Mustafa Hasbahceci

Routine use of positron-emission tomography/ computed tomography for staging of primary colorectal cancer: Does it affect clinical management?

BackgroundThe use of positron emission tomography-computed tomography (PET/CT) for the preoperative staging of patients with colon and rectal cancer has increased steadily over the last decade. The aim of this study was to evaluate the effect of PET/CT on the preoperative staging and clinical management of patients with colorectal cancer.MethodsBetween December 2010 and February 2012, 64 consecutive patients with colorectal cancer were evaluated with both PET/CT scans and conventional preoperative imaging studies. We prospectively recorded the medical reports of these patients. The PET/CT findings were compared with conventional imaging studies and the rate of over-staging or down-staging and changes in clinical management were evaluated. The correlation of the PET/CT with the conventional imaging was compared by a kappa agreement coefficient. Differences in the accuracy for N and T staging were assessed by χ 2 and related-samples marginal homogeneity tests.ResultsThirty-nine (60.9%) patients had rectal cancer and 25 (39.1%) had colon cancer. Based on PET/CT, additional lesions were found in 6 (9.4%) of the patients: hilar and paratracheal lesions in 4 patients, hepatic in 1 and supraclavicular in 1 patient. In four of six patients, detailed imaging studies or biopsies revealed chronic inflammatory changes. Hepatic and supraclavicular involvement was confirmed in two patients. Therefore, the false positivity rate of PET/CT was 6.25%. Based on the additional PET/CT, 2 (3.2%) patients had a change in surgical management. A chemotherapy regimen was administered to the patient with a 1.5 cm hepatic metastasis near the right hepatic vein; for another patient with an identified supraclavicular lymph node metastasis, a simultaneous excision was performed.ConclusionsRoutine use of PET/CT for preoperative staging did not impact disease management for 96.8% of our patients. The results of our study conclude that PET/CT should not be routinely used for primary staging of colorectal cancer. More studies are required for identifying the subgroup of patients who might benefit from a PET/CT in their initial staging.

Reverse Relationship Between Blood Boron Level and Body Mass Index in Humans: Does It Matter for Obesity?

The exact role of boron in humans is not known although its supplementation causes several important metabolic and inflammatory changes. The objective of this study is to evaluate the possibility of an association between blood boron level and obesity in normal, overweight, obese, and morbidly obese subjects. A total number of 80 subjects, categorized into four groups based on their body mass index as normal, overweight, obese, and morbidly obese, were enrolled in this study. Age, sex, body mass index, and blood boron levels were recorded for each subject. Although the distribution of female and male subjects and blood boron levels were similar between groups, the mean age of normal subjects was significantly lower than the others (p = 0.002). There was a significant relationship between age and quantitative values of body mass index for each subject (β = 0.24; p = 0.003). In addition, between blood boron levels and quantitative values of body mass index for each subject, a significant reverse relationship was detected (β = −0.16; p = 0.043). Although age seemed to be an important variable for blood boron level and body mass index, blood boron levels were shown to be lower in obese subjects in comparison to non-obese subjects.

A New Proposal for Learning Curve of TEP Inguinal Hernia Repair: Ability to Complete Operation Endoscopically as a First Phase of Learning Curve

Background. The exact nature of learning curve of totally extraperitoneal inguinal hernia and the number required to master this technique remain controversial. Patients and Methods. We present a retrospective review of a single surgeon experience on patients who underwent totally extraperitoneal inguinal hernia repair. Results. There were 42 hernias (22 left- and 20 right-sided) in 39 patients with a mean age of 48.8 ± 15.1 years. Indirect, direct, and combined hernias were present in 18, 12, and 12 cases, respectively. The mean operative time was 55.1 ± 22.8 minutes. Peritoneal injury occurred in 9 cases (21.4%). Conversion to open surgery was necessitated in 7 cases (16.7%). After grouping of all patients into two groups as cases between 1–21 and 22–42, it was seen that the majority of peritoneal injuries (7 out of 9, 77.8%, P = 0.130) and all conversions (P = 0.001) occurred in the first 21 cases. Conclusions. Learning curve of totally extraperitoneal inguinal hernia repair can be divided into two consequent steps: immediate and late. At least 20 operations are required for gaining anatomical knowledge and surgical pitfalls based on the ability to perform this operation without conversion during immediate phase.

