Fahrettin Acar

Incisional hernia rate may increase after single-port cholecystectomy.

BACKGROUND The major concerns of single-port cholecystectomy are port-site hernia and cost. Essentially, a larger transumbilical incision is more likely to increase the incidence of incisional hernia. The effect of single-port cholecystectomy on hospital cost is controversial. This study evaluated single-port cholecystectomy and traditional four-port cholecystectomy with respect to perioperative outcomes, hospital cost, and postoperative complications. PATIENTS AND METHODS Between January 2010 and March 2011, 52 patients underwent single-port cholecystectomy, and 111 patients underwent traditional laparoscopic cholecystectomy. We used equal instruments in patients undergoing operation with the same surgical technique. Demographics, diagnosis, operative data, complications, length of hospital stay, and cost were compared between the two groups. RESULTS The patients undergoing laparoscopic cholecystectomy were significantly older than patients undergoing single-port cholecystectomy (55.8±13.8 years versus 48.7±12.7 years, P=.002). The trocar site hernia rate was 1.8% in laparoscopic cholecystectomy, and the port-site hernia rate was 5.8% in single-port cholecystectomy. This is the highest rate reported in the literature for port-site hernia following single-port cholecystectomy. Surgical techniques were not different in terms of conversion to open surgery, postoperative hospital stay, and operative time. The relative cost of single-port cholecystectomy versus laparoscopic cholecystectomy was 1.54. CONCLUSIONS Although single-port cholecystectomy seems to be a feasible surgical technique, it is not superior over the traditional laparoscopic cholecystectomy. Single-port cholecystectomy is equal to laparoscopic cholecystectomy with respect to conversion to open surgery, postoperative hospital stay, and operative time, but it is associated with high hospital cost and high port-site hernia rate.

Effect of laparoscopic cholecystectomy techniques on postoperative pain: a prospective randomized study.

Purpose Minimally invasive surgical technics have benefits such as decreased pain, reduced surgical trauma, and increased potential to perform as day case surgery, and cost benefit. The primary aim of this prospective, randomized, controlled study was to compare the effects of single incision laparoscopic cholecystectomy (SILC) and conventional laparoscopic cholecystectomy (CLC) procedures regarding postoperative pain. Methods Ninety adult patients undergoing elective laparoscopic cholecystectomy were included in the study. Patients were randomized to either SILC or CLC. Patient characteristics, postoperative abdominal and shoulder pain scores, rescue analgesic use, and intraoperative and early postoperative complications were recorded. Results A total of 83 patients completed the study. Patient characteristics, postoperative abdominal and shoulder pain scores and rescue analgesic requirement were similar between each group except with the lower abdominal pain score in CLC group at 30th minute (P = 0.04). Wound infection was seen in 1 patient in each group. Nausea occurred in 13 of 43 patients (30%) in the SILC group and 8 of 40 patients (20%) in the CLC group (P > 0.05). Despite ondansetron treatment, 6 patients in SILC group and 7 patients in CLC group vomited (P > 0.05). Conclusion In conclusion, in patients undergoing laparoscopic surgery, SILC or CLC techniques does not influence the postoperative pain and analgesic medication requirements. Our results also suggest that all laparoscopy patients suffer moderate and/or severe abdominal pain and nearly half of these patients also suffer from some form of shoulder pain.

Experiences of single incision cholecystectomy.

Purpose: Single incision laparoscopic surgery in suitable cases is preferred today because it results in less postoperative pain, a more rapid recovery period, more comfort, and a better cosmetic appearance from smaller incisions. This study aims to present our experiences with single incision laparoscopic cholecystectomy to evaluate the safety and feasibility of this procedure. Methods: A total of 150 patients who underwent single incision laparoscopic cholecystectomy between January 2009 and December 2011 were evaluated retrospectively. In this serial, two different access techniques were used for single incision laparoscopy. Results: Single incision laparoscopic cholecystectomy was performed successfully on 150 patients. Median operative time was 29 (minimum-maximum=5-66) minutes. Median duration of hospital stay was found to be 1.33 (minimum-maximum=1-8) days. Patients were controlled on the seventh postoperative day. Bilier complication was not seen in the early period. Five patients showed port site hernia complications. Other major complications were not seen in the 36-month follow-up period. Conclusion: Operation time of single incision laparoscopic cholecystectomy is significantly shortened with the learning curve. Single incision laparoscopic cholecystectomy seems a safe method.

