Mesut Tez

Red cell distribution width as a predictor of mortality in acute pancreatitis.

INTRODUCTION Acute pancreatitis (AP) is a common cause for hospitalization worldwide. Identification of patients at risk for mortality early in the course of AP is an important step in improving outcome. Red cell distribution width (RDW) is reflective of systemic inflammation. The objective of this study was to investigate the association between RDW and mortality in patients with AP. METHODS A total of 102 patients with AP were included. Demographic data, etiology of pancreatitis, organ failure, metabolic disorder, hospitalization time, and laboratory measures including RDW were obtained from each patient on admission. RESULTS Estimating the receiver operating characteristic area under the curve showed that RDW has very good discriminative power for mortality (area under the curve = 0.817; 95% confidence interval, 0.689-0.946). With a cutoff value of 14.8 for RDW, mortality could be correctly predicted in approximately 77% of cases. CONCLUSIONS Red cell distribution width on admission is a predictor of mortality in patients with AP.

Role of surgery in colorectal cancer liver metastases.

Colorectal carcinoma (CRC) is the third most common cancer, and approximately 35%-55% of patients with CRC will develop hepatic metastases during the course of their disease. Surgical resection represents the only chance of long-term survival. The goal of surgery should be to resect all metastases with negative histological margins while preserving sufficient functional hepatic parenchyma. Although resection remains the only chance of long-term survival, management strategies should be tailored for each case. For patients with extensive metastatic disease who would otherwise be unresectable, the combination of advances in medical therapy, such as systemic chemotherapy (CTX), and the improvement in surgical techniques for metastatic disease, have enhanced prognosis with prolongation of the median survival rate and cure. The use of portal vein embolization and preoperative CTX may also increase the number of patients suitable for surgical treatment. Despite current treatment options, many patients still experience a recurrence after hepatic resection. More active systemic CTX agents are being used increasingly as adjuvant therapy either before or after surgery. Local tumor ablative therapies, such as microwave coagulation therapy and radiofrequency ablation therapy, should be considered as an adjunct to hepatic resection, in which resection cannot deal with all of the tumor lesions. Formulation of an individualized plan, which combines surgery with systemic CTX, is a necessary task of the multidisciplinary team. The aim of this paper is to discuss different approaches for patients that are treated due to CRC liver metastasis.

Can biliary-cyst communication be predicted before surgery for hepatic hydatid disease: does size matter?

BACKGROUND The aim of this study was to determine if there is any predictive factor indicating the risk of bile leakage before surgery for hepatic hydatid disease in clinically asymptomatic patients. METHODS The data of 116 patients who underwent surgery for hepatic hydatid disease were reviewed retrospectively. There were 43 men (37%) and 73 women (63%) with a mean age of 45 +/- 15 years. Because of high preoperative serum bilirubin and liver function test levels, 12 patients were excluded from the study. These patients underwent preoperative endoscopic retrograde cholangiopancreatography. In addition, 2 medically treated patients were excluded from the study. The following variables were analyzed as potential predictors of biliary-cyst communication: age, sex, physical examination findings, leukocyte count, liver function test results, and ultrasonographic cyst features (type, diameter, number, and localization). RESULTS Bile leakage was detected in 24 out of 102 patients. There were no differences in age, sex, cyst type, alkaline phosphatase level, gamma-glutamyl transpeptidase level, alanine aminotransferase level, aspartate aminotransferase level, bilirubin level, and number of cysts and cyst locations between the patients with and without bile leakage. The mean cyst size in patients with biliary leakage was 10.2 cm as compared with 6.1 cm in patients with no biliary leakage (P < .05). When the cut-off value of cyst diameter was accepted as 7.5 cm, the specificity and sensitivity for biliary-cyst communication were 73% and 79%, respectively. CONCLUSIONS These data suggest that cyst diameter is an independent factor that is associated with a high risk of biliary-cyst communication in clinically asymptomatic patients. Preoperative endoscopic retrograde cholangiopancreatography should be performed in these asymptomatic patients to reduce the incidence of postoperative complications.

Randomized, prospective comparison of postoperative pain in low- versus high-pressure pneumoperitoneum

Background:  Reduced postoperative pain after laparoscopic cholecystectomy (LC) compared to open cholecystectomy (OC) may be able to be further optimized. To reduce pain, focus should be directed on the effects of individual components of pain.

