Ali Akyuz

Effects of surgical laparoscopic experience on the short-term postoperative outcome of rectal cancer: results of a high volume single center institution.

Purpose The purpose of the study was to assess the effects of the surgeons learning curve on the short-term outcome of laparoscopic resections performed for rectal cancer. Methods A total of 284 patients who underwent laparoscopic resection for rectal cancer performed by 3 different surgical teams between 2005 and 2008 were included in the study. The operative experience was represented by the teams previous surgical case numbers (frequency). Four skill levels were categorized as follows: Level 1: the first 60 cases, Level 2: 61 to 120 cases, Level 3: 121 to 180 cases, and Level 4:>180 cases. Characteristics of the patients, perioperative variables, and the experience levels of the surgeons were analyzed and compared. To investigate the learning curve, we used the following parameters: duration of operative time, conversion rates, general complications, anastomotic leak rates, and oncologic parameters. Results Operative time gradually decreased with increasing experience. The mean operative times for Level 1, Level 2, and Level 3 were 195.0±46.7, 181.7±34.2, and 172.3±33.0 minutes, respectively, whereas the mean operative time for Level 4 was 151.3±27.7 minutes (P<0.05). With increased experience, conversion rates, complication rates, anastomotic leak rates, and hospitalization durations decreased (P<0.05). The resected specimen length was found to be longer with increased surgical experience (P<0.05). There were no significant differences among the groups with regard to tumor size, T stage, harvested lymph node count, lateral margin involvement, and R0 resections. Conclusions The operative time is inversely proportional to the level of skill. Laparoscopic surgical procedures do not have any negative effects on short-term surgical outcome. With the strict application of surgical principles, the oncologic quality of the specimen is not influenced by the experience period. With increased experience, the surgeon feels more confident and performs more difficult and complex laparoscopic surgical interventions for rectal cancer.

Endoscopic diagnosis and management of complications following surgery for gallstones.

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is increasingly being performed for therapeutic purposes. This report reviews our experience in an attempt to determine the role and efficacy of ERCP in the management of postoperative complications following surgery for gallstones. Methods: This study analyzes ERCP records of 418 patients performed in a single referral center after a surgery for gallstones, in the period from December 1991 to June 2000. Results: A total of 451 endoscopic procedures were performed for 418 patients. The primary operations which required ERCP and were included in the study were laparoscopic cholecystectomy (n = 161, 38.5%), choledocholithotomy and T-tube drainage (n = 157, 37.5%), open cholecystectomy (n = 82, 19.6%), choledochoduodenostomy (n = 14, 3.3%), and cholecystostomy (n = 4, 1%). Procedure was carried out successfully in 403 patients (96.4%), whereas a proper endoscopic diagnosis was not achieved in 15 (3.5%). Retained biliary stones (without any associated abnormality) were found in 163 (38.9%), ductal injuries in 44 (10.5%), biliary strictures in 21 (5.0%), papillary stenosis in 36 (8.6%), cystic stump leak (with or without retained stones) in 30 (7.1%), leak from T-tube tract (with/or without retained stones) in 20 (4.8%), and unsuspected malignancies in 18 (4.3%). A sole diagnostic cholangiography was obtained in 63 patients (15.0%). Patients were managed by debris or stone extraction in 169 (40.4%), endoscopic sphincterotomy (ES) in 145 patients (34.6%), stent insertion in 19 (4.5%), or dilatation in 2 (0.4%). Overall successful stone removal rate was 97.4%. Thirty-nine patients with normal cholangiographic findings underwent ES for the relief of presenting signs and symptoms. ERCP-related morbidity was 13.6%. Conclusions: The need for ERCP is rising, especially for stones retained after cholecystectomies. Endoscopy offers safe and effective methods in the treatment of bile leaks, unless associated with major ductal injuries. ES is a reasonable method for treating papillary stenosis and some post-cholecystectomy pain or symptoms.n

Laparoscopic surgery for rectal cancer: outcomes in 513 patients.

