The Effects of the Staple Line Reinforcement Procedures on Gastrointestinal Symptoms and Its Early Results in Sleeve Gastrectomy.

Background: The laparoscopic sleeve gastrectomy (LSG) procedure is the most common bariatric surgical technique worldwide, but controversy continues over staple line reinforcement (SLR) techniques. This prospective randomized study aimed to compare the effects of SLR methods on early postoperative complications and gastrointestinal symptoms in patients undergoing LSG for morbid obesity. Materials and Methods: Ninety patients who underwent LSG surgery for obesity between June 2019 and February 2020 in the Department of General Surgery of Bezmialem Vakif University were included in our prospective randomized study. According to the SLR techniques, three groups were determined as Group 1: using fibrin sealant (Tisseel®), Group 2: omentopexy, Group 3: no SLR, with each group having 30 randomly assigned patients. Gastrointestinal symptoms were assessed by performing the Gastrointestinal Symptom Rating Scale (GSRS) for all patients following the first week and first month. On the second postoperative day, all patients underwent swallow-graphy to investigate twists and fistula. Results: The test group included 90 patients totally, of which 17 are males and 73 are females with a mean age of 35.3 ± 11.6 years and a mean body mass index of 45.3 ± 7.7 kg/m2. According to the GSRS, reflux and indigestion scores in Group 3 were significantly higher than those in the other groups in the first week (P < .001). There was no statistically significant difference in abdominal pain scores in the first week. Group 3's operation time was statistically significantly shorter than the other groups (Group 1 P = .005; Group 2 P = .001). In Group 3, 2 patients (2.2%) had bleeding. There was no mortality. There were no twists or fistulas found in swallow graphs. Symptomatic reflux was not observed in the first-year follow-up period. Conclusions: SLR methods reduce gastrointestinal system complaints in the early postoperative period. In our study, omentopexy and fibrin sealant used in LSG did not show a statistically significant difference in early postoperative complications.

Prospective multi-center study of surgeon's assessment of the gallbladder compared to histopathological examination to detect incidental malignancy.

PURPOSE: Routine histopathological examination after cholecystectomy for gallstones is performed despite the low rates of incidental findings of malignancy. The aim of this study was to assess predictive values of macroscopic examination of cholecystectomy specimens by surgeons in gallstone disease. METHODS: A prospective multi-center diagnostic study was carried out between December 2015 and March 2017 at four different centers. All patients undergoing cholecystectomy for gallstone disease were consecutively screened for eligibility. Patients whose ages are 18 to 80 years, and preoperative imaging findings without any pathology except cholelithiasis were included. The gallbladder was first evaluated macroscopically ex situ by two operating surgeons and rated as macroscopically benign (group S1), suspicious for a benign diagnosis (group S2), and suspicious for malignancy (group S3). Thereafter, a pathologist made a final histopathological examination whose results are grouped as chronic cholecystitis (group P1), benign or precancerous lesions in which only cholecystectomy is the adequate treatment modality (group P2), and carcinoma (group P3). Diagnostic accuracy of the surgeon's assessment to the histopathological examination was evaluated using sensitivity, specificity, positive and negative predictive values, and accuracy, and correlated by a kappa agreement coefficient. RESULTS: A total of 1112 patients were included in this trial. The specificity rates were 96.5%, 100%, and 98.7% for group S1-group S2, group S1-group S3, and group S2-group S3, respectively. Accuracy rates to detect malignancy were 100% and 95. 2% for group S1 and group S2, respectively. Kappa coefficient values were 1.0 and 0.64 for group S1-group S3 and group S2-group S3, respectively (p < 0.001 for both). CONCLUSION: Assessment of the gallbladder specimen and selective histopathological examination may be adequate after cholecystectomy for gallstone diseases. Such a procedure would have the potential to reduce costs and prevent unnecessary loss of labor productivity without affecting patients' safety. However, higher number of patients in more centers is needed to confirm this hypothesis.

Nonclosure of the Peritoneum during Appendectomy May Cause Less Postoperative Pain: A Randomized, Double-Blind Study.

