Mehmet Ali Yagci

Transvaginal appendectomy: a systematic review.

Background. Natural orifice transluminal endoscopic surgery (NOTES) is a new approach that allows minimal invasive surgery through the mouth, anus, or vagina. Objective. To summarize the recent clinical appraisal, feasibility, complications, and limitations of transvaginal appendectomy for humans and outline the techniques. Data Sources. PubMed/MEDLINE, Cochrane, Google-Scholar, EBSCO, clinicaltrials.gov and congress abstracts, were searched. Study Selection. All related reports were included, irrespective of age, region, race, obesity, comorbidities or history of previous surgery. No restrictions were made in terms of language, country or journal. Main Outcome Measures. Patient selection criteria, surgical techniques, and results. Results. There were total 112 transvaginal appendectomies. All the selected patients had uncomplicated appendicitis and there were no morbidly obese patients. There was no standard surgical technique for transvaginal appendectomy. Mean operating time was 53.3 minutes (25–130 minutes). Conversion and complication rates were 3.6% and 8.2%, respectively. Mean length of hospital stay was 1.9 days. Limitations. There are a limited number of comparative studies and an absence of randomized studies. Conclusions. For now, nonmorbidly obese females with noncomplicated appendicitis can be a candidate for transvaginal appendectomy. It may decrease postoperative pain and enable the return to normal life and work off time. More comparative studies including subgroups are necessary.

Influence of Liver Transplantation on Neuropsychiatric Manifestations of Wilson Disease.

OBJECTIVES This study sought to evaluate the effect of liver transplantation on the neuropsychological manifestations of Wilson disease. MATERIALS AND METHODS Nine of 42 Wilson disease patients had neuropsychological symptoms before liver transplantation. They were 7 male and 2 female subjects with a median age of 19 years (range 10 to 25). They were analyzed for their preoperative and postoperative hepatic, neurological, and psychological scores described by the Unified Wilson Disease Rating Scale after a mean 36.6 months of follow-up. RESULTS Preoperative mean Model for End-Stage Liver Disease and Child-Pugh scores were 18.3 (range 15 to 26) and 8.9 (range 6 to 12), respectively. One patient had acute postoperative ischemic stroke unrelated to Wilson disease and was excluded from the statistical analysis. Preoperative and postoperative hepatic, neurological, and psychological scores of the remaining 8 patients were 7.4 ± 2.3 vs 2.4 ± 1.3 (P = .0005), 17.7 ± 11.7 vs 12.7 ± 12.5 (P = .055), and 9.0 ± 1.7 vs 7.0 ± 2.1 (P = .033). CONCLUSIONS Liver transplantation for Wilson disease can provide some improvement of the neuropsychological symptoms in addition to the hepatic recovery.

Living Donor Liver Transplantation With Vena Cava Replacement

OBJECTIVES This study sought to evaluate the indications, techniques, and results of inferior vena cava (IVC) replacement at living donor liver transplantation (LDLT). MATERIALS AND METHODS We performed 821 LDLTs and 11 (1.3%) patients required concomitant IVC replacement. We analyzed the indications, replacement materials, and outcomes. RESULTS Right, left, and left lateral liver lobes were transplanted in 7, 2, and 2 patients, respectively. The indications for IVC replacement were thrombosis/fibrosis in 7 patients (Budd-Chiari 4, hereditary tyrosinemia 1, congenital hepatic fibrosis 1, cryptogenic 1), involvement with mass in 3 patients (Echinococcus alveolaris 2, hepatoblastoma 1) and iatrogenic narrowing at IVC in 1 patient. Cryopreserved grafts (aorta n = 5, IVC n = 4, iliac vein n = 1) or synthetic graft (n = 1) were used for replacements. In 1 patient, hepatic outflow obstruction developed at 39 days and was treated successfully by interventional radiology. There was only 1 hospital mortality (8.9%) that was unrelated to caval replacement (subarachnoid hemorrhage). Of the remaining patients, the caval grafts were patent after a mean 7.7 months of follow-up (range 1 to 17 months). CONCLUSIONS Although rare, IVC replacement can be necessary at LDLT. Budd-Chiari and E. alveolaris are the main underlying diseases for replacement requirements. Caval replacement with cryopreserved vascular grafts can provide successful short-term and long-term patency.

