Ilter Ozer

Surgical outcomes and survival after multiorgan resection for locally advanced gastric cancer

BACKGROUND Multiple organ resection for locally advanced (assumed T4) gastric cancer is associated with high morbidity and mortality. Our aim was to evaluate the efficacy of these surgeries with regard to surgical morbidity, mortality, and survival. METHODS Fifty-six patients underwent potentially radical gastrectomy combined with invaded organ resection. Early and late results of multiorgan resection and clinicopathologic factors influencing these results were evaluated. RESULTS Forty patients (71.4%) received 1 additional organ resection and 16 patients (28.6%) received 2 or more additional organ resections. Postoperative morbidity and mortality was 37.5% and 12.5%, respectively. Resection of 2 or more additional organs increased postoperative morbidity and advanced age increased mortality. The 1- and 3-year survival rates were 53.3% and 28.1%, respectively. Advanced age, lymph node metastasis, and resection of more than 1 additional organ were significant prognostic factors for survival. CONCLUSIONS For patients with locally advanced gastric carcinoma, multiple organ resection is worthwhile with careful patient selection.

A novel screening biomarker in gastric cancer: serum Dickkopf-1.

BACKGROUND/AIMS Despite all the knowledge about gastric cancer, there is no prognostic biomarker which could be useful for early detection. Dickkopf-1 (DKK-1), a secreted protein, is known as a negative regulator of the Wnt signaling pathway. DKK-1 is reported to be over expressed in many malignant tissues. The purpose of this study was to elucidate the normal level of serum DKK-1 (sDKK-1) levels in healthy Turkish peoples and to investigate the clinical utility of sDKK-1 levels for gastric cancer screening. METHODOLOGY Serum DKK-1 levels were measured in 69 healthy controls and in 60 gastric adenocarcinoma patients with ELISA and sDKK-1 levels were compared with clinicopathological features and outcomes in gastric cancer patients. RESULTS Serum concentrations of DKK-1 in gastric adeno cancer patients were significantly higher than control patients (p<0.001). The optimal cut-off for sDKK-1 levels order to discriminate control group from gastric cancer patients was 25U/mL with sensitivity equal to 100% and specificity equal to 100%. CONCLUSIONS Serum DKK-1 levels may be a potentially useful novel serologic marker for gastric cancers.

Predictive Factors for Conversion to Open Surgery in Patients Undergoing Elective Laparoscopic Cholecystectomy

BACKGROUND Laparoscopic cholecystectomy (LC) has become the standard surgical procedure for symptomatic gallbladder disease. The aim of this study was to identify factors that may be predictive of cases that would require a conversion to laparotomy. METHODS In the period of 2002-2007, 2015 patients who underwent elective LC were included in the study. Patients were divided into two groups. Group 1 (n = 1914) consisted of patients whose operation was successfully completed with LC. Group 2 (n = 101) consisted of patients who had a conversion. A prospective analysis of parameters, including patient demographics, laboratory values, radiologic data, and intraoperative findings, was performed. Multivariate stepwise logistic regression was used to determine those variables predicting conversion. RESULTS One-hundred and one (5.0%) patients required a conversion. Significant predictors of conversion to open cholecystectomy in univariate analysis were increasing age, male gender, previous upper abdominal or upper plus lower abdominal incisions, an elevated white blood cell count, high aspartate transaminase, alkaline phosphatase and total bilirubin levels, preoperative ultrasound findings of a thickened gallbladder wall and dilated common bile duct, preoperative endoscopic retrograde cholangiopancreatography (ERCP), high-grade adhesion, and scleroatrophic appearance of the gallbladder intraoperatively. Multivariate analysis revealed that a history of previous abdominal surgery, preoperative ERCP, high-grade adhesion, and scleroatrophic appearance of the gallbladder predicted conversion. CONCLUSIONS Patient selection is very important for efficient, safe training in LC. Based on the presented data, pathways could be suggested that enable the surgeon to precisely decide, during LC, when to convert to open surgery.

Long-term Results of Percutaneous Biliary Balloon Dilation Treatment for Benign Hepaticojejunostomy Strictures: Are Repeated Balloon Dilations Necessary?