Objective: We aim to evaluate the effect of peritoneal closure on postoperative pain and life quality associated with open appendectomy operations. Methods: This is a single-center, prospective, randomized, and double-blinded study. Here, 18-65-year-old patients who underwent open appendectomy for acute appendicitis were included. Demographic data of the patients, operation time, length of hospital stay, pain scores using a 10 cm visual analogue scale (VAS) on the first postoperative day, quality of life assessment using the EuroQol-5D-5L questionnaire on postoperative 10th day, deep wound dehiscence, bowel obstruction, and mortality data were recorded. Results: In total, 112 patients were included in the study. The demographic data showed no significant difference between the groups. The median VAS score was lower in the group with open peritoneum, but this difference was not statistically significant (3 vs. 4, p=0.134). The duration of surgery was significantly shorter in the peritoneal nonclosure group (31.0 ± 15.1 vs. 38.5 ± 17.5 minutes, p=0.016). Overall complication rates and life quality test (EuroQol-5D-5L) results were similar between groups. Conclusion: Nonclosure of the peritoneum seems to shorten the duration of surgery without increasing complications during open appendectomy. Postoperative pain and life quality measures were not affected by nonclosure of the peritoneum. This trial is registered with NCT02803463.

Intraoperative palpation of sentinel lymph nodes can accurately predict axilla in early breast cancer.

Recent randomized trials have shown that completion axillary lymph node dissection (ALND) is not required in all patients with a positive sentinel lymph node (SLN) who will receive radiation therapy. Although routine intraoperative pathologic assessment (IPA) becomes unnecessary and less indicated by breast surgeons in the United States and some European countries, it is still widely used all around the world. In this prospective study, the feasibility of intraoperative nodal palpation (INP) as opposed to IPA of the SLN has been analyzed. Between March 2014 and June 2015, 305 patients with clinical T1-2/N0 breast cancer from two different breast clinics (cohort A; [n = 225] and cohort B; [n = 80]) who underwent any breast surgery with sentinel lymph node biopsy (SLNB) were included in this study. Surgeons evaluated the SLNs by manual palpation before sending for IPA, and findings compared with the final pathology. The positive predictive values (PPV) of INP and IPA were 81.8% and 97.9%, respectively, whereas the negative predictive values (NPV) of INP and IPA were 83% and 92.4%. The accuracies of INP and IPA were 82.6% and 94.1%, respectively. If patients with SLNB including micrometastasis were also considered in the final pathologic assessment (FPA) (-) group that would not require a further axillary dissection, the revised NPV of INP and FPA were found to be 92.6% and 98.1%, respectively. The revised accuracy of INP also found to be increase to 86.9%. Our study, which is the only prospective one about palpation of dissected SLNs in the literature, suggests that INP can help to identify patients who do not need ALND, which encourages omitting IPA in cT1-2 N0 breast cancer.

Impact of anxiety on sedative medication dosage in patients undergoing esophagogastroduodenoscopy.

INTRODUCTION: Esophagogastroduodenoscopy (EGD) is a diagnostic method used in the investigation of upper gastrointestinal system diseases. A high level of anxiety of patients who undergo EGD increases the duration of the procedure and the sedation and analgesic requirements. Sedation is used to increase patient comfort and tolerance by reducing the anxiety and pain associated with endoscopic procedures. AIM: In this study, the effect of anxiety scores on medication doses was investigated in patients who underwent EGD under sedation. MATERIAL AND METHODS: A psychiatrist, an endoscopist and an anesthesiologist conducted a prospective observational study blindly to investigate the effect of pre-procedural (before EGD) anxiety level on medication doses for sedation. Patients were divided into two groups, with and without additional medication doses. RESULTS: The study included 210 consecutive patients who underwent EGD under sedation. The average STAI-S score was 40.28 and the average STAI-T score was 40.18. There was no relationship between anxiety scores and gender (p = 0.058, p = 0.869). Statistically significant results were obtained for anxiety scores with additional sedation dosing (p < 0.05). It was observed that an additional dose of medication was affected by age, body mass index and anxiety scores (p < 0.005). Patients who were young, had a low body mass index and had high anxiety scores had significantly higher additional dose requirements. CONCLUSIONS: The medications used for sedation during EGD may be inadequate or an additional dose of medication may be needed for patients who have higher anxiety scores, younger age, and lower body mass index.

