Ersin Gundogan

Risk factors for early postoperative morbidity and mortality in patients underwent radical surgery for gastric carcinoma: A single center experience

BACKGROUND Aim of this study is to analyze the incidence and risk factors for early postoperative morbidity and mortality that occur after gastric carcinoma surgery. MATERIALS AND METHODS All consecutive patients with gastric adenocarcinoma resected with curative intent between 2005 and 2011 were included to a retrospective analysis. Patient, disease and operation related parameters were questioned as risk factors for postoperative morbidity and mortality. RESULTS A total of 160 patients (103 [64.8%] male and the average age was 62.4 ± 11.5) were abstracted. Early postoperative morbidity, operation related morbidity and mortality were observed in 46 (28.7%), 31 (19.4%) and 19 (11.9%) cases, respectively. No other factors but ASA score was found to be a risk factor for overall morbidity (p = 0.021 and 0.033 in univariate and multivariate analyses, respectively). The incidence of anastomotic leak was increasing in patients who received a D2 dissection in univariate analysis (p = 0.039), but not in multivariate calculation. There were no factors effecting surgical site infection risk. Although univariate analysis revealed that age over 70 (p = 0.008), ASA score (p = 0.018), operation time (p = 0.032), D2 dissection (p = 0.026) and type of anastomosis (p = 0.023) were effecting the risk for early mortality, multivariate analysis showed that age was the only risk factor (p = 0.005). CONCLUSION Current study has revealed that early morbidity and mortality are not rare after gastric cancer surgery with curative intent. Since multivariate analyses have revealed that ASA score and older age may be only risk factors for postoperative morbidity and 30-day mortality, respectively; it may be logical to consider these factors during the preoperative decision making in patients with gastric cancer.

Management of Acute Sleeve Gastrectomy Leaks by Conversion to Roux-en-Y Gastric Bypass: a Small Case Series

Management of early sleeve gastrectomy leak remains challenging. The recommended approach is endoscopic stenting and abdominal drainage. Conversion to a Roux-en-Y gastric bypass (RYGB) is a common procedure used for late fistulas with distal obstruction. Here, we have presented three cases of early staple line leaks treated by conversion to RYGB. These patients had uncontrolled abdominal infections despite intensive medical treatments, and surgery was elected for abdominal drainage as well as to control the source of sepsis. All the patients were discharged without problems, and successful weight loss processes continued. Conversion to RYGB of a sleeve gastrectomy leak in an acute setting can be a feasible method in the case of inevitable surgical drainage for abdominal sepsis.

Does prophylactic antibiotic reduce surgical site infections after rhomboid excision and Limberg flap for pilonidal disease: a prospective randomized double blind study

Dear Editor: Pilonidal sinus disease is a common chronic disorder of the sacrococcygeal region. It is also referred to as pilonidal abscess, pilonidal cyst or sacrococcygeal fistula, inflammation, abscess, and sinus formation are commonly seen in this clinical entity. Pilonidal sinus is mostly very painful and typically occurs between the ages of 15 and 35 years in young adults with high incidence (26–700/100,000) and remains major obstacle for active working, since inability causes loss of working hours. Optimal surgical choice for pilonidal sinus disease is still an ongoing debate; there is nomutual consensus. Ideal therapy should be performed easily with minimal complication rates; also time to return to daily activities should be minimized. Previous literature describes two different types of surgical procedure; open and closed techniques. Excision of the sinus and repair with reconstructive flaps are the most frequent methods in our surgical clinic and also in our country. Early complications related to surgical site are main causes of recurrences and result in work delays. Skin macerations due to sutures and possible infections are most common causes of local wound dehiscence and recurrences. Although there is not conclusive evidence to show its benefit, prophylactic antibiotics are commonly administered in pilonidal sinus surgery. In this present study, we aimed to evaluate the effects of single-dose prophylactic antibiotic application on surgical site infections and early recurrences in the patient undergone rhomboid excision with Limberg transposition flap. Setting and patients All patients with pilonidal sinus who attended our outpatient clinic between January 2013 and July 2014were prospectively included. Participation in this study was completely voluntary. Patients were allowed to exit the study at any time without explanation. All patients were provided an informed consent form describing the study with sufficient information for them to make an informed decision about their participation in this study. Additionally, patients were informed in detail directly by the members of the study team. There were 148 consecutive outpatients assessed for eligibility; of these, 11 met the exclusion criteria and 13 refused to participate. One hundred twenty-four patients were randomized into two groups according to prophylactic antibiotic application (prophylaxis and non-prophylaxis groups). Randomization was made with a computer program (Research Randomizer Version 4.0). During the follow-up period, four patients were lost to follow-up evaluation and two patients were not motivated to continue their check-ups in prophylaxis arm. In the nonprophylaxis arm, one patient was lost at follow-up evaluation and one patient was not motivated to continue their check-ups.

