Orhan Alimoglu

Surgical treatment of sacrococcygeal pilonidal sinus with the Limberg transposition flap

BACKGROUND Pilonidal sinus is a common chronic disease of the sacrococcygeal region. Although many surgical methods have been suggested, an ideal method is still lacking because of high recurrence rates. METHODS This prospective study was conducted in 63 patients who were treated with the use of a rhomboid excision and Limberg flap closure for sacrococcygeal pilonidal sinus. The follow-up period ranged from 4 to 52 months (mean, 25 months). RESULTS The mean hospital stay was 3 days (range, 2-7 days) and the mean time to return to work was 15 days (range, 12-26 days). Early wound complications and recurrence were encountered in 6% and 3%, respectively. Nineteen percent had numbness at the operation site and 63% were not pleased with cosmetic appearance of the scars. CONCLUSIONS The results favor rhomboid excision and Limberg flap closure in the treatment of sacrococcygeal pilonidal sinus, especially in recurrent cases and in patients with extensive involvement. Low recurrence rates, shorter hospital stay, and time off from work may outweigh the disadvantages related to unfavorable cosmetic appearance.

Timing of Cholecystectomy for Acute Biliary Pancreatitis: Outcomes of Cholecystectomy on First Admission and after Recurrent Biliary Pancreatitis

Biliary stones are the leading cause of acute pancreatitis. Although cholecystectomy and selective endoscopic retrograde cholangiography (ERC) comprise the current treatment in patients with acute biliary pancreatitis (ABP), the time of intervention is still controversial. In this study we evaluated the outcomes of cholecystectomy on first admission for ABP and in patients with recurrent biliary pancreatitis. A series of 43 patients with ABP between January 1997 and November 2000 were evaluated retrospectively. Patients were classified into two groups. Group I included 27 patients who underwent cholecystectomy on first admission before discharge from the hospital. Group II comprised 16 patients who had recurrent biliary pancreatitis and then underwent cholecystectomy. The severity of the pancreatitis was determined by Ranson’s criteria. Age, gender, length of hospital stay, severity of pancreatitis, amylase level, and complications of cholecystectomy were evaluated in both groups. Patients in group I underwent cholecystectomy during the original hospital admission and patients in group II during an admission for a recurrence. There were 24 patients with a Ranson’s score ≤ 3 in group I and 12 in group II. The mean hospital stays were 15.29 days (range 4–48 days) and 36.66 days (range 15–123 days) in groups I and II, respectively (p = 0.006). Morbidity was 11% without mortality in group I and 43% with one mortality in group II (p = 0.023). Definitive treatment of ABP can be accomplished effectively and safely by cholecystectomy following clinical improvement, with selective ERC performed during the first admission (delayed cholecystectomy). Waiting to perform cholecystectomy (interval cholecystectomy) may result in recurrent biliary pancreatitis, which may increase morbidity and the length of the hospital stay.

Umbilical Pilonidal Sinus Disease: Predisposing Factors and Treatment

Pilonidal sinus disease is a common problem of sacrococcygeal region. However, it is also observed in the periumbilical area. There are only a few reports about umbilical pilonidal sinus in the literature. In this study, 26 patients (24 men (92 %), 2 women (8 %) with a mean age of 22 years) with umbilical pilonidal sinus disease were included. Predisposing factors, patient characteristics, treatment modalities, and their results have been studied. Male sex, young age, hairiness, deep navel, and poor personal hygiene were found to be predisposing factors. Twenty-five patients were treated conservatively. However, two patients failed to respond to conservative treatment. Those patients underwent surgery where umbilectomy was carried out without reconstruction. One patient was also operated on for the preoperative misdiagnosis of irreducible umbilical hernia. Patients were followed for 14–96 months. We recommend conservative treatment in patients with umbilical pilonidal sinus. Surgery should be performed in recurrent cases resistant to conservative treatment. The importance of differential diagnosis of umbilical pilonidal sinus from other umbilical pathologies is also emphasized.