Co-existence of acute appendicitis and inflammatory myofibroblastic tumor of the small intestine: A case report

Introduction Inflammatory myofibroblastic tumor as a rare neoplastic lesion is seen most commonly in the pulmonary system. Beside the presence of limited number of inflammatory myofibroblastic tumors of the gastrointestinal tract in the literature, co-existence with acute appendicitis has not been reported before. Presentation of case A 27-year-old woman admitted to emergency department with acute abdominal pain at the right lower quadrant. The initial diagnosis was as acute appendicitis. Intraoperatively, a mass with a diameter of almost 5 cm originated from the distal ileal segments neighboring the appendix was seen. The patient was managed by segmental resection of the small intestine including the mass with appendectomy. Histologically, there were bundles of spindle cells accompanied by lymphoplasmocytic infiltration. The immunohistochemical studies showed that tumor cells were positive for smooth muscle actin, vimentin, perinuclear activity for anaplastic lymphoma kinase and CD 68. The final pathologic diagnosis was inflammatory myofibroblastic tumor. Discussion Concomitant resection of tumoral lesions detected in the neighbor intestinal segments during appendectomy should be considered to diagnose and treat. For the diagnosis of inflammatory myofibroblastic tumor, immunohistochemistry pattern including positivity for actin, vimentin, CD 68 and anaplastic lymphoma kinase plays a crucial role. Therefore, detailed immunohistochemistry analysis should be performed in suspicious cases. Conclusion Coexistence of inflammatory myofibroblastic tumor located in the gastrointestinal system with acute appendicitis is a rare event. Complete surgical excision should be regarded as the mainstay of the treatment. Long-term follow up with serial imaging techniques is recommended.

Laparoscopic excision of a retroperitoneal ganglioneuroma.

This study suggests that excision of retroperitoneal tumors can be reliably performed with minimally invasive surgical techniques.

Mesh Inguinal Hernia Repair and Appendectomy in the Treatment of Amyand’s Hernia with Non-Inflamed Appendices

Amyands hernia is defined as protrusion of the vermiform appendix in an inguinal hernia sac. It is a rare entity with variable clinical presentation from normal vermiform appendix to abscess formation due to perforation of acute appendicitis. Although surgical treatment includes appendectomy and hernia repair, appendectomy in the absence of an inflamed appendix and use of a mesh in cases of appendectomy remain to be controversial. The aim of this study was to review the experience of mesh inguinal hernia repair plus appendectomy performed for Amyands hernia with noninflamed appendices. There were five male patients with a mean age of 42.4 ± 16.1 years in this retrospective study in which Amyands hernia was treated with mesh inguinal hernia repair plus appendectomy for noninflamed appendices. Patients with acute appendicitis and perforated vermiform appendix were excluded. There were four right sided and one bilateral inguinal hernia. Postoperative courses were uneventful. During the follow-up period (14.0 ± 7.7 months), there was no inguinal hernia recurrence. Mesh inguinal hernia repair with appendectomy can be performed for Amyands hernia in the absence of acute appendicitis. However, presence of fibrous connections between the vermiform appendix and the surrounding hernia sac may be regarded as a parameter to perform appendectomy.

Is concomitant cholecystectomy with laparoscopic sleeve gastrectomy safe

BACKGROUND/AIMS To study the effect of selective concomitant cholecystectomy (SCC) on laparoscopic sleeve gastrectomy (LSG). MATERIALS AND METHODS A retrospective case-control study of 16 morbidly obese patients treated with concomitant LSG as the primary bariatric surgery and SCC for proven gallbladder (GB) pathology (Group A) between November 2010 and February 2013 was performed. Randomly selected 32 patients who underwent laparoscopic sleeve gastrectomy was the control group (Group B). RESULTS A total of 48 patients with a mean age of 35.5±10.7 years were included. Demographic data of groups were similar except that there were more female patients in the Group A (p=0.036). Mean body mass index (kg/m2) was 51.1±5.6 and 50.9±5.4 in Groups A and B, respectively (p=0.894). The mean operative time for patients with and without cholecystectomy was 157.2±40 and 95.72±6.2 min, respectively (p=0.001). Cholecystectomy resulted in an additional mean operative time of 49.1±27.9 min without any specific complication. There was no statistical difference with regard to overall morbidity (p=0.316) and the length of hospital stay (p=0.528) between groups. CONCLUSION Although an increase in operative time may be an important issue, SCC can be performed on all patients with proven GB pathology during LSG without an increase in morbidity or length of hospital stay.

