Ismail Hamzaoglu

Single-Port Laparoscopic Sphincter-Saving Mesorectal Excision for Rectal Cancer: Report of the First 4 Human Cases

HYPOTHESIS Single-port laparoscopic rectal surgery can be performed using the principles of oncologic surgery in institutes experienced in laparoscopy with the advantages of minimally invasive surgery. DESIGN Sphincter-saving mesorectal excision in 4 human cases via a single laparoscopic port. SETTINGS A university hospital and a private hospital. PATIENTS A series of 4 patients who underwent single-port laparoscopic sphincter-saving rectal resection for rectal cancer. Two of them were total and 2 were partial mesorectal excisions. INTERVENTIONS An umbilical incision was made to place the multichannel single port. The sigmoid colon was hung to the left lateral abdominal wall using an intracorporeal stitch passing through its appendices epiploicae to achieve medial dissection and vascular ligation. The mesorectum was sharply dissected down to the pelvic floor. Endoscopic linear roticulating staplers were used to divide the rectum and proximal colon. A specimen was retrieved using an extraction bag through the umbilicus. Anastomosis was performed using a circular stapler, or pull-through hand-sewn anastomosis was performed. MAIN OUTCOME MEASURES Duration of the operation, length of hospital stay, surgical complications, wound size, and histopathologic data. RESULTS There were no perioperative or postoperative complications. Mean operative time was 347 minutes (range, 240-480 minutes). Mean hospital stay was 4.25 days (range, 4-5 days). Mean wound size was 3.5 cm (range, 3-4 cm). Mean number of harvested lymph nodes was 15 (range, 8-28). CONCLUSIONS With the help of sophisticated surgical technology and techniques, single-port laparoscopic surgery for rectal cancer will be feasible while also maintaining oncologic principles and patient safety.

Transumbilical totally laparoscopic single-port Nissen fundoplication: a new method of liver retraction: the Istanbul technique.

IntroductionMustafa Kemal Atatürk, founder of the Turkish Republic, had guarded many German scientists of a Jewish descent before the Second World War. Dr. Rudolf Nissen was one of the outstanding surgeons who had served in the Turkish university hospitals. He had created an antireflux procedure which is named after his own name while he was working in our clinic, the Cerrahpaşa Hospital. From a laparoscopic approach, the Nissen fundoplication was the gold standard intervention for the surgical treatment of gastroesophageal reflux disease (GERD). Currently, video laparoscopic surgery is evolving quickly with the guidance of new technology. Single-port (SP) laparoscopic transumbilical surgery is one of the newest branches of advanced laparoscopy.DiscussionSimple or complex manipulations may be performed with SP laparoscopic transumbilical surgery. The advantages, which are gained from conventional laparoscopy, can be invigorated by an SP laparoscopic approach. The retraction technique of the liver and the optical system were the most important factors, which made the Nissen fundoplication possible via single port. Here, we report that totally laparoscopic transumbilical SP Nissen fundoplication procedure was performed in three patients for sliding hiatal hernia with GERD.ConclusionTotally laparoscopic transumbilical SP Nissen fundoplication is a safe and feasible technique for the surgical treatment of GERD.

What have we gained by performing robotic rectal resection? Evaluation of 64 consecutive patients who underwent laparoscopic or robotic low anterior resection for rectal adenocarcinoma.

Background: Robotic surgery is thought to be a solution to overcome the limitations of laparoscopy in sphincter-saving resections. In this study, we present our results on patients undergoing robotic and laparoscopic low anterior resection (LAR) consecutively for rectal adenocarcinoma. Materials and Methods: Between February 2008 and June 2011, consecutive patients who underwent laparoscopic or robotic LAR by a single surgical team for rectal cancer were evaluated. The patients’ demographic, operative, postoperative short-term follow-up, and histopathologic data were analyzed. Results: Twenty-seven patients underwent robotic LAR, whereas 37 patients underwent laparoscopic LAR. The operation time of the laparoscopy group was significantly shorter than that of the robotic group (P=0.02). The complete total mesorectal excision rate was significantly higher in the robotic group (P=0.02). The overall complication rates were 11.11% and 21.62% in the robotic and laparoscopy groups, respectively (P=0.45). Conclusions: Good quality of resected specimens could be achieved with robotic LAR. Further prospective studies including long-term oncologic outcomes and costs with higher patient number are definitely needed to assess the benefits of robotic resection in rectal cancer treatment.

