Interleukin-21 and Interleukin-32 gene expression levels and their relationship with clinicopathological parameters in colorectal cancer.

BACKGROUND AND AIMS: The immune cells in tumor microenvironment release chemokines and cytokines which determine the immune phenotype of the tumor and play an important role in the prognosis. Present study evaluates the gene expression levels of IL-21 and IL-32 and their relations to clinicopathologic parameters in colorectal cancer. PATIENTS AND METHODS: 31(17F) patients with colorectal cancer were included. Samples were obtained from normal and tumor tissues. After RNA isolation, IL-21 and IL-32 gene expression levels were measured. Immunohistochemistry was also carried out for CD4+, CD8+ and NKcells to measure cell density. The relations between expression levels, immune cell density and differentiation, stage, presence of vascular, perineural invasion and lymph node metastasis(MLN) were investigated. RESULTS: IL-32 gene expression levels were increased in tumor tissues. IL-21 levels were found to be decreased in 50% of the patients. IL-32 levels were also increased with the stage however, it was decreased significantly with the increased number of the MLN. On the other hand, expression levels of IL-21 increased significantly with the presence of vascular invasion. CD4+ density was decreased with increased T-stage, vascular invasion whereas CD8+ density decreased only with the vascular invasion. CONCLUSIONS: IL-32 expressed by tumor microenvironment reveals that expression increased to control tumor growth, but levels are decreased with the increased number of MLNs which might be due to decreased CD4+ cell density. Changes on IL-21 and IL-32 together with the changes on immune cell density, indicate their role in tumor growth and invasion in colon cancer. KEY WORDS: Colorectal Cancer, Cytokines, Immune Cell Density, Interleukin-21, Interleukin-32, Tumor Microenvironment.

The current role of robotics in bariatric surgery.

Significant improvements have been made in bariatric surgery for the past two decades. Thus, early and late complication rates decreased significantly. Thanks to its promising results, robotic surgery is finding increasing use in the field of surgery and the bariatric surgery is one of these areas. Following the first robotic bariatric surgery in 1997, it continues to be performed at increasing rates thanks to the advantages it brings. Robotic surgery offers new opportunities to improve bariatric surgery, thanks to remote control mechanical arms. The three-dimensional (3D) view, together with the precision of movements and the freedom of arms offer new insights into the more difficult surgeries. Hospitals should prepare a good business plan to financially activate robotic surgery, thus, more robotic procedures can be achieved. Among the expressed concerns for the Da Vinci Systems are issues such as the costs, operational times, and lack of tactile feedback. Annual maintenance fees and instrument costs are undoubtedly higher than laparoscopic surgery methods. Robotic surgery is now integrated into obesity surgery, such as sleeve gastrectomy, Roux-en-Y gastric bypass, one anastomosis gastric bypass, biliopancreatic diversion and single anastomosis duodenal switch. It allows for more efficient and ideal anastomosis and exposure in challenging fields. Robotic bariatric surgery is a safe procedure with a short learning curve, outcomes comparable to laparoscopy and other benefits of robotic technology.

Emergency Department visits after bariatric surgery.

BACKGROUND: Although bariatric surgery (BS) has an excellent safety profile, postoperative complications have undoubtedly increased due to the rise in the amount of operations performed annually. In parallel, the number of visits to the Emergency Department (ED) after surgery is increasing. The aim of this study was to describe the frequency, and the risk factors associated with postoperative ED visits after BS. METHODS: This study included patients who had undergone different types of BS procedures between June 2016 and December 2019. Patients' prior surgery types, ED visiting timings, main complaints, symptoms and the diagnoses they received, readmissions, and the interventions they had were noted and compared. RESULTS: A total of 408 patients operated on using either the robotic or laparoscopic method due to morbid obesity, including 91 (22.3%) SG, 231 (56.6%) OAGB, 62 (15.2%) SADS-p, and 24 (5.8%) RS, were included into the study. During follow-up, fifty-three of the 408 patients applied to the Emergency Department 62 times with different complaints. ED admission rates in the OAGB group were significantly higher (P=0.04). While the most common complaint seen in the patients admitted to the ED after BS was localized abdominal pain with 25.8%, the most common diagnosis of the patients was cholelithiasis with a rate of 16.1%. CONCLUSIONS: ED visits after BS usually continue intensively during the first year. Most of these applications can be prevented with regular outpatient follow-ups. Some of these require life-saving surgery in emergency conditions and do not allow the patient to be transferred to a bariatric center.