Diffusion MRI on lymph node staging of gastric adenocarcinoma

OBJECTIVE The purpose of this study was to evaluate the accuracy of diffusion weighted magnetic resonance imaging (MRI) in preoperative assessment of metastatic lymph nodes of gastric cancer. METHODS A total of 23 gastric cancer patients with a mean age of 59.4±10.9 years were analyzed. Lymph nodes were grouped as perigastric lesser curvature (Group Ia), perigastric greater curvature (Group Ib), D1+/D2 lymph nodes (Group II). Identification of histologically metastatic lymph nodes by diffusion weighted MRI was regarded as the main outcome. RESULTS A total of 1,056 lymph nodes including 180 histologically proven metastatic lymph nodes were dissected. Although diffusion weighted MRI could identify the metastatic lymph nodes in 18 out of 23 patients (77.8%), only 69 of total 1,056 nodes (6.53%), either metastatic or non-metastatic, could be detected. There was no correlation between histopathology and diffusion weighted MRI with regard to lymph node groups (P>0.05 for all). Overall accuracy was calculated as 69.56, 65.21 and 52.17 for Groups II, Ib and Ia lymph nodes, respectively. Apparent diffusion coefficient (ADC) values could not be helpful to differentiate metastatic lymph nodes (P=0.673). CONCLUSIONS Diffusion weighted MRI has low accuracy to detect or to differentiate metastatic and non-metastatic lymph nodes based on their ADC values in gastric cancer.

Factors Affecting Mortality in Blunt Thoracic Trauma

BACKGROUND Blunt thoracic trauma is usually associated with extra-thoracic injuries, but the effect of blunt thoracic trauma on mortality is not known. METHODS Patients with blunt thoracic trauma were evaluated with regard to clinical findings and factors affecting mortality. RESULTS There were 76 patients (37.2±15 years) in the study group. Traffic accidents (63%) were the most common cause of trauma. Pneumothorax (54%), rib fracture (42%), hemothorax (22%) and lung contusion (22%) were common thoracic injuries. Extra-thoracic injuries were most commonly seen in the extremities (46%) and abdomen (40%). Glasgow Coma, Injury Severity and Revised Trauma Scores were 14±2.6, 19±13 and 7.4±1.5, respectively. Non-operative management was effective in 37 (48.7%) patients, tube thoracotomy and thoracotomy were performed in 37 (48.7%) and 2 (2.6%) patients, respectively. Mortality rate was 10.5%. Systolic blood pressure lower than 90 mmHg and superficial and apneic respiration at the first admission, and values of trauma scoring systems were significantly associated with mortality (p<0.05). CONCLUSION The effect of thoracic trauma on mortality with regard to thoracic pathology is not shown, although it is usually associated with extra-thoracic injuries. There was a close relationship between the pattern of respiration, values of systolic blood pressure and trauma scoring systems, and mortality. Non-operative management and tube thoracotomy were effective in most of the cases.

Laparoscopic sleeve gastrectomy in management of weight regain after failed laparoscopic plication

INTRODUCTION Weight regain after bariatric surgery remains a challenging problem with regard to its surgical management. PRESENTATION OF CASE A 30 year-old-female patient with weight regain after failed laparoscopic gastric plication and previous gastric banding was evaluated in a tertiary-care university setting. Her last body mass index was calculated as 40.4kg/m(2). Preoperative ultrasonography revealed cholelithiasis. Laparoscopic sleeve gastrectomy with cholecystectomy was planned as a redo surgery. A floopy and plicated stomach with increased wall thickness of the greater curvature was seen. After adhesiolysis between the plicated part of stomach and the surrounding omental tissues, concomitant laparoscopic sleeve gastrectomy and cholecystectomy were performed. She was discharged on the 4th post-operative day without any complaint. At the postoperative 3rd month, her body mass index was recorded as 24kg/m(2). DISCUSSION Redo surgery of morbid obesity after failed bariatric surgery is a technically demanding issue. Type of the surgical treatment should be decided by the attending surgeon based on the morphology of the remnant stomach caused by previous operations. CONCLUSION As a redo surgery after failed laparoscopic gastric plication and gastric banding procedures, laparoscopic sleeve gastrectomy may be regarded as a safe and feasible approach in experienced hands.