Major retroperitoneal vascular injuries during laparoscopic cholecystectomy and appendectomy.

BACKGROUND Serious complications may occur during laparoscopic surgery, as in any surgical procedure. Injuries of major retroperitoneal vascular structures are uncommon but important complications of laparoscopy. METHODS We report on 9 major vascular injuries in 8 patients in the course of 8 laparoscopic procedures between 1994 and 2002. RESULTS The primary operations were cholecystectomy in 7 patients and appendectomy in one patient. Six vascular injuries occurred during placement of the first umbilical trocar, two in the course of the insertion of a Veress needle, and one during the insertion of the second trocar. A laparotomy was performed immediately in all cases. Left common iliac arteries were injured in two patients, aorta in three patients, right common iliac vein in one patient, both right common iliac artery and vein in one patient, and inferior vena cava in one patient. Polytetrafluoroethylene (PTFE) graft interposition was employed in two common iliac arteries and a tubular PTFE graft in one aortic injury, and Dacron patchplasty in one common iliac artery injury. Two aortic, two common iliac vein, and an inferior vena cava injury were repaired primarily. There were also four visceral organ injuries, which were repaired primarily. The major retroperitoneal vascular complication rate was 0.07%. An average of 3.5 units of whole blood were transfused in each case and the average stay in hospital was 6.8 days. There was no mortality. CONCLUSIONS The surgeons experience and knowledge are the essential factors for prevention of major vascular injuries during laparoscopic procedures. In case of an injury, immediate laparotomy must be performed to achieve hemostasis and a surgeon who is familiar with vascular surgery should employ the definitive treatment.

Comparison of Surgical Techniques for Treatment of Benign Toxic Multinodular Goiter

Controversy remains regarding the best surgical approach for toxic multinodular goiter (MNG). The aim of this study was to evaluate the results of various thyroid operations for managing toxic MNG. A group of 100 patients with toxic MNG were divided into three groups and managed with total thyroidectomy (TT; group I, n-17), near-total thyroidectomy (NTT; group II, n = 48), or bilateral subtotal thyroidectomy (BST; group III, n = 35). Patients were compared with regard to age, gender, surgical operations, complications, thyroid hormone status, duration of hospitalization, and the reoperation rate for incidentally found thyroid carcinomas. There were 14 men (14%) and 86 women (86 %) with a mean age of 47.03 ± 13.56 years (range 19–77 years). After the operation two patients had a hematoma, and one patient had a seroma. Four patients had unilateral vocal cord paralysis, and one had permanent paralysis. Moreover, 18 patients had transient and 2 patients permanent hypocalcemia. There was no significant difference between the groups regarding complications (p < 0.05). Permanent hypothyroidism was achieved in all patients in group I and 44 patients (92 %) in group II, whereas in group III only 10 (29%) patients had hypothyroidism. Conversely, hyperthyroidism, both subclinical and clinical, was noted only in group III (12 patients, 34 %) during follow-up. We think that TT and NTT are safe, effective approaches in the treatment of toxic MNG, preventing recurrence of thyrotoxicosis and reoperation for incidentally found thyroid cancers. The complication rates for TT and NTT were similar to that for BST. Hence these operation should be considered for patients referred for surgical treatment of toxic MNG.

CEA and CA 19-9 are Still Valuable Markers for the Prognosis of Colorectal and Gastric Cancer Patients