The first modified Delphi consensus statement on sleeve gastrectomy.

INTRODUCTION: Sleeve gastrectomy (SG) is the commonest bariatric procedure worldwide. Yet there is significant variation in practice concerning its various aspects. This paper report results from the first modified Delphi consensus-building exercise on SG. METHODS: We established a committee of 54 globally recognized opinion makers in this field. The committee agreed to vote on several statements concerning SG. An agreement or disagreement amongst ≥ 70.0% experts was construed as a consensus. RESULTS: The committee achieved a consensus of agreement (n = 71) or disagreement (n = 7) for 78 out of 97 proposed statements after two rounds of voting. The committee agreed with 96.3% consensus that the characterization of SG as a purely restrictive procedure was inaccurate and there was 88.7% consensus that SG was not a suitable standalone, primary, surgical weight loss option for patients with Barrett's esophagus (BE) without dysplasia. There was an overwhelming consensus of 92.5% that the sleeve should be fashioned over an orogastric tube of 36-40 Fr and a 90.7% consensus that surgeons should stay at least 1 cm away from the angle of His. Remarkably, the committee agreed with 81.1% consensus that SG patients should undergo a screening endoscopy every 5 years after surgery to screen for BE. CONCLUSION: A multinational team of experts achieved consensus on several aspects of SG. The findings of this exercise should help improve the outcomes of SG, the commonest bariatric procedure worldwide, and guide future research on this topic.

The First Modified Delphi Consensus Statement for Resuming Bariatric and Metabolic Surgery in the COVID-19 Times.

The purpose of this study was to achieve consensus amongst a global panel of expert bariatric surgeons on various aspects of resuming Bariatric and Metabolic Surgery (BMS) during the Coronavirus Disease-2019 (COVID-19) pandemic. A modified Delphi consensus-building protocol was used to build consensus amongst 44 globally recognised bariatric surgeons. The experts were asked to either agree or disagree with 111 statements they collectively proposed over two separate rounds. An agreement amongst ≥ 70.0% of experts was construed as consensus as per the predetermined methodology. We present here 38 of our key recommendations. This first global consensus statement on the resumption of BMS can provide a framework for multidisciplinary BMS teams planning to resume local services as well as guide future research in this area.

Unusual cause of small bowel obstruction: mesodiverticular band of Meckel's diverticulum demonstrated by CT.

Small bowel obstruction resulting from the mesodiverticular band is a rare complication of Meckel's diverticulum and usually presents a diagnostic challenge. We present a case of small bowel obstruction due to the mesodiverticular band of Meckel's diverticulum with CT scan findings.

25-OH-Vitamin D and procalcitonin levels after correction of acute hyperglycemia.

BACKGROUND: Hyperglycemia is a common complication of diabetes melitis (DM) and in the absence of metabolic decompensation is a common finding in the Emergency Department (ED). We aimed to evaluate the 25 OH Vit D [25(OH)D] and procalcitonin (PCT) levels during hyperglycemia and after normalization of blood glucose. MATERIAL AND METHODS: The study included 88 patients over the age of 18 years who presented with acute hyperglycemia at the Hacettepe University Department of Emergency Medicine. Euglycemia was obtained within 6-12 hours and serum samples were taken from patients on admission and 6 hours after normalization of blood glucose. Along with plasma glucose, plasma 25(OH)D and PCT levels were measured using ELISA. RESULTS: There were 88 (45 males) patients, with a median age of 60.0±13.9 years. Serum 25(OH)D levels increased in all patients after normalization of blood glucose, and serum PCT levels decreased in the whole group. This decrease was independent of type of diabetes or presence of infection. CONCLUSIONS: We demonstrated an increase in 25(OH)D after normalization of blood glucose, and a decrease in PCT in patients with hyperglycemia. This effect was independent of the type of diabetes and presence of infection. Further studies are needed to evaluate the faster link between metabolic abnormalities, vitamin D, PCT, and inflammation.

