Kıvanç Derya Peker

An alternative view on the necessity of EGD before sleeve gastrectomy

BACKGROUND Esophagogastroduodenoscopy (EGD) is particularly recommended for choosing a surgical method to be used with asymptomatic patients and for the assessment of symptomatic patients prior to sleeve gastrectomy. The presence of hiatal hernia, for instance, is a relative contraindication. EGD is used for malignancy scanning as well as surgical planning, but seems inefficient in determining postoperative complications. OBJECTIVE Our aim was to investigate the effectiveness of the pathological evaluation of endoscopic biopsies obtained with esophagogastroduodenoscopy (EGD) according to Sydney classification prior to sleeve gastrectomy in identifying the risk of staple line leak, independently of clinical diagnosis. SETTING Bakırköy Dr. Sadi Konuk Training and Research Hospital, Department of General Surgery. METHODS Patients who underwent laparoscopic sleeve gastrectomy between January 2014-December 2016 received preoperative EGD as per the clinics protocol and upon obtaining ethics board approval and patient consent. Biopsies were taken from the patients according to the Sydney protocol. The pathology results were examined retrospectively by considering the exclusion criteria. The results were given in line with the Sydney classification, and patients with and without Staple Line Leak were statistically compared. RESULTS A total of 630 patients were enrolled in the study. Of these, 71.1% (n = 448) were female and 28.9% (n = 182) were male. Mean age was 38.9 years (17-68), mean body weight was 130.8kg (94-240) and body mass index (BMI) values were 47.4kg/m2 (36-106). In evaluation of median values, no statistically significant relationship was found between staple line leak and H. pylori occurrence grade (P = 0.438; P>0.05), activation grade (P = 0.568; P>0.05) or intestinal metaplasia grade (P = 0.319; P>0.05). Atrophy (P = 0.001; P<0.01) and chronic inflammation grade (P = 0.026; P<0.05) were significantly higher in Staple Line Leak patients. CONCLUSIONS EGD prior to sleeve gastrectomy and biopsies obtained in line with the Sydney protocol predict Staple Line Leak risk.

The Effect of Rabeprazole on LES Tone in Experimental Rat Model

ABSTRACT Introduction: Despite adequate treatment with proton pump inhibitors (PPIs), symptoms of gastroesophageal reflux disease (GERD) may remain persistent as well as Barretts esophagus may emerge. It may be proposed that the relaxant effect of PPIs on the smooth muscles may lead to resistance of symptoms. The aim of this study is to investigate effects of rabeprazole on the lower esophageal sphincter (LES) pressure with a rat model. Materials and Methods: Sixteen rats were grouped as control and treatment groups. After obtaining LES tissues followed by a 60 min equilibration period for stabilization, contractile response to carbachol was obtained by application of single dose of carbachol to have a final concentration of 10−6 M in the organ bath. After the contractions reached a plateau, concentration-response relationships for rabeprazole were obtained in a cumulative manner in the treatment group. Results: In the carbachol contracted LES preparations; 1.5 × 10−6 and 1.5×10−5 M of rabeprazole caused 6.08% and 11.34% relaxations respectively which were not statistically significant. However, mean integral relaxation value for 4.5 × 10−5 M of rabeprazole was 17.34% and this relaxation was significant compared with controls. Conclusions: In the present study, rabeprazole caused no direct significant change in LES tone in the therapeutic dose range applied to the organ bath. However, rabeprazole at the high dose caused a significant decrease in the LES tone.