PURPOSE To determine the safety, efficacy, and long-term results of percutaneous biliary balloon dilation (PBBD) of benign hepaticojejunostomy strictures and evaluate the necessity of repeated PBBD in this setting. MATERIALS AND METHODS PBBD was performed after traversing hepaticojejunostomy strictures in 89 patients (40 male, 49 female; age range, 19-84 y; mean age ± SD, 54.5 y ± 14.0), who were divided into three groups: group I (one satisfactory initial PBBD; n = 41), group II (two or more PBBDs with satisfactory initial PBBD; n = 33), and group III (two or more PBBDs without satisfactory PBBD; n = 15). Groups I and II were randomized. The primary outcome measure was the absence of clinical biliary obstruction symptoms at 24 months. Secondary outcome measures included technical and clinical success, primary and secondary patency, major complications, and mortality. Categoric variables were compared between groups I and II. RESULTS Procedure-related mortality and major morbidity rates were 0% and 5.6%, respectively. Mean primary and secondary patency durations were 45.3 months ± 2.2 and 71.3 months ± 15.4, respectively. The follow-up period was 36.4 months ± 15.1. The primary outcome measure was achieved in 73% of patients. Technical and clinical success rates (secondary outcome measures) were 97.8% and 84.3%, respectively. Repeated PBBD procedures were not satisfactory in 16.9% of patients. No significant differences in categoric variables were observed between groups I and II. CONCLUSIONS PBBD of benign hepaticojejunostomy strictures is a safe and effective procedure. Repeated PBBD is not required when the first procedure is successful.

Surgical Outcome of Patients with Perforation After Endoscopic Retrograde Cholangiopancreatography

BACKGROUND The most important criterion in the management of endoscopic retrograde cholangiopancreatography (ERCP)-related perforations is the delineation of the injury pattern. The aim of the present study was to evaluate in a retrospective manner the patients who undergo surgery due to ERCP-related perforations. PATIENTS AND METHODS Between January 2006 and December 2010, a total of 9209 ERCPs were performed at Turkiye Yuksek Ihtisas Teaching and Research Hospital, Ankara, Turkey. From these, perforation was diagnosed in 52 patients (0.56%). Twenty-four patients (46.2%) underwent surgery. Patients were evaluated according to age, gender, ERCP indication, comorbid disease, the time between diagnosis and perforation, the time between ERCP and surgical intervention, radiological and clinical signs, localization of the perforation, surgical procedure, hospitalization period, and postoperative outcome. RESULTS Twenty-four patients underwent surgery. Thirteen patients (54.1%) had lateral duodenal wall perforation, 4 patients (16.7%) had perforation in the afferent loop (these patients had Billroth-II gastroenterostomy at ERCP admission), 2 patients (8.3%) had bile duct perforation, and 1 patient (4.1%) had esophageal perforation. In 4 patients (16.7%), the localization of the perforation could not be found. Nine patients (37.5%) died in the postoperative period. Six patients had lateral duodenal wall perforation, 2 patients had afferent loop perforation, and one patient had esophagus perforation. Three patients died of nonsurgical reasons (myocardial infarction, serebrovascular occlusion, and cardiac dysrhythmia). CONCLUSIONS Duodenal wall perforations have a serious fatal outcome even if early surgical intervention is performed. In contrast to duodenal wall injuries, perivaterian and choledochal injuries have a better outcome.

Management of choledochal cysts in adults: a retrospective analysis of 23 patients.

BACKGROUND/AIMS Choledochal cysts are rare congenital anomalies of the pancreaticobiliary system, whose etiology remains unknown. We aimed to review patients with choledochal cysts and to compare our results with current literature. METHODOLOGY Twenty-three patients diagnosed as having choledochal cysts between January 2004 and July 2010 were evaluated retrospectively. RESULTS Thirteen patients had type I (56.5%), 3 patients type II (13%), 3 patients type III (13%), 1 patient type IV-A (8.3%) and the remaining 3 patients had type V (13%) choledochal cysts. All patients with type I cysts underwent cyst excision with Roux-en-Y hepaticojejunostomy. Two patients with type II cysts underwent cyst excision with choledochoduodenostomy, whereas cyst excision with T-tube drainage was applied to the other. Endoscopic unroofing was performed type III cysts. The patient with type IV-A cyst was not eligible for surgery due to low cardiopulmonary performance status but ERCP was applied successfully more than 3 times for the extraction of the stones which fell from the intrahepatic ducts into the common bile duct. Patients with Type V cysts underwent left hepatectomy, choledocoduodenostomy and cadaveric liver transplantation, respectively. Wound infection developed in 5 patients and anastomotic leakage occurred in 3; one died from sepsis. CONCLUSIONS Choledochal cysts are rare congenital malformations. Although treatment varies depending on the type of the cysts, complete excision of the cysts should be performed if possible.

Effects of previous abdominal surgery incision type on complications and conversion rate in laparoscopic cholecystectomy.

For laparoscopic cholecystectomy, previous abdominal operations are seen as a relative contraindication. The purpose of this study was to investigate the effects of the incision type of previous abdominal surgery on laparoscopic cholecystectomy in terms of complications and conversion to open surgery. Data from 677 patients who had previously undergone abdominal surgery before undergoing laparoscopic cholecystectomy were prospectively collected and evaluated. From the previous operations, the incisions were upper abdominal in 66 patients, lower abdominal in 567, and upper plus lower in 44. Conversion rates in the upper, lower and upper plus lower groups were 27.27%, 2.82%, and 25%, respectively. Intraoperative major complications were bile duct injury (1 patient, upper plus lower incision group), small bowel mesentery injury, and aortic injury (1 patient each, both in the lower incision group). Postoperative major intra-abdominal complications were duodenal injury (1 patient, upper incision group) and small intestine injury (1 patient, lower incision group). The lower abdominal incision group had fewer adhesions in the upper abdomen than did the other 2 groups, and as a result had a much lower conversion rate.

