Erdal Göçmen

Receiver operating characteristic analysis of leukocyte counts in operations for suspected appendicitis.

STUDY OBJECTIVE There has been no clear-cut value of the white blood cell (WBC) count in differential diagnosis of acute appendicitis in emergency medicine. Therefore, the aim of this study was to assess the preoperative WBC counts in 3 groups of patients operated on for a clinical suspicion of acute appendicitis with different findings at appendectomy: uninflamed appendix, uncomplicated acute appendicitis, or complicated acute appendicitis. METHODS The medical records of 540 patients who underwent appendectomy for suspected acute appendicitis during a 17-month period were retrospectively reviewed. Data for 3 groups of patients were analyzed to calculate the sensitivity and specificity of the WBC count in the diagnosis of acute appendicitis, and we calculated likelihood ratios for 2 cut-points with either high sensitivity or high specificity. Receiver operating characteristic curves were used to evaluate the WBC count in relation to the true diagnosis and severity of acute appendicitis. RESULTS We were able to identify patients with appendicitis on a statistically significant level using receiver operating characteristic curves of WBC counts (area under the curve = 0.756, P < .001), but the WBC count had no diagnostic value in differentiating between uncomplicated and complicated groups (area under the curve = 0.55, P = .086). Likelihood ratio ranged from 1.79 (95% confidence interval, 1.17-2.3) for WBC count of more than 10,500 cells/mm(3) to 3.20 (95% confidence interval, 2.72-3.24) for WBC count of more than 14,300 cells/mm(3). CONCLUSION White blood cell count is helpful in the diagnosis and exclusion of appendicitis. However, there is no value to differentiate advanced appendicitis.

Can biliary-cyst communication be predicted before surgery for hepatic hydatid disease: does size matter?

BACKGROUND The aim of this study was to determine if there is any predictive factor indicating the risk of bile leakage before surgery for hepatic hydatid disease in clinically asymptomatic patients. METHODS The data of 116 patients who underwent surgery for hepatic hydatid disease were reviewed retrospectively. There were 43 men (37%) and 73 women (63%) with a mean age of 45 +/- 15 years. Because of high preoperative serum bilirubin and liver function test levels, 12 patients were excluded from the study. These patients underwent preoperative endoscopic retrograde cholangiopancreatography. In addition, 2 medically treated patients were excluded from the study. The following variables were analyzed as potential predictors of biliary-cyst communication: age, sex, physical examination findings, leukocyte count, liver function test results, and ultrasonographic cyst features (type, diameter, number, and localization). RESULTS Bile leakage was detected in 24 out of 102 patients. There were no differences in age, sex, cyst type, alkaline phosphatase level, gamma-glutamyl transpeptidase level, alanine aminotransferase level, aspartate aminotransferase level, bilirubin level, and number of cysts and cyst locations between the patients with and without bile leakage. The mean cyst size in patients with biliary leakage was 10.2 cm as compared with 6.1 cm in patients with no biliary leakage (P < .05). When the cut-off value of cyst diameter was accepted as 7.5 cm, the specificity and sensitivity for biliary-cyst communication were 73% and 79%, respectively. CONCLUSIONS These data suggest that cyst diameter is an independent factor that is associated with a high risk of biliary-cyst communication in clinically asymptomatic patients. Preoperative endoscopic retrograde cholangiopancreatography should be performed in these asymptomatic patients to reduce the incidence of postoperative complications.

Randomized, prospective comparison of postoperative pain in low- versus high-pressure pneumoperitoneum

Background:  Reduced postoperative pain after laparoscopic cholecystectomy (LC) compared to open cholecystectomy (OC) may be able to be further optimized. To reduce pain, focus should be directed on the effects of individual components of pain.

Evaluation of P-POSSUM and CR-POSSUM Scores in Patients with Colorectal Cancer Undergoing Resection

IntroductionThe aim of this study was to evaluate the predictive accuracy of P-POSSUM and CR-POSSUM models on patients undergoing colorectal resection.MethodsP-POSSUM and CR-POSSUM predictor equations for mortality were applied retrospectively to 321 patients who had undergone colorectal resection for cancer. P-POSSUM and CR-POSSUM scores were validated by assessing their calibration and discrimination. Calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test and the corresponding calibration curves. Evaluation of the discriminative capability of both models was performed using receiver-operating characteristic (ROC) curve analysis.ResultsOverall, 22 deaths were observed. CR-POSSUM predicted 25 deaths (χ2 = 12.20, P = 0.13), and P-POSSUM predicted 29 deaths (χ2 =18.85, P = 0.002). ROC curves analysis revealed that CR-POSSUM has reasonable discriminatory power for mortality.ConclusionsThese data suggest that CR-POSSUM may provide a better estimate of the risk of mortality for patients who undergoing colorectal resection.

