Metin Ercan

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.

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.

Topical Ankaferd Application to Presacral Bleeding due to Total Mesorectal Excision in Rectal Carcinoma

Kerem Karaman, MD, Erdal Birol Bostanci, MD, and Metin Ercan, MD Department of Gastroenterological Surgery, Turkiye Yuksek Ihtisas Teaching and Research Hospital, Ankara, Turkey Mevlut Kurt, MD Department of Gastroenterology, Turkiye Yuksek Ihtisas Teaching and Research Hospital, Ankara, Turkey Zafer Teke, MD, Enver Reyhan, MD, and Musa Akoglu, MD Department of Gastroenterological Surgery, Turkiye Yuksek Ihtisas Teaching and Research Hospital, Ankara, Turkey

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.

Pancreatic schwannoma: A rare case and a brief literature review

Highlights • Pancreatic schwannoma is an extremely rare tumor.• Pancreatic schwannoma was stained with S-100 and vimentin.• The preoperative diagnosis of pancreatic schwannoma is an important in terms of choose surgery method.• Surgical resection is a curative treatment method for pancreatic schwannoma.

Ectopic liver (choristoma) attached to the gallbladder wall

Ectopic liver is a rare developmental anomaly in which liver tissue is located outside the liver, and it has been found in various sites including gallbladder, gastrohepatic ligament, umbilical cord, adrenals, splenic capsule, pancreas or thoracic cavity. Among these, ectopic liver tissues in the serosa, subserosa or mucosa of the gallbladder are more frequent than others. Heterotopic liver or choristoma may occur in association with acute or chronic cholecystitis and more frequently with cholelithiasis, although these conditions appear to be in no way related. A 63-year-old man with a 2-year history of biliary colic was found to have gallstones on ultrasound and underwent an elective laparoscopic cholecystectomy. During the procedure, a half-moon shape of brown tissue measuring 11 mm ¥ 4 mm ¥ 4 mm was seen to be attached to the serosa of the inferior wall of the gallbladder by a thin mesentery (Fig. 1). We performed a laparoscopic cholecystectomy. The encapsulated nodule showed histologically normal hepatic architecture. Normal portal triads were present which eventually drained into the artery, vein and bile duct at the hilum of the nodule. Liver choristomas or ectopic nodules of liver tissue attached to the gallbladder by their own mesentery and completely detached from the liver are uncommon. These anomalies occur rather frequently during embryogenesis, but quickly undergo atrophy or fibrosis because of incomplete development. Consequently, they disappear and are not commonly found. It is usually an incidental finding during a laparoscopy, laparotomy or autopsy. Ectopic liver nodules are generally without clinical symptoms. Liver choristomas in the gallbladder can undergo fatty change, haemosiderosis, cholestasis or cirrhosis. Ectopic liver tissue is also at increased risk of carcinogenesis. In our case, the presence of the two vessels and bile ducts at the hilum of the ectopic liver demonstrates that it was functionally active.

Laparotomy with a curative intent in patients with suspected locally recurrent gastric cancer.

AIMS AND BACKGROUND Most recurrent gastric tumors are unsuitable for further resection or palliative surgery. The aim of the present study was to evaluate the role of re-resection in patients with local-regional recurrences of gastric cancer. METHODS AND STUDY DESIGN Between 1998 and 2007, 26 patients underwent laparotomy for local-regional gastric cancer recurrence. Length of time to recurrence, recurrence patterns, operative procedures, morbidity, mortality and survival after re-resection were evaluated. RESULTS Re-resection was possible in 13 patients (50%). Among patients with resectable tumors, survival times were markedly longer, with 2 patients reaching 60 months of survival and 2 other patients reaching 48 and 28 months, respectively. Among patients with early recurrence, peritoneal carcinomatosis was more common. After re-resection, morbidity and mortality were seen, each in one patient. CONCLUSIONS Most of the re-resected recurrences were intraluminal. In patients with early recurrences of gastric cancer, peritoneal carcinomatosis was encountered most frequently. Re-resection was beneficial and long-term survival was achieved after re-resection.

The Effects of Duration of CO2 Pneumoperitoneum on Colonic Anastomosis

The aim of this study is to evaluate the effects of duration of carbon dioxide (CO2) pneumoperitoneum on experimental colonic anastomosis. Forty-eight male Sprague–Dawley rats were used. The rats were divided into three groups. The rats in group 1 (n = 16) underwent laparotomy and colonic anastomosis without pneumoperitoneum. The rats in group 2 (n = 16) and group 3 (n = 16) were subjected to 2 and 4 hours of 12 mm Hg pneumoperitoneum, respectively, before laparotomy and colonic anastomosis. Half of the rats were sacrified on the third postoperative day; and the other half, on the seventh postoperative day. A colonic segment including anastomosis site was resected for histopathologic and biochemical evaluation. On day 3, hydroxyproline levels of the three groups were similar. The edema score of group 2 was significantly higher than that of group 1, and the necrosis score was higher in group 2 than in group 3. The scores of the other histopathologic parameters were similar. On day 7, group 3 showed significantly higher hydroxyproline levels than group 1, and group 1 showed a higher necrosis score than group 3. In conclusion, CO2 pneumoperitoneum of 12 mm Hg for 2 and 4 hours did not result in impaired healing of experimental colonic anastomosis.