Influence of Drain Placement on Postoperative Pain Following Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity: Randomized Controlled Trial

BackgroundThere is currently no evidence to support the routine use of an abdominal drain following laparoscopic Roux-en-Y gastric bypass (RYGB). Our aim was to investigate drain use in laparoscopic RYGB and its effects on postoperative pain.MethodsSixty-six patients were randomly divided into two groups as no-drain (n = 36) and with-drain (n = 30). Intraoperative (time, blood loss, complications) and postoperative outcomes (morbidities, pain scores, hospital stay) were compared.ResultsDemographics of both groups were comparable. Three patients in the no-drain group required a drain (8.3%). Median visual analog scale scores for days 1–3 for with-drain and no-drain groups were 4.5 (2–9) vs. 3 (0–8) (p = 0.02), 3 (0–7) vs. 2 (0–7) (p = 0.10), and 2 (0–7) vs. 0 (0–4) (p = 0.0004), respectively. There was no difference between the groups in terms of complications and length of hospital stay.ConclusionDrain use increased the postoperative pain following laparoscopic RYGB. Drain placement following laparoscopic RYGB should be selective instead of a routine application.

Randomized controlled trial of monopolar cautery versus clips for staple line bleeding control in Roux-en-Y gastric bypass

BACKGROUND Bleeding from the staple line is a rare but serious problem following bariatric surgery. Staple line bleeding control (SLBC) can be achieved in different ways such as the application of sutures, clips, glue or buttressing materials over the staple line. Cauterization alone is generally not preferred due to concerns about debilitating the staple line. OBJECTIVES The aim of this study was to compare the clip and monopolar cauterization methods for SLBC in laparoscopic Roux-en-Y gastric bypass. SETTING University hospital. METHODS A total of 70 morbidly obese patients were randomized into two groups. Patients with previous upper gastrointestinal surgery, re-do procedures and open surgeries were excluded. Their demographic characteristics, intraoperative and postoperative outcomes were examined. RESULTS A total of 489 SLBC interventions (274 clips and 215 cauterizations) were performed after 280 stapling applications. SLBC intervention number and location, additional trocar requirement, blood loss and operation time were not different between the groups. In the clip group, two patients required monopolar cauterization when clipping failed. No intraabdominal bleeding or gastrointestinal leakage was seen in any group. Postoperative gastrointestinal hemorrhage was seen in three patients, two in the clip group and one in the cautery group. There was no difference between the groups in terms of postoperative pain score, abdominal drainage amount, hemoglobin level alteration, morbidity or length of stay. CONCLUSIONS In laparoscopic Roux-en-Y gastric bypass, monopolar cauterization for SLBC can be used instead of clipping. It appears that monopolar cautery is a safe and effective approach for SLBC in laparoscopic Roux-en-Y gastric bypass.

Two cases of laparoscopic total colectomy with natural orifice specimen extraction and review of the literature

We present two cases of natural orifice specimen extraction (NOSE) after laparoscopic total colectomy and ileorectal anastomosis (TC-IRA), and we also review all of the previously reported cases. Our aim was to focus on patient selection for NOSE after TC-IRA. The PubMed and Google Scholar databases were scanned. Demographic features, surgical indications, and techniques were analyzed. Basic calculations were used for statistical analysis. A total of 13 cases were detected in addition to our 2 cases. All of the specimens were removed through the natural orifices successfully. No case required a diverting ileostomy. No patients were converted to open surgery or to conventional laparoscopy. Complications were reported in three patients. Transanal extractions were performed in 12 cases (10 colonic inertia, 2 polyposis), and transvaginal extractions were performed in 3 cases (2 malignancy, 1 colonic inertia). Both transanal and transvaginal specimen extractions after laparoscopic TC-IRA can be preferred. However, transanal extraction seems to be feasible in cases of TC for benign disease with a limited mesenteric-omental resection. If the indication is a malignancy requiring a mesenteric-omental resection, a transvaginal route should be preferred for a voluminous specimen.

