for predicting mortality and morbidity.

BACKGROUND: Preoperative risk estimation evaluating mortality and morbidity might help surgical decision. AIMS: The aim of this study was to compare the sensitivities of physiologic and operative severity score for the enumeration of mortality and morbidity (POSSUM), portsmouth-POSSUM (P-POSSUM), colorectal-POSSUM (CR-POSSUM), the Association of Coloproctology of Great Britain and Ireland colorectal cancer model (ACPGBI CRC) and revised ACPGBI CRC scoring systems that are used for evaluating mortality and morbidity in colorectal surgery performed in third-level healthcare centers. SETTINGS AND DESIGN: A retrospective analysis has been performed on 335 consecutive patients undergoing colorectal cancer surgery between 2002 and 2012. MATERIALS AND METHODS: Mortality and morbidity risks of 335 patients who underwent colorectal cancer were evaluated using these scoring systems and the results were compared with actual mortality and morbidity within postoperative 30-day that extend the duration of hospital stay. STATISTICAL ANALYSIS USED: The receiver operating characteristic (ROC) curves were designed to identify the score values. RESULTS: Results of POSSUM and P-POSSUM systems showed statistical differences compared with those of CR-POSSUM, ACPGBI CRC and revised ACPGBI CRC systems (P < 0.05). P-POSSUM was found to be the best scoring system for predicting mortality risk, although all scoring systems seem to be appropriate for this parameter. On the other hand POSSUM, which can predict morbidity, was found to have moderate differentiation ability due to the magnitude of the area under the ROC curve. CONCLUSIONS: Despite altering patient demographics and surgical conditions, POSSUM seems to lead as the best scoring system for predicting mortality and morbidity among others including those most-recently proposed.

Fournier's gangrene: evaluation of 68 patients and analysis of prognostic variables.

CONTEXT: Fournier's gangrene (FG) is a rapidly progressing acute gangrenous infection of the anorectal and urogenital area. AIMS: The objectives of this study were to investigate patients with FG and to determine risk factors that affect mortality. SETTINGS AND DESIGN: Retrospective clinical study. MATERIALS AND METHODS: Clinical presentations and outcomes of surgical treatments were evaluated in 68 patients with FG. STATISTICAL ANALYSIS USED: Chi-square, Student's t -test, and logistic regression test. RESULTS: Mean age of patients was 54 and female-to-male ratio was 9:59. Among the predisposing factors, diabetes mellitus (DM) was the most common ( n =24, 35.3%), and sepsis on admission was detected in 31 (45.6%) and 15 (22.1%) patients, respectively. Seven (10.3%) patients died. Using logistic regression test, Fournier's Gangrene Severity Index (FGSI)> 9, DM and sepsis on admission were found as prognostic factors. CONCLUSIONS: FG has a high mortality rate, especially in patients with DM and sepsis. An FGSI value> 9 indicates high mortality rate.

Multivisceral resections for locally advanced rectal cancer.

OBJECTIVE: The aim of this study was to evaluate the effectiveness of en bloc multivisceral resection of organs involved by locally advanced rectal carcinoma. METHOD: A total of 312 patients with primary rectal cancer underwent surgery between January 1994 and April 2005. Of these, 57 patients (18.3%) had macroscopically direct invasion of an adjacent organ or structure, and underwent multivisceral resection with curative intent. Survival analyses were made by the Kaplan-Meier and the Cox proportional hazards regression model. RESULTS: The postoperative mortality was 3.5%. The overall survival rate at 1, 3 and 5 years was 96.4%, 81.6% and 49.0%. Age (> or = 65 years), depth of tumour invasion (pT3 stage), lymph node status (pN0), tumour stage (III A-B), grading (G1), vascular and neural invasion (not extensive), type of adhesion (inflammatory) and type of resection (R0) were significant factors favouring survival in the univariate analysis. Only two factors, lymph node status pN0 (P = 0.007) and R0 resection (P = 0.005) were independently significant factors in the multivariate analysis. CONCLUSION: R0 resection and pN0 status influence overall survival for locally advanced rectal carcinoma.

Laparoscopic cholecystectomy accompanied by simultaneous umbilical hernia repair: a retrospective study.

BACKGROUND: Umbilical defects may cause technical problems for general surgeons in patients during laparoscopic cholecystectomy (LC) operations and may increase the incidence of incisional hernia. AIM: The objectives of this study were to determine the optimal repair method for umbilical hernias that already exist or are encountered incidentally and to present data regarding potential problems that may occur during LC. SETTINGS AND DESIGN: Medical records of patients who had received simultaneous umbilical hernia repair (UHR) with LC were investigated retrospectively. MATERIALS AND METHODS: Cholelithiasis was accompanied by umbilical hernia in 64 (8.6%) out of 745 patients who underwent LC and UHR simultaneously in our hospital between 2000 and 2004. STATISTICAL ANALYSIS USED: The Mann-Whitney U, Chi-square, One-Way Anova, Kaplan-Meier survival analysis, the log-rank test and t test were used for statistical analyses. RESULTS: LC was followed by UHR using primary suture (Group 1), Mayo repair (Group 2) and flat mesh-based repair (Group 3) in 32 (50%), 18 (28.1%) and 14 (21.9%) patients, respectively. Mean body mass indexes (BMI) of patients were 26.6 kg/m 2, 29.2 kg/m 2 and 39.9 kg/m 2 in Groups 1, 2 and 3, respectively. Recurrence rates were 9.4%, 5.6% and none (0%) in Groups 1, 2 and 3, respectively. Recurrence was observed in three (7.0%) out of 43(67.2%) patients with BMI > or = 30 kg/m 2 while umbilical hernia recurred in one (4.8%) out of 21 (32.8%) patients with BMI < 30 kg/m 2. Overall morbidity and mortality rates were 14.1% and 0%, respectively. CONCLUSIONS: The outcomes of the UHR with mesh after laparoscopic surgeries appear to be better for either obese or non-obese patients than primary suture techniques in recurrence rates.

Factors affecting morbidity and mortality in incarcerated abdominal wall hernias.

BACKGROUND: Incarcerated abdominal wall hernia cases may necessitate emergency interventions, but under such circumstances morbidity and mortality rates may increase. The aim of this study was to investigate the factors that affect morbidity and mortality in patients with incarcerated abdominal wall hernias who underwent emergency surgery. METHODS: Urgent surgical interventions due to incarcerated abdominal wall hernias were performed in 182 patients in our clinics between January 1998 and January 2006. Factors that affect morbidity and mortality in incarcerated abdominal wall hernias were investigated retrospectively by browsing the archives. Logistic regression analysis was used to evaluate parameters that affect morbidity and mortality. RESULTS: Morbidity and mortality occurred in 43 (23.6%) and 9 (4.9%) patients, respectively. A symptomatic period of longer than 8 h, presence of accompanying disease, high American Society of Anesthesiology (ASA) score, general anesthesia, presence of strangulation, and necrosis were found to affect morbidity significantly by univariate analysis. Necrosis was the sole factor affecting morbidity significantly by multivariate analysis. Advanced age, presence of accompanying disease, high ASA score, presence of strangulation, necrosis, and hernia repair with graft were found to affect mortality significantly by univariate analysis; however, necrosis was the sole factor affecting mortality significantly by multivariate analysis. CONCLUSIONS: Intestinal necrosis, which was followed by bowel resection, was the sole factor affecting morbidity and mortality using multivariate logistic regression analysis. Emergency surgery is required for incarcerated abdominal wall hernias before intestinal necrosis develops.