Specimen index may be a predictive factor for recurrence after primary closure of pilonidal disease

Purpose The aim of the present study was to evaluate the predictive value of volume of the specimen/body mass index (VS/BMI) ratio for recurrence after surgical therapy of pilonidal disease. Methods Ninety-eight patients with primary pilonidal disease were enrolled in this study. The VS/BMI ratio was calculated for each patient. This ratio was defined as the specimen index (SI). VS, BMI and SI were evaluated to determine whether there is a relationship between these parameters and recurrence of pilonidal disease. In addition, the predictive ability of SI for recurrence was analyzed by receiver operating characteristic (ROC) curve. Results VS and SI were found to be higher in patients with recurrence. ROC curve analysis showed that VS and SI are predictive factors for recurrence in patients treated with primary closure, nevertheless our new index had higher sensitivity and specificity than VS (sensitivity 85.7% vs 71.4% and specificity 90.7% vs 85.1%, respectively). The cut-off level for the greatest sensitivity and specificity for SI was 1.29. Conclusion Recurrence is higher in patients with high VS regardless of the operation method. SI may be a predictive value in patients treated with primary closure.

Minimally invasive management of anastomotic leak after bariatric Roux-en-Y gastric bypass

The aim of this retrospective study was to examine the anastomotic erosion due to drain and success of fibrin sealant in its management. Between 2013 and 2014, 102 patients underwent LRYGB and gastrojejunal anastomotic leak occurred due to drain erosion in 2 of them. The diagnosis was established with saliva drainage and was confirmed by upper gastrointestinal series. The absence of hemodynamic instability was directed us to conservative treatment. During the endoscopy, dehiscence was assessed and fibrin sealant was applied. The leaks healed progressively in a few days, and the drains removed within 6 days. Seven and 9 days later, the patients were discharged without any problem. Anastomotic leaks after bariatric surgery can cause severe morbidity, cost, and effects quality of life. Hemodynamically stable and drained patients are candidates for conservative methods. Endoscopic injection of fibrin sealant has been successful in closing gastric leaks.

A gastrointestinal stromal tumor of the third portion of the duodenum treated by wedge resection: A case report

A 65-year old woman was admitted to our hospital with abdominal pain. Computed tomography showed a tumor measuring about 3 cm in diameter with no metastatic lesion or signs of local infiltration. Gastroduodenal endoscopy revealed the presence of a submucosal tumor in the third portion of the duodenum and biopsy revealed tumor cells stained positive for c-kit. These findings were consistent with gastrointestinal stromal tumors (GISTs) and we performed a wedge resection of the duodenum, sparing the pancreas. The postoperative course was uneventful and she was discharged on day 6. Surgical margins were negative. Histology revealed a GIST with a diameter of 3.2 cm and < 5 mitoses/50 high power fields, indicating a low risk of malignancy. Therefore, adjuvant therapy with imatinib was not initiated. Wedge resection with primary closure is a surgical procedure that can be used to treat low malignant potential neoplasms of the duodenum and avoid extensive surgery, with significant morbidity and possible mortality, such as pancreatoduodenectomy.

The effects of bariatric surgical procedures on the improvement of metabolic syndrome in morbidly obese patients: Comparison of laparoscopic sleeve gastrectomy versus laparoscopic Roux-en-Y gastric bypass

OBJECTIVE The objective of this study was to evaluate patients who underwent laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy in terms of weight loss, metabolic parameters, and postoperative complications. MATERIAL AND METHODS Data on patients who underwent laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy with a diagnosis of morbid obesity between January 2012 and June 2014 were retrospectively evaluated. Patients were compared in terms of age, sex, body mass index, duration of operation, American Society of Anesthesiologists score, perioperative complications, length of hospital stay, and long term follow-up results. RESULTS During the study period, 91 patients (45 laparoscopic Roux-en-Y gastric bypass and 46 laparoscopic sleeve gastrectomy) underwent bariatric surgery. There was no difference between the two groups in terms of preoperative patient characteristics. Both groups showed statistically significant weight loss and improvement in co-morbidities when compared with the preoperative period. Weight loss and improvement in metabolic parameters were similar in both groups. The duration of operation and hospital stay was longer in the laparoscopic Roux-en-Y gastric bypass group. Furthermore, the rate of total complications was significantly lower in the laparoscopic sleeve gastrectomy group. CONCLUSION Laparoscopic sleeve gastrectomy is a safe and effective method with a significantly lower complication rate and length of hospital stay than laparoscopic Roux-en-Y gastric bypass, with similar improvement rates in metabolic syndrome.