BackgroundFew reports have demonstrated the feasibility and efficacy of laparoscopic resection in patients with rectal cancer (RC). The objective of the present study was to assess the effectiveness of laparoscopic resection for RC, with an emphasis on perioperative variables and long-term oncological outcomes.MethodsThis prospective study was carried out between January 2005 and September 2010 and included 513 patients diagnosed with RC who underwent laparoscopic surgery. Patients with locally advanced RC (cT3/cT4 or N+) received neoadjuvant treatment. Adjuvant treatment was applied to patients with stage II/III disease or according to the neoadjuvant protocol. All patients were followed-up prospectively for the evaluation of complications and oncological outcome. Survival rate analysis was performed using the Kaplan–Meier method.ResultsSphincter-preserving surgery was performed on 389 patients, and the remaining 124 patients underwent abdominoperineal resection. Perioperative mortality occurred in only one patient (0.2xa0%), and 27 (5.3xa0%) intraoperative complications were recorded. The most common postoperative complication was anastomotic leakage (5.5xa0%). The conversion rate was 6.4xa0%. The mean number of harvested lymph nodes was 23.6xa0±xa013. The mean distance to the distal margin was 2.6xa0±xa01.9 (0–7)xa0cm. Distal margin positivity was detected in 9 (1.7xa0%) patients. The circumferential margin was positive in 39 (7.6xa0%) cases. After a median follow-up period of 30 (1–78)xa0months, recurrence occurred in a total of 59 patients (11.5xa0%). Local recurrence was detected in 16 patients (3.1xa0%), and both local and distant recurrence was found in 7 patients (1.4xa0%). Distant recurrence only was detected in 43 patients (8.4xa0%). The overall 5-year survival rate was 84xa0%, and the 5-year disease-free survival rate was 77.4xa0%. The local recurrence-free survival rate was 98.4xa0% at 2xa0years, 95.7xa0% at 3xa0years, and 94.3xa0% at 5xa0years.ConclusionsOur results, together with the review of the literature, clearly demonstrate that laparoscopic resection for RC is a feasible method at specialized high-volume centers. The long-term outcomes are at least as good as those from open surgery as long as the principles of oncologic surgery are respected and faithfully performed.

COMPARISON OF SODIUM PHOSPHATE, POLYETHYLENE GLYCOL AND SENNA SOLUTIONS IN BOWEL PREPARATION: A PROSPECTIVE, RANDOMIZED CONTROLLED CLINICAL STUDY

Background:u2002 Low volume oral solutions for colon cleansing before colonoscopy are gaining popularity over large volume oral lavage solutions. Therefore, we aimed to compare three oral solutions for colonoscopy to determine any changes in either patient compliance or cleansing ability.

Revisiting stapled and handsewn loop ileostomy closures: a large retrospective series

OBJECTIVE: To compare the surgical outcomes of stapled and handsewn closures in loop ileostomies. METHODS: The data of 225 patients requiring loop ileostomies from 2002 to 2007 were retrospectively evaluated. The patients underwent partial small-bowel resections and either handsewn or stapled anastomoses for the ileostomy closures. They were followed up postoperatively with routine surgical examinations. RESULTS: The study group consisted of 124 men and 101 women with a mean age of 49.12 years. The ileostomy closure was performed with handsewn in 129 patients and with stapled in 96 patients. The mean time to the first postoperative flatus was 2.426 days in the handsewn group and 2.052 days in the stapled group (p<0.05). The mean time to the first postoperative defecation was 3.202 days in the handsewn group and 2.667 days in the stapled group (p<0.05). The mean duration of patient hospital stay was 8.581 days for the handsewn group and 6.063 days for the stapled group (p<0.05). CONCLUSIONS: Patients who underwent ileostomy closure with stapled recovered faster in the postoperative period and required shorter hospital stays than those whose closures were performed with handsewn. In our opinion, stapled should be considered the gold standard for loop ileostomy closures.

Adjuvant chemoradiotherapy after D2 resection in gastric cancer: a single-center observational study

PurposePrevious studies demonstrated survival benefits in association with the addition of chemoradiotherapy after surgery in gastric cancer. This study aimed to examine the efficacy in terms of loco-regional control and survival and safety of 5-FU-based adjuvant chemoradiotherapy after D2 curative surgery.MethodsThis study included 228 patients (81 female, 147 male) treated for gastric cancer with curative surgery plus adjuvant chemoradiotherapy. Majority of the patients underwent at least D2 lymph node resection. Median three cycles of fluorouracil chemotherapy were administered, and 45-Gy radiotherapy was delivered at 1.8xa0Gy/fraction concomitantly during the second cycle of chemotherapy. Local control, regional control, distant metastasis and overall survival rates were estimated.ResultsThe median age of the patients was 54xa0years (range 25–74xa0years). The most common grade III toxicities were nausea (10xa0%) and neutropenia (9xa0%). During radiotherapy, grade IV local skin reaction occurred in one patient. Median duration of follow-up was 47xa0months. Local, regional and distant recurrence developed in 9 (4xa0%), 41 (18xa0%) and 45 (20xa0%) patients, respectively. Overall 5-year survival rate was 57.2xa0%, and disease-free 5-year survival rate was 53.8xa0%. Multivariate analysis identified less than 15 lymph node involvement as an independent predictor of better survival (pxa0<xa00.001).ConclusionsConcomitant 5-FU-based chemoradiotherapy seems to be an effective and tolerable adjuvant regimen on local control and survival in curatively resected node-positive stomach cancer, particularly when combined with D2 resection.