Femoral vessel blood flow dynamics following totally extraperitoneal vs Stoppa procedure in bilateral inguinal hernias.

BACKGROUND: Both totally extraperitoneal (TEP) and open preperitoneal (Stoppa) procedures involve the placement of prosthetic material preperitoneally. Because the prosthetic material overlies the femoral artery and vein, the aim of this study was to assess its effect on the velocities and diameters of the artery and vein using color Doppler ultrasonography in both approaches. METHODS: Sixty-four patients with bilateral groin hernias were prospectively randomized to undergo either TEP (n = 32) or Stoppa (n = 32) repair. All patients underwent color Doppler ultrasound 6 months after the procedures, and the median follow-up period was 18 months. RESULTS: Neither mean diameter nor mean flow velocity was changed by the insertion of the mesh preperitoneally. The only change was observed in peak systolic femoral arterial blood velocity, which was significantly decreased in the Stoppa group. Also, no patient in this study developed clinically significant deep venous thrombosis during 6 months of follow-up. CONCLUSIONS: The insertion of a prosthetic mesh during TEP and Stoppa procedures does not influence the mean peak flow velocities and cross-sectional areas of the vessels in the inguinal region and can be used safely for open and laparoscopic preperitoneal approaches.

Development of the European Organisation for Research and Treatment of Cancer quality of life questionnaire module for older people with cancer: The EORTC QLQ-ELD15.

BACKGROUND AND AIM: There is a lack of instruments that focus on the specific health-related quality of life (HRQOL) issues that affect older people with cancer. The aim of this study was to develop a HRQOL questionnaire module to supplement the European Organisation for Research and Treatment of Cancer (EORTC) core questionnaire, the EORTC QLQ-C30 for older (>70years) patients with cancer. METHODS: Phases 1-3 were conducted in seven countries following modified EORTC Quality of Life Group guidelines for module development. Phase 1: potentially relevant issues were identified by a systematic literature review, a questionnaire survey of 17 multi-disciplinary health professionals and two rounds of qualitative interviews. The first round included 9 patients aged >70. The second round was a comparative series of interviews with 49 patients >70years with a range of cancer diagnoses and 40 patients aged 50-69years matched for gender and disease site. In Phase 2 the issues were formulated into a long provisional item list. This was administered in Phase 3 together with the QLQ-C30 to two further groups of cancer patients aged >70 (n=97) or 50-69years (n=85) to determine the importance, relevance and acceptability of each item. Redundant and duplicate items were removed; issues specific to the older group were selected for the final questionnaire. RESULTS: In Phase 1, 75 issues were identified. These were reduced in Phase 2 to create a 45 item provisional list. Phase 3 testing of the provisional list led to the selection of 15 items with good range of response, high scores of importance and relevance in the older patients. This resulted in the EORTC QLQ-ELD15, containing five conceptually coherent scales (functional independence, relationships with family and friends, worries about the future, autonomy and burden of illness). CONCLUSION: The EORTC QLQ-ELD15 in combination with the EORTC QLQ-C30 is ready for large-scale validation studies, and will assess HRQOL issues of most relevance and concern for older people with cancer across a wide range of cancer sites and treatment stages.

Effect of increased abdominal pressure on cytokines (IL1 beta, IL6, TNFalpha), C-reactive protein (CRP), free radicals (NO, MDA), and histology.