Reply to the Letter to the Editor on “A New Algorithm to Reduce the Incidence of Gastroesophageal Reflux Symptoms after Laparoscopic Sleeve Gastrectomy”

Thank you very much for your kind attention to our manuscript. This study does not constitute our first experience with this topic. We fully understand that gastroesophageal reflux disease (GERD) after laparoscopic sleeve gastrectomy is a serious complication of this surgical technique. Therefore, we developed a new algorithm to overcome this problem. In the literature, most reports of GERD are based on subjective observations. We aimed to evaluate the preoperative risk of GERD objectively and to highlight our methods of prevention. Insufficient dissection of retrogastric tissue and creation of a large sleeve pouch are not closely associated with GERD symptoms. Large sleeve gastrectomy is often related to weight regain and poor weight loss. Therefore, we do not need to explain the technical details of surgery. Many techniques for adjusting the final volume of the sleeve have already been described in the literature; some of these references were cited in our article. For this study, most of the bariatric operations were performed by a senior laparoscopic surgeon (H. Yilmaz) who has experience with over 500 laparoscopic sleeve gastrectomies, over 200 laparoscopic Roux-en-Y gastric bypasses, over 30 laparoscopic diverted sleeve gastrectomies with ileal transposition, over 20 laparoscopic pancreaticoduodenectomies, over 50 bariatric revisional surgeries, and over 500 single-incision laparoscopic surgeries of various types. Over the last 3 years, we have performed preoperative and postoperative gastric volumetric measurements for each patient using 3-D CT scans. These data are the subject of a separate ongoing study. The postoperative gastric volume of our patients is similar to that reported in the literature [1]. Some authors claim that the great majority of hiatal hernias are asymptomatic but that most of them can be detected during surgery. Therefore, these authors advocate the dissection of both diaphragmatic pillars to identify a missed hiatal hernia [2]. However, we think that the routine exploration of both pillars can be a possible cause of postoperative GERD, due to the division of the posterior ligaments of the gastroesophageal junction. Thus, we do not recommend the destruction of the ligaments around the abdominal esophagus (Fig. 1). In an attempt to avoid staple line leak, some surgeons inadvertently leave too much fundus during the operation. This phenomenon, called neofundus, was first described by Himpens et al. [3]. Residual fundus, or neofundus, is associated with the release of larger amounts of ghrelin, increased appetite of patients, and weight regain or insufficient weight loss after surgery. In our study group, only 4.9% of 402 patients required a revisional surgery due to weight regain or poor weight loss. Fundus dilation was detected in only three of these patients. Furthermore, we know that the embryonic rotation of the stomach creates a diverticulum on the posterior aspect of the stomach; we checked this area during resection and found no residual fundus. Because the stomach is extensible, we do not think that it is suitable to measure it with a tie. Insufficient tension on the tie can affect the measurements. At this point in the procedure, the experience and capability of the surgeon become more * Ilhan Ece ilhanece@yahoo.com

Comparison of mid-term clinical outcomes of laparoscopic partial cystectomy versus conventional partial cystectomy for the treatment of hepatic hydatid cyst

Background: The aim of this study was to compare the mid-term outcomes of open and laparoscopic partial cystectomy (LPC). Methods: The medical records of patients who underwent conventional partial cystectomy (CPC) and LPC for liver hydatid cyst from May 2010 to February 2015 were retrospectively reviewed. Operative time, blood loss, length of hospital stay, post-operative morbidity, mortality and mid-term follow-up outcomes were evaluated. Results: Amongst 130 patients, 38 patients were underwent LPC and 92 underwent CPC. Blood loss and post-operative complications were similar in both groups. The mean operative time in the LPC and the CPC groups was, respectively, 95.4 ± 13.1 and 63.5 ± 15.6 min, which showed a significant difference between the both groups. The mean length of hospital stay in CPC group was significantly longer when compared the LPC group. The mean diameter of cyst in LPC group was 6.1 ± 1.1 cm and 7.8 ± 2.1 cm in CPC group with a significant difference. The overall complication rates were 13.1% in LPC group and 17.3% in CPC group without significant difference. The most common complication was biliary leakage and surgical site infection. Conclusion: LPC for the surgical treatment of liver hydatid cyst appears to be safe and effective method with low morbidity rates in selected patients.

Extensive sacral hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic inflammation of apocrine sweat glands, and reduces the quality of life of patients and causes many morbidities. The patients often use various antibiotics, retinoids, and immunosuppressive drugs for many years before surgical intervention. The main purpose of surgical treatment is to provide an acceptable disease control and minimize the recurrence rate after surgery. Drainage or local excision methods have very high recurrence rates. In this case, we aimed to present the treatment of extensive sacral HS, with wide excision and bilateral V-Y advancement flap.