Comparison and Validation of Scoring Systems in a Cohort of Patients Treated for Biliary Acute Pancreatitis

Objectives: There are a few prospective studies assessing the severity of acute pancreatitis with exclusive criteria for biliary etiology. The aim of this study was to assess the reliability of prediction of the severity and mortality of acute biliary pancreatitis by using the Ranson, Acute Physiology And Chronic Health Evaluation II and III, Simplified Acute Physiology Score II, and Mortality Probability Model (MPM) II systems. Methods: Fifty-eight patients with acute biliary pancreatitis were studied prospectively. Disease severity scores and mortality predictions were calculated using the collected data in the first 24 hours of admission and for Ranson score in the first 48 hours. Discrimination and calibration characteristics of each system were determined by using area under receiver operating characteristics curve and Hosmer-Lemeshow goodness-of-fit test, respectively. Results: Among 58 patients included, there were 4 mortalities (6.8 %). Fifteen patients (25.8 %) had severe disease, and 5 patients (8.6 %) had systemic and local complications. All systems had reliable power of discrimination and calibration. Among systems tested MPM II was the best performing as far as discrimination, and calibration characteristics are considered. The items of MPM II that were positive in patients with severe pancreatitis were those related to systemic perfusion. Conclusions: Mortality Probability Model II predicted mortality at admission is better than the other systems in predicting the severity of pancreatitis. Results also indicate the important role of systemic perfusion at the early phases of acute pancreatitis in the progression of disease.Abbreviations: AUC - area under curve, ROC - receiver operating characteristic, APACHE - Acute Physiology and Chronic Health Evaluation, SAPS - Simplified Acute Physiology Score, MPM - Mortality Probability Model, ABP - acute biliary pancreatitis

Evaluation of P-POSSUM and CR-POSSUM Scores in Patients with Colorectal Cancer Undergoing Resection

IntroductionThe aim of this study was to evaluate the predictive accuracy of P-POSSUM and CR-POSSUM models on patients undergoing colorectal resection.MethodsP-POSSUM and CR-POSSUM predictor equations for mortality were applied retrospectively to 321 patients who had undergone colorectal resection for cancer. P-POSSUM and CR-POSSUM scores were validated by assessing their calibration and discrimination. Calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test and the corresponding calibration curves. Evaluation of the discriminative capability of both models was performed using receiver-operating characteristic (ROC) curve analysis.ResultsOverall, 22 deaths were observed. CR-POSSUM predicted 25 deaths (χ2 = 12.20, P = 0.13), and P-POSSUM predicted 29 deaths (χ2 =18.85, P = 0.002). ROC curves analysis revealed that CR-POSSUM has reasonable discriminatory power for mortality.ConclusionsThese data suggest that CR-POSSUM may provide a better estimate of the risk of mortality for patients who undergoing colorectal resection.

Risk factors for surgical site infection after gastrectomy with D2 lymphadenectomy.

Surgical site infection (SSI) is a potentially morbid and costly complication of surgery. We conducted this study to establish the preoperative and operative factors predisposing to SSI after gastric resection and D2 lymphadenectomy. Data on all patients undergoing gastrectomy and D2 lymphadenectomy within a 2-year period, at a tertiary reference hospital in Turkey, were collected retrospectively. The outcome of interest was a diagnosis of incisional SSI as defined by the Centers for Disease Control and Prevention. Multivariate analysis by stepwise logistic regression was then performed on those variables associated with incisional SSI. We identified 72 patients with SSI after gastrectomy and D2 lymphadenectomy. The median age of the patients was 61 years (range 31–81 years) and 43 were men. Incisional SSI was diagnosed in 15 (20.8%) patients. Of all the preoperative and operative variables measured, an increased patient body mass index was an independent predictor of incisional SSI. An increased incidence of SSI was found in overweight patients, but these infections were transient and not life threatening.

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.

Red cell distribution width to platelet ratio: New and promising prognostic marker in acute pancreatitis

AIM To evaluate the accuracy of red cell distribution width (RDW) to platelet ratio (RPR) to predict in-hospital mortality in acute pancreatitis (AP). METHODS Between January 2010 and June 2012, 102 patients with AP were recruited to the study. In this retrospective cohort study, for all subjects, demographic data on hospital admission, AP etiology, co-morbid diseases, organ failure assessment, laboratory parameters and length of hospital stay were examined. Additionally, we used a non-invasive prediction method in addition to the RPR to evaluate the disease severity. Multivariate logistic regression analyses were used to evaluate the impact of RPR on hospital admission to predict mortality. RESULTS The male-female ratio (59/43) was 1.37 with a median age of 56.5 years (17-89 years). In both univariate and multivariate analyses, RDW and RPR were presented as independent and significant variables on admission to predict mortality. The RPR obtained on hospital admission was persistently higher among non-survivors than among survivors (P < 0.0001). The median RPR was 0.000087 in the non-survivor group and 0.000058 in the survivor group. RPR with a cutoff value of 0.000067 presented an area under the curve of 0.783 (95%CI: 0.688-0.878) in receiver operating characteristic curves and could predict the mortality of approximately 80% of the patients. CONCLUSION We identified RPR as a valuable, novel laboratory test to predict mortality in AP.