BACKGROUND: It is generally accepted that proinflammatory mediators, including cytokines, are responsible for the metabolic changes associated with injury. Recent clinical and experimental studies have also shown that the laparoscopic procedures actually produce ischemia-reperfusion injury in the organs by oxygen-derived free radicals. This study aimed to assess the effect of different insufflation pressures and laparotomy on tissue response by comparing the proinflammatory cytokines, C-reactive protein, and serum and tissue levels of oxygen-derived free radicals. METHODS: Forty mature New Zealand white rabbits were assigned to 4 groups of 10 animals. In groups 1 to 3, CO2 pneumoperitoneum was created using an automatic insufflator to the designated pressure of 10, 15, and 20 mm Hg, respectively. The remaining 10 animals underwent laparotomy using 10 cm midline incision (group 4). Blood samples were collected before (0 min) and at the end of the procedure (60 min). After the collection of last blood samples, all animals were killed and samples from liver and gut were obtained for measurements of tissue malondialdehyde levels and histology. RESULTS: The proinflammatory cytokine levels were increased significantly in groups 1 to 3, but did not change in the laparotomy group. Serum C-reactive protein levels were elevated in all groups. The comparison of the results between the laparotomy and laparoscopy groups showed that serum interleukin 6 and nitric oxide levels were significantly elevated in relation the intra-abdominal pressure, and serum interleukin 6 and nitric oxide levels peaked in group 3. Tissue malondialdehyde levels were significantly higher in groups 1 and 2 than in groups 3 and 4. CONCLUSIONS: The findings of our experiment suggest that the elevated intra-abdominal pressure is responsible for ischemia, free radical production, and proinflammatory cytokine response-mediated cell damage during laparoscopic surgery.

Ergonomic problems encountered by the surgical team during video endoscopic surgery.

BACKGROUND: The aim of this study is to analyze the problems related to the ergonomic conditions faced by video endoscopic surgical teams during video endoscopic surgery by means of a questionnaire. METHODS: A questionnaire was distributed to 100 medical personnel, from 8 different disciplines, who performed video endoscopic surgeries. Participants were asked to answer 13 questions related to physical, perceptive, and cognitive problems. RESULTS: Eighty-two questionnaires were returned. Although there were differences among the disciplines, participants assessment of various problems ranged from 32% to 72% owing to poor ergonomic conditions. CONCLUSIONS: As the problems encountered by the staff during video endoscopic surgery and the poor ergonomic conditions of the operating room affect the productivity of the surgical team and the safety and efficiency of the surgery, redesigning of the instruments and the operating room is required.

Diagnostic value of blood D-dimer level in acute mesenteric ischaemia in the rat: an experimental study.

OBJECTIVE: The high mortality rate of mesenteric ischaemia is mainly due to delay in diagnosis. For this reason, it is of great importance to find a specific and rapidly elevating marker. The present study investigated the diagnostic value of blood D-dimer level as a potential marker for acute mesenteric ischaemia in a rat model. METHODS: Thirty male Wistar albino rats were divided into three groups. Basal D-dimer and L-lactate levels were determined in the non-operative control group (I). In the operated control group (II), the superior mesenteric artery was simply manipulated, while the artery was ligated in Group III. Blood samples were drawn in all groups for D-dimer and L-lactate assays. RESULTS: Both Group II (p=0.016) and Group III (p=0.001) had significantly higher mean D-dimer levels in the first postoperative hour compared with the basal level in Group I. However, there was no difference between the levels in Groups II and III. The mean level in Group II in the sixth hour had dropped to a statistically insignificant level compared with the basal value, while the mean value in Group III kept rising during this period (p=0.001). Nevertheless, there was no significant difference between Groups II and III. On the other hand, the mean L-lactate level in the first postoperative hour in Group III was significantly higher than the basal level in Group I (p=0.003). No significant rises were recorded in Group II in the first and sixth postoperative hours. The difference between Groups II and III in the first hour was significant (p=0.005). Group III also had significantly higher mean serum L-lactate value in the sixth hour compared with both the basal value in Group I (p=0.001) and the sixth-hour value in Group II (p=0.003). CONCLUSION: These results do not adequately support the use of blood D-dimer level as an independent parameter in the diagnosis of mesenteric ischaemia due to arterial thrombosis. However, this parameter can be used together with other tests in eliminating the possibility of a thromboembolic event.