Wireless endoscopy capsule remaining safely for a long time.

Wireless capsule endoscopy is a new diagnostic technique used especially for investigating the entire small bowel [1]. Obscure bleeding is the most important indication. To date, there is no reported case of the capsule remaining for a long time without any obstructive symptoms. Here, we present an interesting case diagnosed with ulcerative jejunoileitis complicating gluten enteropathy and capsule remaining for 1 year with no damage. M-K is a 36-year-old woman; she has been followed up with gluten enteropathy for 20 years. She was admitted to our clinic complaining of abdominal pain and weight loss. With these clinical symptoms, we thought that a serious complication of gluten enteropathy might have developed after such a long time. Abdominal plain film showed airfluid levels in small bowel, and colonoscopy revealed ulcerations and stenosis of terminal ileal valve. Ileal stenosis and proximal dilatation were detected by small bowel barium enema, and laparotomy was performed. In laparotomy, multiple strictures and ulcerations were found; stricturoplasty with partial ileal resection was done. Histological examination confirmed ulcerative jejunoileitis. Methylprednisolone (0.5 mg/kg) and azathiopurine (2 mg/ kg) were started. On postoperative second month severe iron-deficiency anemia (hemoglobin 3.5–5 g/dl) developed. She was transfused many times during the follow-up period. No lesions were detected by gastroscopic, colonoscopic, and sintigraphic examinations. Then, capsule endoscopy was performed in another center, as it was not suitable in our center at that time and no bleeding cause was found. She did not complain of abdominal pain or diarrhea; fatigue was the only symptom and she needed red

Imatinib response of gastrointestinal stromal tumor patients with germline mutation on KIT exon 13: A family report

Familial gastrointestinal stromal tumor (GIST) is a rare autosomal dominant disorder associated with mutations in the KIT gene in the majority of cases. Although, exon 11 appears to be the hot spot region for approximately 95% of germline mutations, pathogenic variations have also been identified in exon 8, 13 and 17. Exon 13 germline mutations are extremely rare amongst familial GISTs and seven families with a germline mutation have been reported to date. Moreover, the role of imatinib mesylate in this rare familiar settings is not completely known so far. We describe here clinical, imaging, pathological and genetic findings of a family with four affected members; grandmother, his son and two grand-sons having a germline gain-of-function mutation of KIT in exon 13 and discuss the imatinib mesylate treatment surveillance outcomes towards disease management.

Ileostomy Site Cutaneous Metastasis of Colorectal Carcinoma without Visceral Involvement: An Unusual Case

Introduction: The development of cutaneous metastasis during the course of colorectal carcinoma occurs very rarely (4% of patients with rectal carcinoma) and indicates widespread disease. The abdominal wall and perineal area are frequently the sites of cutaneous metastasis. nCase presentation: A 64-year-old woman who received series of daily radiotherapy over 30 days in 1974 due to cervical carcinoma underwent surgery for stage IIA sigmoid colon adenocarcinoma in 1995. In 2001, she underwent abdominoperineal resection, total abdominal hysterectomy, bilateral salpingo-oophorectomy, and left-sided end colostomy for stage IIIC distal rectal tumor. In 2004, the colostomy site changed to the right lower abdominal quadrant due to unsuccessful parastomal hernia repair in 2003. In 2008, she underwent right hemicolectomy due to stage IIA cecal tumor with end ileostomy in the right lower quadrant. In 2015, she was hospitalized due to the development of a mass at the end ileostomy site; other organ involvement was not observed. The abdominal wall and segmental small bowel were resected and an end ileostomy in the left lower quadrant was performed. Her pathology report revealed middle dermal invasion of moderately differentiated mucinous adenocarcinoma at the ileocutaneous junction with clear margins. nConclusion: Isolated skin metastasis in colorectal cancer after primary surgery occurs rarely but it must be excluded during follow-up visits by careful examination.