Rare Entities of Histopathological Findings in 755 Sleeve Gastrectomy Cases: a Synopsis of Preoperative Endoscopy Findings and Histological Evaluation of the Specimen.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is the most preferred technique in morbidly obese patients for weight loss. There is a controversy about the routine preoperative evaluation of the stomach and the routine microscopic examination of all LSG specimens. Our aim is to analyze the results of both preoperative upper gastrointestinal endoscopy and endoscopic biopsies and also the results of histopathological examination of LSG specimens. MATERIALS AND METHODS: The data of patients who underwent LSG from January 2011 to November 2016 were analyzed retrospectively from a prospectively collected database. Seven hundred fifty five of 819 patients who met the inclusion criteria were included in this study. Data on patients' demographic variables [age, gender, BMI (kg/m2)], preoperative upper GI endoscopy and biopsy results, postoperative histopathological results of the specimens, and the process of the patients with malignant histopathological investigation in the follow-up period were collected. RESULTS: This study involves 755 patients with a mean age of 39.6 ± 11.7 years and has 496 (65.6%) to 259 (34.4%) female to male ratio. None of the patients harbored macroscopic or microscopic malignant pathological finding in the preoperative assessment. Hiatal hernia was detected in 78 (10.2%) patients and gastric/duodenal ulcers were detected in 52 (6.8%) patients in endoscopy. Incidental malignant and/or premalignant histopathological findings-intestinal metaplasia (1.4%) and malignant lesions (0.5%)-were rarely found in the evaluation of the surgical specimens. CONCLUSIONS: Both preoperative endoscopic assessment and postoperative histopathological examination of the specimen are mandatory in LSG patients.

Is surgery necessary to confirm diagnosis of right-sided diverticulitis in spite of relevant clinical and radiological findings?

BACKGROUND: Diverticulosis of the right colon is an uncommon entity. Aim of the present study was to report outcome in patients with right-sided diverticulitis diagnosed using computed tomography (CT) and treated conservatively. METHODS: Twelve patients with clinical and radiological diagnosis of cecal or right-sided diverticulitis who were treated conservatively between February 2013 and December 2014 were included. Demographic and clinical data were retrospectively analyzed. RESULTS: Female to male ratio was 1:1 with mean age of 45.08±14.4 years. Mean length of symptom history before admission was 2.08±1.3 days. Most common presenting symptom was right lower abdominal pain, seen in 72.7% of the patients. Abdominal ultrasound alone was performed for 10 patients, and 2 also had abdominal CT. Mean duration of hospitalization was 2.8±1.5 days. All patients were successfully treated with medical therapy. There was no recurrence during mean follow-up period of 8.2±5.6 months. CONCLUSION: If uncomplicated diverticulitis of the right colon is correctly diagnosed with radiological evaluation, antibiotic therapy and bowel rest should be considered as treatment modality, as there was no recurrence observed in short-term follow-up period and this option presents advantage of avoiding surgical intervention.

Comparison of Weight Loss, Ghrelin, and Leptin Hormones After Ligation of Left Gastric Artery and Sleeve Gastrectomy in a Rat Model.

BACKGROUND Ligation of the left gastric artery (LLGA), which supplies the fundus of the stomach, may reduce the appetite hormone ghrelin, resulting in weight control. The aim of this study was to compare LLGA and sleeve gastrectomy (SG) in terms of postoperative outcomes in a rat model. MATERIAL AND METHODS Fifteen male Wistar albino rats, weighing >350 grams (range 350-525 grams), were enrolled in LLGA (N=5), SG (N=5), and control (N=5) groups. Blood samples were drawn preoperatively and also during the first and fourth week postoperatively to assay ghrelin and leptin hormone levels. Body weight was measured in each group. RESULTS The maximum reduction in ghrelin level (41.5%) was found in the LLGA group. Considerable% total weight loss (TWL) (mean 24.1%) was observed in the SG group, and slight%TWL was noted in the control and LLGA groups (means of 0.1% and 2.1%, respectively). There was no significant difference in mean percent weight change between the LLGA and the SG groups (p=0.08). Blood sample analysis revealed no statistically significant changes in ghrelin or leptin levels between the groups (p=0.9 and p=0.3, respectively). CONCLUSIONS We present evidence that LLGA causes the same reduction in ghrelin hormone levels as SG at 4 weeks after surgery in a rat model. However, LLGA did not cause the same%TWL as SG. The mechanism of weight loss in SG is most likely due to restriction and to the effects of the procedure, rather than due to neurohormonal changes.

Effects and results of fibrin sealant use in 1000 laparoscopic sleeve gastrectomy cases.