Single center experience in laparoscopic treatment of gallbladder perforation

Introduction Gallbladder perforation (GBP) is a rare disease with potential mortality. Previous series have reported an incidence of approximately 2–11% and it still continues to be a significant problem for surgeons. Aim To present our clinical experience with gallbladder perforation. Material and methods The records of 2754 patients who received surgical treatment for cholelithiasis between 2010 and 2016 were reviewed retrospectively. One hundred thirty-three patients had gallbladder perforation. Age, gender, time from the onset of symptoms, diagnostic procedures, surgical treatment, morbidity and mortality rates were evaluated. Results 15.78% of patients had a body mass index > 35. 6.76% had chronic obstructive pulmonary disease, 6.76% had cardiac disease, 10.52% had diabetes and 4.51% had sepsis. American Society of Anesthesiology scores were I in 54.13%, II in 35.33%, III in 6.01% and IV in 4.51% of the patients. 27.81% of patients were diagnosed during surgery. The perforation site was the gallbladder fundus in 69.17%, body in 17.30%, Hartman’s pouch in 10.53% and cystic duct in 3% of patients. Treatment modalities were laparoscopic cholecystectomy in 82.71%, open cholecystectomy in 3%, percutaneous drainage catheters + laparoscopic cholecystectomy in 3%, laparoscopic cholecystectomy + fistula repair in 10.53% and open cholecystectomy + fistula repair in 0.75% of patients. Mean length of hospital stay was 1.69 days. Mortality and morbidity rates were 8.27% and 10.52%, respectively. Histopathology results were acute cholecystitis in 69.93%, chronic cholecystitis in 20.30% and acute exacerbation over chronic cholecystitis in 9.77% of patients. Conclusions Appropriate classification and management of perforated cholecystitis is essential. Laparoscopic cholecystectomy is a safe and feasible method to decrease morbidity in gallbladder perforations.

Preoperative immunonutrition regulates tumor infiltrative lymphocytes and increases tumor angiogenesis in gastric cancer patients

Introduction An increased number of tumor infiltrative lymphocytes (TILs) is considered a favorable prognostic factor in various cancers because it is a marker of antitumoral activity of the immune system. In this prospective, non-randomized clinical trial, we evaluated the impact of preoperative immunonutrition on tumor infiltrative lymphocytes and neoangiogenesis in cancerous tissue in patients with locoregional and resectable gastric adenocarcinoma. Material and methods Patients with locoregional and resectable gastric adenocarcinoma were divided non-randomly into two study groups. The first (control) group included patients who had standard nutrition, and the second group included those who had immunonutrition for 7 days before surgery. The biopsy samples taken endoscopically in the preoperative period, as well as the gastrectomy samples, were subjected to immunohistochemical staining for quantitative analysis of CD4, CD8, CD16, CD56, CD31 and CD105 antibodies. Main outcome measures were CD4-to-CD8 ratio and CD105 levels. Results Fifty patients were included in the study between January 2013 and December 2014. Twenty-five patients were assigned to each of the first and second group. The CD4-to-CD8 ratio and CD105 levels determined in endoscopic biopsy samples were similar in both groups. The CD4-to-CD8 ratio in gastrectomy samples was significantly higher in the first group (p = 0.0001). The CD105 levels in gastrectomy samples were significantly lower in the first group (p = 0.01). Conclusions Seven-day preoperative immunonutrition use regulates TILs in gastric cancer patients, but prolonged use increases tumor angiogenesis.

Midesophageal pulsion diverticulum: A case report -

Midesophageal pulsion diverticula are rare and asymptomatic clinical entities, which usually develop secondary to esophageal motor dysfunction. Diverticulectomy with myotomy is one of the surgical treatment options. In this case report, we present a patient with midesophageal pulsion diverticulum in whom we managed the postoperative leakage following excision of the diverticulum, by endoluminal esophageal stenting.

In Vitro Effects of Rabeprazole on Human Pylorus Tone

Background/Aims It has been reported that proton pump inhibitors induce relaxation in different types of smooth muscles. The aim of this study is to investigate in vitro effects of proton pump inhibitors on human pylorus muscle. Methods Pyloric sphincters were studied in 10 patients who were operated for stomach cancer. In isolated organ bath, control and response to rabeprazole were recorded following contraction with carbachol. During the treatment experiment, while distilled water was applied during the control experiment in every 5 minutes, rabeprazole was administered in every 5 minutes at doses of 10−6, 10−5, 10−4, and 10−3 M respectively. Contraction frequencies, maximum contraction values and muscle tones were measured. Results The contraction frequencies in the control group were greater than the rabeprazole group in the second, third and fourth intervals while the maximum contraction values in the rabeprazole group were lower in the fourth interval. Even though muscles tones were not different in both groups during all intervals, it was remarkable that the muscle tone was significantly decreased in the rabeprazole group during the fourth interval compared to the first and second intervals. Conclusions In the present study, high doses of rabeprazole reduced contraction frequencies, maximum contraction values, and muscle tone of human pylorus.