Impact of Increased Body Mass Index on Laparoscopic Surgery for Rectal Cancer

Background: Laparoscopy was initially considered to be a risky procedure for rectal cancer patients, especially patients with an increased body weight. The literature is scarce regarding the effects of obesity on laparoscopic rectal surgery. The aim of the current study was to analyze the effect of an increased body mass index (BMI) on outcome of laparoscopic surgery for rectal cancer. Methods: Patients who underwent laparoscopic rectal resection were allocated to one of three groups according to their BMI: normal weight (BMI < 25), overweight (25 ≤ BMI < 30) and obese (BMI ≧ 30). These three groups were compared with each other in terms of patient demographics, postoperative hospital stay, postoperative complications and histopathological data. Results: There were 100 patients operated on for rectal cancer. The median BMI of the patients was 27 (range 18.5–40) kg/m2, and 43, 43 and 14 patients were classified as normal weight, overweight and obese, respectively. The conversion rate was 4.7% in the overweight group and 0% in the other groups. The proportion of complications and oncological outcomes between the groups showed no significant difference (p > 0.05). Conclusions: Apparently, increased BMI is not a contraindication for laparoscopic rectal surgery.

Enteroclysis-guided laparoscopic adhesiolysis in recurrent adhesive small bowel obstructions.

The aim of this study was to point out the efficiency of enteroclysis assay in localization of intraabdominal adhesions that impede small bowel transit in patients with recurrent adhesive small bowel obstruction who underwent laparoscopic partial adhesiolysis. Between January 1998 and June 2001, 15 selected patients with recurrent adhesive small bowel obstructions were treated successfully by medical means and evaluated with enteroclysis to define the pathologic adhesive site that impeded bowel transit. If the results of enteroclysis were indicative, they underwent laparoscopic partial adhesiolysis. The mean duration of the laparoscopic procedure was 99 minutes. In one patient conversion to laparotomy occurred because of excessive adhesions, and in another patient a small bowel injury occurred and enterorrhaphy was performed laparoscopically. Mean postoperative hospital stay was 4 days. During a mean follow-up of 17.2 months (range, 6–39), there was no delayed morbidity or recurrence. Identification of the small bowel site of recurrent obstruction with enteroclysis permits limited laparoscopic adhesiolysis. This approach may be a rational alternative to not only open procedures but also complete laparoscopic adhesiolysis without enteroclysis.

Effect of corticosteroid dose and duration of administration on colonic anastomosis.

Background: Surgical intervention under concomitant steroid therapy can be complicated by impaired anastomotic healing. The aim of this experimental study was to investigate the effects of a corticosteroid (methylprednisolone) on healing colonic anastomoses in relation to the dose and duration of administration. Methods: Fifty male Spraque–Dawley rats weighing 200–220 g were divided into five groups each containing 10 rats. No treatment was given in the control group. Group HDST: high‐dose methylprednisolone (1 mg/kg/day, intramuscular) treatment for a short term of 2 days; group HDLT: high‐dose methylprednisolone treatment for a long term of 60 days; group LDST: low‐dose methylprednisolone (0.28 mg/kg/day) treatment for a short term of 2 days; and group LDLT: low‐dose methylprednisolone treatment for a long term of 60 days. Standard left colonic anastomosis was performed in all rats. Anastomotic bursting pressure, hydroxyproline measurement, and histopathological data were evaluated in all groups on postoperative day 4. Results: The mean anastomotic bursting pressure value was significantly lower in the HDLT group (P < 0.05). The mean hydroxyproline levels were significantly lower in all groups (P < 0.05). Histopathological results demonstrated significant changes according to neutrophil infiltration, granulation tissue formation, presence of vascularization, and peritonitis in the HDLT, LDST, and LDLT groups (P < 0.05). Conclusions: High and low doses of the corticosteroid produced adverse effects on the healing of colon anastomosis in rats regardless of whether it was administered over a long or short preoperative period. However, the most prominent negative effect was associated with high‐dose, long‐term corticosteroid administration. (Inflamm Bowel Dis 2010)