Is partial omentectomy feasible at radical gastrectomy for advanced cancer

We read with interest the article “ Role of omentectomy as part of radical surgery for gastric cancer ” published by Jongerius et al . in the British Journal of Surgery (1). In that study, 100 total omentectomy specimens, all procured during gastric cancer surgeries, were examined histopathologically. Authors allocated the omentectomy specimens from the stomach along the distal margin of the gastroepiploic (GE) arcus. When these omentectomy specimen were examined histopathologically, the researchers found malignancies in five omentum samples that was a marker of an advanced disease. They concluded that the total removal of omentum was thought to have limited benefit to systemic disease. For this reason, routine application of total omentectomy was not suggested. We found the results of this study, which questioned the role of omentectomy during radical gastrectomy, encouraging and rational. However, in this study, the omentum was separated from the distal from the GE arcus. In order to supply the remaining omentum, either the right GE artery or the left GE artery needs to be intact ( Figure 1 ) (2).

Sclerosing Pilonidal Sinus Tracts by Crystallized or Liquid Phenol

Pilonidal disease is one of the most common surgical diseases and common health issues that cause substantial loss of hospital resources and working hours. Although a wide variety of approaches have been described to treat pilonidal disease, including conservative nonsurgical treatments, surgery is still the most commonly used method in the treatment of this disease. An ideal procedure for the treatment of pilonidal disease should provide shorter hospital stay with higher patient satisfaction, as well as low recurrence, morbidity, and cost. In this sense, the use of minimally invasive treatments such as phenol therapy as well as flap reconstructions is frequently on the agenda. Liquid phenol treatment instead of crystalized form because of its easier and safer application may be an attractive alternative in the treatment of limited pilonidal sinus disease thanks to low morbidity rate and short work-off period.

Transvaginal extraction of laparoscopic liver resection specimen

The application of laparoscopic surgery via the vagina has been introduced at the beginning of this millennium. Here, we report a case of transvaginal extraction of a laparoscopic hepatectomy specimen. An exophytic liver mass originated from segment VI in a 24-year-old female was excised with laparoscopic technique using four trocars (0.5–1.2 cm sizes). The specimen (11 × 8.5 cm) was removed transvaginally instead of an abdominal incision. To the best of our knowledge, only six similar cases have been previously reported, with a patient age range of 32–74 years. Our case, due to younger age, had high cosmetic expectations. Specific to this case, we aimed a better aesthetic outcomes and better convalescence period and, we achieved these objectives. We believe that patient selection and experience on natural orifice specimen extraction were the keys to the success of the operation. We shared this technique with a video presentation.

Filling Pilonidal Sinus Tracts with Sealant

To the Editor— We read the article titled “novel approach of treatment of Pilonidal sinus Disease with thrombin Gelatin matrix as a sealant” in Diseases of the Colon & Rectum by elbanna and coworkers with interest. they proposed filling the tracts with a sealant for the treatment of sacrococcygeal pilonidal disease, and they reached to 1-year 96% success rate. We have previously systematically reviewed the outcomes of fibrin sealant use in pilonidal sinus disease, and we wanted to comment on the study of elbanna and associates. 1. they reported that “fibrin glue injection therapy achieved satisfactory results, with recurrence rates ranging between 0% and 17% according to a recent review.” however, so far, there have been only 4 studies that filled the pilonidal sinus tracts with sealants, and their reported recurrence rates were 10%, 17%, 20%, and 26%. the studies with zero recurrences all included pilonidal sinus excisions, and sealant was used there as an adjuvant method, not for filling the tracts. to our best knowledge, there has been no study yet with a zero recurrence rate after sealant injections into the pilonidal sinus tracts. 2. this study declared the best recurrence rates (4%) ever reported after sealant filling into the pilonidal sinus tracts. What was the difference between the authors’ technique and the previous studies to achieve that highest success rate? 3. in our meta-analysis, the overall success rate of the 4 studies that related to the sealant filling into the pilonidal sinus tracts was 80%; in other words, the cumulative recurrence rate was 20%. When we added elbanna’s study to the meta-analysis (figure 1), the overall success rate increased to 85%, and this rate was similar to the other reported minimally invasive treatment methods (eg, phenol) for pilonidal disease. Because sealant is costly, the use of the sealant to fill the sinus tracts should not be advisable, because its success rate is not greater than that of more cost-effective minimally invasive methods.