Carbondioxide Pneumoperitoneum Prevents Postoperative Adhesion Formation in a Rat Cecal Abrasion Model

PURPOSE We aimed to investigate the role of the carbon-dioxide (CO(2)) pneumoperitoneum on the prevention of postoperative adhesion formation. METHODS Thirty adult male Sprague-Dawley rats (250-350 g) were used for this study. The rats were randomly divided into three groups; in the sham group (n = 10) only, laparotomy was made, in group 2 (n = 10), a pneumoperitoneum was applied for a half-hour duration, followed by laparatomy, and in group 3 (n = 10), pneumoperitoenum time was 2 hours and after a pneumoperitoneum laparotomy was made. A cecal abrasion model was studied for making an adhesion formation. On day 14, all rats were sacrificed and adhesions were scored. Tissue samples from adhesions and peritonea and the cecum wall were examined, both pathologically and biochemically, for tissue hydroxyproline content. RESULTS There was a statistically significant difference between the control and pneumoperitoneum groups, regarding adhesion numbers and grades (P < 0.001). Cecal tissue hydroxypyroline content level was lower in group 1, and statistically significant differences were observed between groups 1, 2, and 3 regarding hydroxyproline content (P < 0.001). There was a statistically significant difference between the control and pneumoperitoneum groups regarding inflammation (P = 0.002). CONCLUSIONS Pretreatment with the CO(2) pneumoperitoneum had a prophylactic effect on postoperative adhesion formation in this study.

The effects of Pycnogenol® on colon anastomotic healing in rats given preoperative irradiation☆

Pycnogenol(®) has excellent radical scavenging properties and enhances the production of antioxidative enzymes which contributes to the anti-inflammatory effect of the extract. Irradiation delivered to the abdominal region, typically results in severe damage to the intestinal mucosa. The effects of ionizing radiation are mediated by the formation of free radicals through radiolysis. Irradiation has local effects on tissues. These local effects of irradiation on the bowel are believed to involve a two-stage process which includes both short and long term components. In our study we aimed to investigate the short term effects of Pycnogenol(®) on the healing of colon anastomoses in irradiated bowel. Sixty male Wistar-Albino rats were used in this study. There were three groups: Group I, control group (n = 20); group II which received preoperative irradiation (n = 20); group III which received per oral Pycnogenol(®) before irradiation (n = 20). Only segmeter colonic resection and anastomosis was performed to the control group (Group I). The other groups (Group II, III) underwent surgery on the 5th day after pelvic irradiation. On postoperative days 3 and 7, half of the rats in each group were sacrificed and then relaparotomy was performed. There was no statistical difference between groups with respect to biochemical parameters. Bursting pressure was significantly higher in the Control and Group III compared with the Group II. In conclusion, the present study showed that preoperative irradiation effect negatively on colonic anastomoses in rats by means of mechanical parameters and administration of Pycnogenol(®) preoperatively ameliorates this unfavorable effect.

Effects of Thyroid Hormone Supplementation on Anastomotic Healing After Segmental Colonic Resection

BACKGROUND Alterations of thyroid hormones in colorectal surgery were previously studied. The aim of the present study was to determine the effects of triiodothyronine (T3) supplementation on anastomotic healing after segmental colectomy. MATERIAL AND METHODS Thirty male Wistar albino rats were divided into sham (n = 6), control (n = 12), and experimental (n = 12) groups. Sham group rats were immediately sacrificed after segmental colonic resection. Control and experimental group rats underwent resection and anastomosis. Experimental group rats received a single dose of T3 (400 μg/100 g) in postoperative day 1. Half of both control and experimental group rats were sacrificed on postoperative d 3 and the remaining half were sacrificed on postoperative d 7. Hydroxiproline (HP), myeloperoxidase (MPO), thyroid stimulating hormone (TSH), free T3 (FT3), and free thyroxine (FT4) levels, bursting pressure, and histologic analyses of the anastomotic segments were compared. RESULTS FT3 levels significantly decreased in control groups rats compared with the sham group (P < 0.01). However, T3 hormone given rats had no decline in FT3 levels. Anastomotic bursting pressure was significantly higher in the experimental group rats on postoperative d 7 (P = 0.015). Histopathologic analyses of the anastomotic segments determined significantly more severe edema and necrosis in control group rats (P < 0.05). Collagen deposition in the anastomotic tissue was significantly higher in experimental group rats on postoperative d 7 (P = 0.015). CONCLUSION Anastomosis after colon resection is associated with decreased FT3 level. T3 supplementation ameliorates the reduction in FT3 and seems to provide constructive therapeutic effects on anastomotic healing.