Portosystemic Shunt Surgery in Patients with Idiopathic Noncirrhotic Portal Hypertension.

BACKGROUND Idiopathic noncirrhotic portal hypertension (INCPH) is a rare disease characterized by increased portal venous pressure in the absence of cirrhosis and other causes of liver diseases. The aim of the present study was to present our results in using portosystemic shunt surgery in patients with INCPH. MATERIAL AND METHODS Patients who had been referred to our Liver Transplantation Institute for liver transplantation and who had undergone surgery from January 2010 to December 2015 were retrospectively analyzed. Patients with INCPH who had undergone portosystemic shunt procedure were included in the study. Age, sex, symptoms and findings, type of portosystemic shunt, and postoperative complications were assessed. RESULTS A total of 1307 patients underwent liver transplantation from January 2010 to December 2015. Eleven patients with INCPH who did not require liver transplantation were successfully operated on with a portosystemic shunt procedure. The mean follow-up was 30.1±19 months (range 7-69 months). There was no mortality in the perioperative period or during the follow-up. Two patients underwent surgery again due to intra-abdominal hemorrhage; one had bleeding from the surgical site except the portacaval anastomosis and the other had bleeding from the h-graft anastomosis. No patient developed encephalopathy and no patient presented with esophageal variceal bleeding after portosystemic shunt surgery. Shunt thrombosis occurred in 1 patient (9.9%). Only 1 patient developed ascites, which was controlled medically. CONCLUSIONS Portosystemic shunt surgery is a safe and effective procedure for the treatment of patients with INCPH.

Small bowel perforation due to a migrated esophageal stent: Report of a rare case and review of the literature

Highlights • Palliation of dysphagia with esophageal stenosis via esophageal stent placement is an effective procedure.• Migration is one of the most common complication after stent placement.• The lumen of stent is often allow to the passage in the intestine, so symptoms may develop much later.• Intestinal perforation is a rare but serious complication of stent migration.

Histopathological Examination of Explanted Liver After Transplantation in Patients With Cryptogenic Cirrhosis.

OBJECTIVES Cryptogenic cirrhosis is a common indication for liver transplantation. Diagnosis is made after exclusion of other causes of cirrhosis. In this study, the aim was to evaluate patients with cryptogenic cirrhosis after histopathological examination of explanted liver. MATERIALS AND METHODS A retrospective histopathological chart review of 117 patients with cryptogenic cirrhosis who had liver transplantation between November 2009 and June 2014 was performed. Age, sex, operative features, survival rates, and preoperative and postoperative diagnosis were evaluated. RESULTS During the study period, 123 liver transplantations were performed for these 117 patients. Deceased donor liver transplantations were performed in 23 (18.7%) of the cases. Retransplantations were performed in 5 patients. Median age was 48 years, and female-to-male ratio was 41:76. Hepatosteatosis were observed in 29 patients. Nonalcoholic fatty liver disease and nonalcoholic steatohepatitis were observed in 20 (12%) and 9 (7.7%) of these patients, respectively. Autoimmune hepatitis was observed in 2 patients. The definitive cause of cirrhosis was unclear in 68 (58%) of the patients. Incidental malignant and premalignant lesions were observed in 15 patients. CONCLUSIONS Histopathological examination of the explanted liver after liver transplantation in those patients with cryptogenic cirrhosis may significantly help to diagnose the cause of cirrhosis, such as nonalcoholic steatohepatitis or autoimmune hepatitis, with using the scoring system developed by the International Autoimmune Hepatitis Workgroup. In addition, incidental malignant or premalignant lesions may be observed.

Total laparoscopic subtotal gastrectomy with transvaginal specimen extraction is feasible in advanced gastric cancer

Highlights • Laparoscopic gastrectomy had satisfactory results in patients with gastric cancer.• Natural orifice surgery (NOS) is an ever-evolving advanced laparoscopic technique.• NOS promises minimizing surgical injury, less wound complications and faster recovery.• Laparoscopy plus NOS can potentiate the advantages of both minimal invasive techniques.• We presented a transvaginal extraction of an advanced gastric cancer after laparoscopic gastrectomy.