Prediction of clinical outcomes using artificial neural networks for patients with acute biliary pancreatitis.

To the Editor: Gallstones and alcohol have been implicated as etiologic factors in 80% of acute pancreatitis cases. Acute biliary pancreatitis (ABP) range from a mild, self-limited disease to severe, and sometimes fatal, disorder. Early identification of patients at greater risk of complications may determine a more rational use of diagnostic studies and prompt treatment, leading to decreased mortality rates. Inquiry in prediction of severity of acute pancreatitis dates back to the 19th century, when Reginald Heber Fitz first reported a classification scheme based on autopsy studies. After this publication, detailing pathology of acute pancreatitis, many different scoring systems have been evaluated for predicting severity of pancreatitis on which treatment decisions can be based. These systems can be grouped into two, the first group including those systems that attempts to correlate laboratory and clinical markers specific to pancreatitis with subsequent outcome and disease severity, Ranson score being an example. The second type of scoring systems, such as the Acute Physiologic and Chronic Health Evaluation System (APACHE) II and III, Simplified Acute Physiology Score (SAPS) II, and the Mortality Probability Models (MPM) II were developed to quantify the severity of illness and the likelihood of hospital survival for a general intensive care unit (ICU) population. In the last 10 years, a class of techniques inspired by the workings of biologic neurons, artificial neural networks (ANNs), have been proposed as a supplement or alternative to standard statistical techniques for predicting complex biologic phenomena. Briefly, ANNs are a class of nonlinear mathematical models that are characterized by a complex structure of interconnected computational elements, the neurons. These computational elements aggregate a series of inputs (factors that influence the outcomes of ABP) by using a summation operation and produce an output, such as the severity of ABP. The aim of this study was to evaluate a novel ANN for the prediction of severity and mortality in patients with ABP and to compare it with the results of the other scoring systems. This prospective study has been conducted in a cohort of patients with ABP admitted to the Ankara Numune Hospital between August 2005 and September 2006. Diagnosis of ABP was based on clinical (acute abdominal pain in upper quadrants associated with nausea and vomiting), laboratory (increase in serum amylase at least 3 times to normal) and ultrasonographic data (cholelithiasis, choledocholithiasis, or biliary sludge). Cases with alcoholic or metabolic causes of pancreatitis and those admitted more than 24 hours later than onset of symptoms were excluded from the study. The main outcomes measured in this study were mortality and severity. We determined severity of the disease according to clinically based classification of Atlanta. An outcome was defined as severe if it was associated with organ failure and/or local complications, whether or not the patient was admitted to the ICU. Organ failure was established if one or more of the following factors were present: shock (systolic blood pressure G90 mm Hg), pulmonary insufficiency (PO2 G60 mm Hg), renal failure (creatinine levels 92.0 mg/dL after rehydration), and gastrointestinal bleeding (9500 mL/24 h). Local complications include the development of pancreatic necrosis, abscess, or pseudocyst. Mortality was calculated as the number of patients dying during hospital admission with pancreatitis. All patients were managed conservatively unless a complication had arisen. Cholangitis was treated with intravenous antibiotics and endoscopic retrograde cholangiopancreatography with sphincterotomy where appropriate. Pancreatic necrosis, abscess, acute fluid collection, or pseudocysts were managed by either radiologically guided percutaneous fineneedle aspiration or surgery. Data related to calculations of Ranson score, APACHE II, and score at admission and 48 hours for Ranson score were collected by a physician unaware of the study end points within the first 48 hours of admission, and calculations were performed by using clinical calculators of the Muavenet Intensive Care Information System (http://www.icu.hacettepe.edu.tr/ micis.html). The optimum variables used to construct the ANN were selected previous literature. Three demographic and/or physical data points (age, presence of other illness, temperature) and 8 laboratory data points (white blood cell count, serum amylase level, lactate dehydrogenase level, calcium level, creatinine level, glucose level, serum urea nitrogen level, and base deficit) were used in the final assessment. Three-layered, multilayer perceptron ANN models, with back propagation circuit, were constructed using Neuro-Solutions version 5 neural network software (NeuroDimension, Inc, Gainesville, Fla). This is a simple neural network design in which the neurons are arranged in parallel layers, and each layer is connected fully to the previous layer through synaptic connections, leading to a single predictive outcome. The ANNs were trained through back propagation of error, which is a process by which the error of prediction is minimized by adjusting the weights associated with the synaptic connections in the hidden layers of the ANN. The training was stopped when the predictive error reached a minimum on this set. One third of the data were used to train the ANN, one third to improve it, and one third for testing the system. Discrimination and calibration describe the overall predictive power of a model. Model discrimination was measured by the area under the receiveroperator characteristic curve (AUC) to evaluate how well the model distinguished patients experienced the events LETTERS TO THE EDITOR