Icodextrin and Seprafilm do not interfere with colonic anastomosis in rats.

Background: Physical barriers and instilled solutions have been studied to prevent intra-abdominal adhesions. However, undesirable side effects of these substances on the healing of intestinal anastomoses may limit their use. This study was designed to compare the effects of antiadhesives on the healing of colonic anastomosis in rats. Methods: Sixty female Sprague-Dawley rats were divided into 3 groups of 20. The animals received isotonic saline and 7.5% icodextrin, intraperitoneally after standard left colonic anastomosis. In group 3, Seprafilm® was wrapped around the anastomosis and also laid over the abdominal viscera. Half of the animals from each group were killed on postoperative day (POD) 4 and the remaining half on POD 21. Adhesion scoring, bursting pressure and tissue hydroxyproline measurements and histopathological assessment were performed. Results: Mean hydroxyproline levels were significantly higher in groups receiving icodextrin and Seprafilm compared with the control group, whereas mean bursting pressures were significantly higher in the group that received icodextrin (p < 0.05). Intraperitoneal administration of icodextrin resulted in significant reduction of adhesion formation on POD 21 (p < 0.05). Conclusions: Seprafilm does not prevent formation of adhesions as much as icodextrin does, but its effect on the healing of colonic anastomoses is similar.

Association between bactericidal/permeability increasing protein (BPI) gene polymorphism (Lys216Glu) and inflammatory bowel disease

BACKGROUND Increasing evidence suggests that innate immune system may have a key role in the pathogenesis of the inflammatory bowel disease (IBD). Bactericidal/permeability increasing protein (BPI) has an important role in the recognition and neutralization of gram-negative bacteria by host innate immune system. The polymorphism on BPI gene called Lys216Glu is on the suspected list of IBD pathogenesis. METHODS We studied the Lys216Glu polymorphism on BPI gene, in a Turkish IBD patient population. A total of 238 IBD patients; 116 Crohns disease (CD) and 122 ulcerative colitis (UC), besides 197 healthy controls were included in this study. RESULTS The Glu/Glu genotype and allele frequencies were found to be statistically higher compared to healthy control group not only in CD patients [P: 0.03, OR: 1.87 (CI 95% 1.02-3.42) and P: 0.00001 (OR: 2.07 CI 95% 1.47-2.91) respectively] but also in UC patients [P: 0.0002, OR: 2.71 (CI 95% 1.53-4.80) and P: 0.00002 (OR: 2.71 CI 95% 1.53-4.80) respectively]. CONCLUSIONS BPI polymorphism (Lys216Glu) is associated both to CD and UC. Our findings differ from the two Western European studies; one without any association and the other indicating an association only with CD. Our study is the first one reporting a novel association between BPI gene mutation (Lys216Glu) and UC.

Does Becaplermin (Platelet-Derived Growth Factor-BB) Reverse Detrimental Effects of Ischemia on Colonic Anastomosis?