Transvaginal Mini-Laparoscopic Splenectomy.

We aimed to perform a more and more minimal invasive splenectomy by only through two 5 mm umbilical trocars and one vaginal trocar. A 43-year-old female (BMI 31 kg/m2, ASA II) with immune thrombocytopenic purpura was planned for splenectomy. She had a history of a previous cesarean section for three times. Two 5 mm trocars were inserted separately through the umbilicus. We did not use any single port device or similar modifications. A 15 mm trocar was inserted through the posterior fornix of the vagina under umbilical laparoscopic vision. The 5 mm umbilical ports were used for camera and retraction of the spleen. The transvaginal port was used for dissection and division of the spleen by a 10-mm LigaSure Atlas vessel sealing system. No clips or staples were used. As the spleen became completely free in the abdomen, it was removed through the vagina in a bag without fragmentation. The operating time was 200 minutes and the blood loss was minimal (< 20 ml). No drain or abdominal fascia suturing was used but closing the posterior fornix of the vagina. Her postoperative course was uneventful and she was discharged on day two without complication. She did not require any analgesics postoperatively. Platelet values increased to 408.000 mm3 in the follow-up. To the best of our knowledge, this report described the most minimal invasive splenectomy even. Additionally, it provided an unfragmented spleen extraction. The transvaginal approach seems to be a feasible way to perform natural orifice splenectomy.

Transanal extracorporeal anvil fixation to the proximal colon during laparoscopic rectal resection

Dear Editor, We read the article by Katsuno et al. published in the Asian Journal of Endoscopic Surgery with great interest and wanted to share our technical modification: natural orifice specimen extraction using the prolapsing technique for low anterior resection.(1) We agree with their conclusions that the natural orifice specimen extraction technique is a safe way to cut the lower rectum under direct vision. In their article, Katsuno et al. reported that they preferred to place the anvil at the umbilical SILS port. They removed the SILS port, brought the proximal bowel through the abdominal wall, placed the circular stapler anvil, secured it, pushed it back to the abdomen, and placed the SILS port again. We use the everting technique as well, but we prefer to use the anus as the natural orifice for the anvil placement site rather than the abdominal wall (2). Before closing the rectal stump, we cut and remove the specimen. We pull the proximal colon out through the open rectal stump and anus. We place the stapler anvil into the proximal bowel and fix it with a purse-string suture under transanal direct vision (Figure 1). We push back the proximal colon into the abdomen, and after that, we close the rectal stump with a linear stapler. With this technique, there is no need for SILS port removal and no risk of contaminating the abdominal wall. Moreover, the surgeon can be sure that there is no tension on the anastomosis.

Intracorporeal Mesenteric Division of the Colon Can Make the Specimen More Suitable for Natural Orifice Extraction

Laparoscopic surgery combined with natural orifice specimen extraction (NOSE) avoids extra incisions to the abdominal wall and causes less pain and fewer wound complications, together with a shorter recovery and reduced time off from work. However, the size of the specimen is a limiting factor for NOSE. We describe a novel method for natural orifice colorectal specimen extraction that reduces the diameter of the specimen and provides an easier extraction through the vagina. A totally laparoscopic right hemicolectomy for a cecal adenocarcinoma 5 cm in diameter was performed on a 62-year-old woman. Ileocolic anastomosis was done intracorporeally. Before transvaginal extraction, the largest width of the specimen was measured as 12 cm. The bulky mesentery of the cecum that limited the NOSE was divided partially along the bowel with a LigaSure™ (Covidien, Boulder, CO) device. The largest width of the specimen was reduced to 9 cm, and the specimen was extracted without difficulty through the vagina in a bag. The stage of the tumor was pT3pN1. There was no recurrence with a 7-month follow-up. Transvaginal specimen extraction may fail because of the size of the specimen. Reduction of the width of the specimen by partial division of the mesocolon provides a high success rate for NOSE. This novel technique should be in the repertoire of laparoscopic colorectal surgeons.