BACKGROUND: Staple-line leakage and bleeding are worrisome and feared postoperative complications after laparoscopic sleeve gastrectomy (LSG) in morbidly obese patients. The purpose of this study was to review clinical evidence following the use of fibrin sealant in standard LSG. METHODS: Morbidly obese patients who underwent standard technique of LSG with using fibrin sealant were included in the study. Demographics variables [age, gender, body mass index (kg/m2), and comorbid conditions], the re-admission rate, and postoperative early complications, such as bleeding, staple-line leak, twist and stricture, were evaluated at the follow-up during the postoperative first month. RESULTS: In total, 1000 patients [586 female (58.6 %)] with a mean age of 42.6 ± 13.6 years underwent LSG. Fibrin sealant was used in all operations. In total, 186 patients (18.6 %) had previous abdominal surgery. The mean operative time was 72 ± 19 min, and the mean hospital stay was 3.2 ± 1.1 days. Only 3 patients (.3 %) experienced bleeding. Staple-line leakage, twist and stricture were not observed. The re-admission rate was .5 %, and no mortalities were noted. CONCLUSION: This retrospective study indicates that bariatric surgeons should consider implementing standardized surgical operative technique for reduced postoperative complications in LSG. Fibrin sealant is a reliable and useful tool to reinforce the staple line and may prevent potential twists of the sleeved stomach.

The Effects of Preoperative Endoscopic Tattooing on Distal Surgical Margin and Ileostomy Rates in Laparoscopic Rectal Cancer Surgery: A Prospective Randomized Study.

AIM: This study aimed to evaluate the effect of endoscopic marking on the distal surgical margin and ileostomy rates in laparoscopic rectal cancer surgery. MATERIALS AND METHODS: Forty patients, who underwent surgery between September 2012 and December 2013 for rectal cancer limited to or with invasion of the upper rectum, were included in the study. The distal tumor margin was marked with purified carbon particles by colonoscopy before surgery in one group (n=20); no marking was performed in the second group (n=20). Patients were assigned randomly to each group. Laparoscopic anterior or low-anterior resection was performed in all patients. Demographic and operative data, pathology results, morbidity, and ileostomy rates were measured. RESULTS: There was no statistically significant difference in the demographic data, the tumor size, the amount of bleeding, the specimen length, the harvested lymph node number, postoperative complications, the length of hospital stay, rehospitalization, and the operation duration between groups 1 and 2, respectively. The distal surgical margin was significantly shorter in the marked group. The protective ileostomy rates were also lower in the marked group; however, the difference did not reach statistical significance. CONCLUSIONS: Preoperative endoscopic tattooing decreases distal resection margins and may reduce protective ileostomy rates in laparoscopic rectal surgery.

The effects of lauromacrogol on thyroid tissue in rabbits. Is this a safe option for the treatment of nodular thyroid disease?

AIM: The effects of lauromacrogol as a sclerosing agent were evaluated on rabbit thyroid tissue. MATERIAL AND METHODS: Twelve rabbits were divided into two equal groups. Intra-thyroid injections of 0.1 ml lauromacrogol were administered in the study group and 0.1 ml physiologic serum in the control group. The blood levels of free T3, free T4, TSH, postoperative adhesions and histopathologic differences of the thyroid tissues were evaluated. RESULTS: The values of serum free T3, free T4 and TSH levels did not differ significantly (p>0.05), but the free T3 levels were significantly different in the inter-group analysis (p=0.020). Postoperative macroscopic adhesion scores did not differ significantly (p>0.05). In the histopathologic evaluation, the inflammation and fibrosis scores were significantly higher in the study group (p=0.003). DISCUSSION: In our study, we found two important outcomes. Firstly, tests of thyroid function were not significantly different between the control and study groups. This important finding suggests lauromacrogol can be safely used without the risk of hypothyroidism or hyperthyroidism. Secondly, the Erlich-Hunt Model histopathologic evaluation results revealed that inflammation and fibrosis were significantly increased in the study group. This finding shows lauromacrogol can be effectively used to treat thyroid nodules by means of fibrosis. CONCLUSIONS: Lauromacrogol causes fibrosis in thyroid tissue without significant perithyroidal adhesion formation and functional differences. Treatment of nodular thyroid disease with lauromacrogol may be safe. KEY WORDS: Lauromacrogol, Nodule, Thyroid.

Metachronous metastatic paraganglioma in jejunum as a rare entity: A case report.

Pheochromocytomas and paragangliomas are neuroendocrine tumors that arise from chromaffin cells of adrenal medulla and extra-adrenal paraganglia, respectively. The recurrence of these neuroendocrine tumors as a jejunal mass causing obstruction in the small intestine is an exceptional entity. The present study reports the case of a 70-year-old male who presented to the Emergency Department of Bezmialem Vakif University Hospital with abdominal pain and vomiting. The patient possessed a history of left nephrectomy due to malignant pheochromocytoma that had invaded into the left kidney eight months prior to presentation. Bowel obstruction was diagnosed and the patient underwent a laparoscopic procedure. Partial resection of the jejunum was performed and immunohistochemical studies revealed the lesion to be malignant paraganglioma. The majority of paragangliomas are chemo- and radioresistant. Surgical excision remains the primary treatment. Metachronous paraganglioma arising from the small intestine is an extremely rare entity and may be a relevant consideration in patients presenting with bowel obstruction.