BACKGROUND The purpose of this study was to assess the predictive effect of preoperative CEA and CA 19-9 levels on the prognosis of colorectal and gastric cancer patients. MATERIALS AND METHODS CEA and CA 19-9 were evaluated preoperatively in patients undergoing surgery for colorectal cancer (n=116) and gastric cancer (n=49). Patients with CEA levels <5 ng/mL were classified as CEA Group 1, 5-30 ng/mL as CEA Group 2 and >30 ng/ mL were classified as CEA Group 3. Similarly the patients with a CA 19-9 level <35 U/mL were classified as CA 19-9 Group 1, with 35-100 U/mL as Group 2 and with >100 U/mL as Group and 3. TNM stages and histologic grades were noted according to histopathological reports. Patients with a TNM grade 0 or 1 were classified as Group A, TNM grade 2 patients constituted Group B and TNM grade 3 and 4 patients constituted Group C. Demographic characteristics, tumor locations and blood types of the patients were all recorded and these data were compared with the preoperative CEA and CA19-9 values. RESULTS A significant correlation between CA 19-9 levels (>100 U/mL) and TNM stage (in advanced stages) was determined. We also determined a significant correlation between TNM stages and positive vlaues for both CEA and CA 19-9 in colorectal and gastric cancer patients. In comparison between CEA and CA 19-9 levels and age, gender, tumor location, ABO blood group, and tumor histologic grade, no significant correlation was found. CONCLUSIONS Positive levels of both CEA and CA 19-9 can be considered to indicate an advanced stage in colorectal and gastric cancer patients.

Acute Appendicitis during Pregnancy

Background: To analyze the diagnosis and surgical treatment of acute appendicitis during pregnancy. Methods: The records of 24 pregnant patients who underwent surgery with preliminary diagnosis of acute appendicitis between January 1990 and July 2000 were reviewed retrospectively. Results: Between January 1990 and July 2000, there were 31,480 deliveries and the incidence of acute appendicitis was 1/1,312. Twenty patients had pathologically proven acute appendicitis (83.3%). Of the remaining 4 patients, one had hemorrhagic ovarian cyst, one had ovarian cyst rupture and in two cases no surgical pathology was diagnosed. Gestational stage at the diagnosis was first trimester in 7 patients, second trimester in 12 patients and third trimester in 5 patients. Five patients had abortions and premature delivery occurred in 2 patients. Conclusion: Diagnosis of acute appendicitis is difficult in pregnancy. Delay in diagnosis and surgery results in increase in complications. Emergency surgical intervention should be performed when acute appendicitis is suspected during pregnancy.

Colon injury following percutaneous endoscopic gastrostomy tube insertion.

Percutaneous endoscopic gastrostomy (PEG) is used to provide a safe route for enteral feeding. However, serious complications may occur during the procedure, such as transverse colon injuries. It can be difficult to diagnose a colon injury after the procedure in a patient with cobormidities. Herein, we present a case of transverse colon injury following insertion of a PEG tube, discuss the possible complications of PEG, and review the recent literature. This case demonstrates the importance of careful PEG tube insertion and close follow-up of the patients clinical status after a PEG procedure.

Current status of minimally invasive surgery for gastric cancer: A literature review to highlight studies limits *

BACKGROUND Gastric cancer represents a great challenge for health care providers and requires a multidisciplinary approach in which surgery plays the main role. Minimally invasive surgery has been progressively developed, first with the advent of laparoscopy and more recently with the spread of robotic surgery, but a number of issues are currently being investigate, including the limitations in performing effective extended lymph node dissections and, in this context, the real advantages of using robotic systems, the possible role for advanced Gastric Cancer, the reproducibility of completely intracorporeal techniques and the oncological results achievable during follow-up. METHOD Searches of MEDLINE, Embase and Cochrane Central Register of Controlled Trials were performed to identify articles published until April 2014 which reported outcomes of surgical treatment for gastric cancer and that used minimally invasive surgical technology. Articles that deal with endoscopic technology were excluded. RESULTS A total of 362 articles were evaluated. After the review process, data in 115 articles were analyzed. CONCLUSION A multicenter study with a large number of patients is now needed to further investigate the safety and efficacy as well as long-term outcomes of robotic surgery, traditional laparoscopy and the open approach.

Robot-assisted laparoscopic abdominoperineal resection for low rectal cancer

This article reports on patients with low rectal cancer treated with robot‐assisted laparoscopic abdominoperineal resection.