Risk factors for surgical site infection after gastrectomy with D2 lymphadenectomy.

Surgical site infection (SSI) is a potentially morbid and costly complication of surgery. We conducted this study to establish the preoperative and operative factors predisposing to SSI after gastric resection and D2 lymphadenectomy. Data on all patients undergoing gastrectomy and D2 lymphadenectomy within a 2-year period, at a tertiary reference hospital in Turkey, were collected retrospectively. The outcome of interest was a diagnosis of incisional SSI as defined by the Centers for Disease Control and Prevention. Multivariate analysis by stepwise logistic regression was then performed on those variables associated with incisional SSI. We identified 72 patients with SSI after gastrectomy and D2 lymphadenectomy. The median age of the patients was 61 years (range 31–81 years) and 43 were men. Incisional SSI was diagnosed in 15 (20.8%) patients. Of all the preoperative and operative variables measured, an increased patient body mass index was an independent predictor of incisional SSI. An increased incidence of SSI was found in overweight patients, but these infections were transient and not life threatening.

External validation of prognostic models among cancer patients undergoing emergency colorectal surgery

BACKGROUND The aim of this study was to evaluate the predictive accuracy of different scoring systems on patients undergoing emergency colorectal surgery. METHODS The Acute Physiology and Chronic Health Evaluation II or III, the Simplified Acute Physiology Score II, the Mortality Probability Model II, and the Colo-rectal POSSUM scoring systems were applied to 102 patients who underwent colorectal resection for cancer. Validation of scoring systems was tested by assessing calibration and discrimination. Calibration was assessed using Hosmer-Lemeshow goodness-of-fit test and the corresponding calibration curves. Evaluation of the discriminative capability of both models was performed using receiver-operating characteristic curve analysis. RESULTS Overall, 17 deaths occurred. The Simplified Acute Physiology Score II showed good calibration (x(2) = 1.079, P = .982) and discrimination (areas under the receiver-operating characteristic curve .83). CONCLUSIONS These data suggest that the SAPS II scoring system was accurate in predicting outcome for patients undergoing emergency colorectal surgery.

Neurofuzzy is Useful Aid in Diagnosing Acute Appendicitis

In their recent article in World Journal of Surgery, Prabhudesai and colleagues [1] suggest that the artificial neural networks (ANNs) can be an effective tool for accurately diagnosing appendicitis and may reduce unnecessary appendectomies. We agree with the authors. Nevertheless, ANNs are not without problems. They can be ‘‘overtrained’’ to learn the inherent variation of a sample population and are nonrobust. They do not generalize across the specific problem range of variables for either interpolation or extrapolation. More important than these factors, the network is hidden within a functional ‘‘black box.’’ Thus, it is difficult to gain insight into the model obtained from the data and to ensure that clinical and statistical sense prevails. As a result, statisticians are reluctant to believe in the validity of ANNs. In addition, the weights attached to different variables are uninterpretable, making the interrogation of new variables difficult [2]. Fuzzy logic is the science of reasoning, thinking, and inference, which recognizes and uses the real-world phenomenon that everything is a matter of degree. In the simplest terms, fuzzy-logic theory is an extension of binary theory that does not use crisp definitions and distinctions. Instead of assuming that everything must be defined in black and white (binary view), fuzzy logic is a method that captures and uses the concept of fuzziness in a computationally effective manner. Neural networks and fuzzy logic are two complementary technologies. Neural networks can learn (i.e., adapt) from data and feedback, but understanding the pattern learned by neural networks is difficult. Conversely, fuzzy-rulebased models are easy to comprehend because they use linguistic terms and the structure of if–then rules. Unlike neural networks, fuzzy logic does not come with a learning algorithm (i.e., the system cannot learn from feedback). The combination of neural networks and fuzzy logic has created a new term, a ‘‘neurofuzzy system.’’ Neural networks, fuzzy systems, and the combination of the two have already been successfully applied to computer-aided diagnosis [3]. In conclusion, neurofuzzy systems can incorporate data from many clinical, radiologic, and laboratory variables to provide better diagnostic accuracy in acute appendicitis.

External metallic circle in hepaticojejunostomy

BackgroundBiliary-enteric anastomosis especially Roux-en Y hepaticojejunostomy is frequently used for biliary diversion in benign biliary strictures. In this study, we present the results of hepaticojejunostomy with external metallic circle.MethodsHepaticojejunostomy with external metallic circle were performed in eight male Sprague-Dawley rats. At the end of the third month, anastomoses were analysed for patency and stability of external circles.ResultsRelaparotomy revealed that all the anastomoses were patent and circles were in original places.ConclusionTo provide the patency of narrow hepaticojejunostomy anastomoses, external metallic circle can be a good alternative to use of internal stents in suitable cases.