Midgut malrotation causing intermittent intestinal obstruction in a young adult.

Midgut malrotation is a congenital anomaly of intestinal rotation and fixation that is generally seen in neonatal population. Adult cases are rarely reported. Early diagnosis is crucial to avoid life threatening complications. Here, we present an adulthood case of midgut volvulus as a rare cause of acute abdomen.

Mechanism of body weight reducing effect of oral boric Acid intake.

Objective. The effect of oral boric acid intake on reducing body weight has been previously demonstrated although the mechanism has been unclear. This research study reveals the mechanism. Subjects. Twelve mice were used, in groups of six each in the control and study groups. For five days, control group mice drank standard tap water while during the same time period the study group mice drank tap water which contains 0.28 mg/250 mL boric acid. After a 5-day period, gene expression levels for uncoupling proteins (UCPs) in the white adipose tissue (WAT), brown adipose tissue (BAT), and skeletal muscle tissue (SMT) and total body weight changes were analyzed. Results. Real time PCR analysis revealed no significant change in UCP3 expressions, but UCP2 in WAT (P: 0.0317), BAT (P: 0.014), and SMT (P: 0.0159) and UCP1 in BAT (P: 0.026) were overexpressed in the boric acid group. In addition, mice in the boric acid group lost body weight (mean 28.1%) while mice in the control group experienced no weight loss but a slight weight gain (mean 0.09%, P < 0.001). Conclusion. Oral boric acid intake causes overexpression of thermogenic proteins in the adipose and skeletal muscle tissues. Increasing thermogenesis through UCP protein pathway results in the accelerated lipolysis and body weight loss.

Safe thyroidectomy with intraoperative methylene blue spraying.

BACKGROUND: We aimed to minimalize operative complications by spraying of methylene blue stain on thyroid glands and the perithyroidal area. MATERIAL AND METHODS: The intra-operative methylene blue spraying technique was used prospectively on a total of 56 patients who had undergone primary (not recurrent) thyroid surgery for a variety of thyroid diseases. Bilateral total thyroidectomy was performed in all cases. After superior but before inferior pole ligation, 0.5ml of methylene blue was sprayed over the thyroid lobe and perilober area. Tissues, especially parathyroides, the recurrent laryngeal nerve, and the inferior thyroid artery, were identified and evaluated. RESULTS: Recurrent laryngeal nerve and arteries were not stained and thus they remained white in all cases while all other tissues were stained blue. Within three minutes parathyroid glands washed out the blue stain and the original yellow color was regained. Thyroid tissue wash-out time was not less than 15 minutes; perithyroideal muscles, tendinous and lipoid structures took no less than 25 minutes. CONCLUSION: The safety of intravascular methylene blue guidance on thyroid surgery is known. This research demonstrates the effectiveness of the spraying technique, a new technique which ensures not only identification of parathyroid glands within three minutes, but also identification of recurrent laryngeal nerves and inferior thyroid arteries.

Ileocecal Intussusception due to a Lipoma in an Adult.

While intestinal tumors are rare, small intestinal lipomas are even more uncommon benign neoplasms. They are usually asymptomatic, but lipomas larger than 2 cm may become symptomatic due to obstruction, bleeding, or intussusception. In this paper, US and CT findings of a lipoma located in the terminal ileum and causing ileocecal intussusception were discussed. We report a case of small bowel lipoma that became symptomatic due to intermittent obstruction episodes and ileocecal intussuception. If the diagnosis of intestinal lipoma had been made absolutely as in our case, they should be removed surgically in elective conditions.

Intersphincteric resection and coloanal anastomosis in treatment of distal rectal cancer.

In the treatment of distal rectal cancer, abdominoperineal resection is traditionally performed. However, the recognition of shorter safe distal resection line, intersphincteric resection technique has given a chance of sphincter-saving surgery for patients with distal rectal cancer during last two decades and still is being performed as an alternative choice of abdominoperineal resection. The first aim of this study is to assess the morbidity, mortality, oncological, and functional outcomes of intersphincteric resection. The second aim is to compare outcomes of patients who underwent intersphincteric resection with the outcomes of patients who underwent abdominoperineal resection.