AbstractPURPOSE: The aim of this study was to evaluate the effects of becaplermin on normal and ischemic colon anastomoses. METHODS: Forty adult male Wistar-Albino rats were divided into four equal groups of ten. All rats underwent standard left colon resection and end-to-end anastomosis. The groups were as follows: Group 1, normal anastomosis alone; Group 2, ischemic anastomosis alone; Group 3, normal anastomosis and becaplermin therapy; and Group 4, ischemic anastomosis and becaplermin therapy. All animals were killed on postoperative Day 4. Intra-abdominal adhesions were scored, and anastomotic healing was evaluated with both in situ bursting pressure and hydroxyproline levels. RESULTS: According to bursting pressure results, there was a significant difference between Group 2 and Group 4 (P < 0.05), but there was no statistically significant difference between Group 1 and Group 3 (P > 0.05). Hydroxyproline values revealed no statistically significant difference among any of the groups (P > 0.05). With regard to intra-abdominal adhesion scores, Group 3 had significantly lower values than Group 2 and Group 4 (P < 0.05). No statistically significant difference was observed between the other groups. CONCLUSIONS: Detrimental effects of ischemia on colonic anastomotic healing were reversed with becaplermin therapy. However, there was no such benefit on nonischemic anastomoses. Intra-abdominal application of this gel did not lead to an increase in intra-abdominal adhesion formation.

CASE REPORT: Cytomegalovirus Infection of Gastrointestinal Tract with Multiple Ulcers and Strictures, Causing Obstruction in a Patient with Common Variable Immunodeficiency Syndrome

Common variable immunodeficiency (CVID) is a heterogeneous disorder characterized by panhypogammaglobulinemia (especially decreased production of IgG but frequently also IgA and IgM, recurrent bacterial infections, and different gastrointestinal appearances), especially inflammatory bowel disease and granulomatous enteropathy, and increased incidence of malignant and autoimmune disease. A small subpopulation of these patients has reduced numbers of circulating B lymphocytes, suggesting a central failure of the development of this cell line (1–3). In 80–90% of the patients there are normal numbers of B lymphocytes, with immature phenotype, because these cells fail to differentiate into immunoglobulin-secreting plasma cells (4). Most patients with this disorder appear to have an intrinsic B-cell defect. Consistent with the evidence that B lymphocytes are able to recognize the antigens and proliferate but fail to differentiate to plasma cells is the fairly common finding of lymphoid hyperplasia, including splenomegaly and nodular hyperplasia of the gut. In some patients, an increase in T-suppressor activity, quantitative deficiency of helper T cells, and production of abnormal immunoglobulins, which are degraded in cytoplasm, have been observed. Two thirds of patients with common variable immunodeficiency have a normal CD4/CD8 ratio, one third has increased relative and absolute numbers of CD3 and CD8 peripheral blood lymphocytes, resulting in a decreased CD4/CD8 ratio. Less than 10% of the patients with normal ratios and 40% with a decreased ratio are anergic, and 30% of the patients with normal ratios and 70% with decreased ratios have splenomegaly (5). Most of the CD8 T cells expressed the CD57 antigen and activation antigens (HLA-DR) (6). Cytomegalovirus (CMV) is a member of the herpesvirus group and causes a wide spectrum of disorders, ranging from an asymptomatic, subclinical infection to a mononucleosis syndrome in healthy individuals to disseminated disease in the immunocompromised host (7). CMV contains doublestranded DNA, a protein capsid, and a lipoprotein envelope and replicates in the cell nucleus. Virus replication is associated with the production of large intranuclear inclusions and smaller cytoplasmic inclusions. Once infected, an individual probably carries the virus for life. Most commonly these infections remain latent. However, with compromise of Tlymphocyte-mediated immunity, CMV reactivation syndromes frequently develop (8). These cells in vivo Manuscript received April 10, 1999; accepted January 31, 2000. From the Internal Medicine Department, Gastroenterology Department, General Surgery Department, Department of Pathology, and Infectious Diseases Department, Cerrahpasa Medical Faculty, University of Istanbul; and Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Pittsburgh, Pennsylvania. Address for reprint requests: Dr. Veysel Tahan, Cerrahpasa Medical Faculty, Internal Medicine Department, 34303 Aksaray, Istanbul, Turkey. Digestive Diseases and Sciences, Vol. 45, No. 9 (September 2000), pp. 1781–1785