Özgür Akgül

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.

Receiver operating characteristic analysis of leukocyte counts in operations for suspected appendicitis.

STUDY OBJECTIVE There has been no clear-cut value of the white blood cell (WBC) count in differential diagnosis of acute appendicitis in emergency medicine. Therefore, the aim of this study was to assess the preoperative WBC counts in 3 groups of patients operated on for a clinical suspicion of acute appendicitis with different findings at appendectomy: uninflamed appendix, uncomplicated acute appendicitis, or complicated acute appendicitis. METHODS The medical records of 540 patients who underwent appendectomy for suspected acute appendicitis during a 17-month period were retrospectively reviewed. Data for 3 groups of patients were analyzed to calculate the sensitivity and specificity of the WBC count in the diagnosis of acute appendicitis, and we calculated likelihood ratios for 2 cut-points with either high sensitivity or high specificity. Receiver operating characteristic curves were used to evaluate the WBC count in relation to the true diagnosis and severity of acute appendicitis. RESULTS We were able to identify patients with appendicitis on a statistically significant level using receiver operating characteristic curves of WBC counts (area under the curve = 0.756, P < .001), but the WBC count had no diagnostic value in differentiating between uncomplicated and complicated groups (area under the curve = 0.55, P = .086). Likelihood ratio ranged from 1.79 (95% confidence interval, 1.17-2.3) for WBC count of more than 10,500 cells/mm(3) to 3.20 (95% confidence interval, 2.72-3.24) for WBC count of more than 14,300 cells/mm(3). CONCLUSION White blood cell count is helpful in the diagnosis and exclusion of appendicitis. However, there is no value to differentiate advanced appendicitis.

High serum cancer antigen 125 level indicates perforation in acute appendicitis

BACKGROUND The diagnosis of acute appendicitis is sometimes challenging, and prompt evaluation is required because of the risk of complications if not treated appropriately. AIM We aimed to evaluate whether cancer antigen 125 (CA-125) has diagnositic accuracy and predictor of the severity in acute appendicitis. RESULTS Sixty patients with acute appendicitis were recruited prospectively in this study between May 2014 and March 2015. Blood samples were obtained to measure CA-125 levels before appendectomy. Of the 57 patients, 10 had perforated or gangrenous appendicitis intraoperatively. The CA-125 levels were significantly higher in patients with perforated or gangrenous appendicitis than patients with uncomplicated appendicitis (49.9 vs 10.5 U/mL, P=.000). CONCLUSIONS Cancer antigen 125 levels in patients with highly suspected or confirmed appendicitis could help clinicians determine the severity of the disease.

Can outcome of pancreatic pseudocysts be predicted? Proposal for a new scoring system

BACKGROUND The spontaneous resolution rate of pancreatic pseudocysts (PPs) is 86%, and the serious complication rate is 3-9%. The aim of the present study was to develop a scoring system that would predict spontaneous resolution of PPs. METHODS Medical records of 70 patients were retrospectively reviewed. Two patients were excluded. Demographic data and laboratory measurements were obtained from patient records. RESULTS Mean age of the 68 patients included was 56.6 years. Female:male ratio was 1.34:1. Causes of pancreatitis were stones (48.5%), alcohol consumption (26.5%), and unknown etiology (25%). Mean size of PP was 71 mm. Pseudocysts disappeared in 32 patients (47.1%). With univariate analysis, serum direct bilirubin level (>0.95 mg/dL), cyst carcinoembryonic antigen (CEA) level (>1.5), and cyst diameter (>55 mm) were found to be significantly different between patients with and without spontaneous resolution. In multivariate analysis, these variables were statistically significant. Scores were calculated with points assigned to each variable. Final scores predicted spontaneous resolution in approximately 80% of patients. CONCLUSION The scoring system developed to predict resolution of PPs is simple and useful, but requires validation.

Clinical Experience with Lift Technique For Complex Anal Fistulas

Aim: In this study we aimed to assess the results of LIFT technique for the patients with complex anal fistula in our colorectal unit. Methods: A total of 24 consecutive patients with complex anal fistula were recruited in our prospective study between January 2014 and July 2014. Outcome measures included presence of recurrence, fecal incontinence and surgical complications. Results: We enrolled 24 patients with a mean age of 40.5 (range 16-69) years,ten of the patients had recurrent fistulas and 14 were newly diagnosed. Mean follow-up was 4 months. Successful fistula repair was achieved in the 87.5% of the patients, 3 patients had failure at the follow-up. No incontinence was observed in any of the patients. Conclusion: Ligation of the intersphincteric tract is a novel sphincter-preserving method for complex anal fistulas. As a simple, safe, cost-effective procedure with high success rates it could be candidate for being the gold standart method for complex anal fistulas.

Small Intestinal and Mesenteric Multiple Gastrointestinal Stromal Tumors Causing Occult Bleeding

Gastrointestinal stromal tumors are the meseancymal neoplasms which may involve any part of gastrointestinal tract. C-Kit and platelet derived factor receptor alpha polypeptide are believed to be responsible for the genetic basis. This case presentation aimed to discuss the diagnostic and therapeutic modality of multiple small intestinal, omental, and mesenteric GISTs with different sizes which caused occult bleeding in a 43-year-old male patient.

The unbearable lightness of understanding clinical influence of lymph node micrometastasis.

Dear Sir, In a recent article in Langenbeck’s Archives of Surgery, Scheunemann and colleagues [1] suggest that the further studies with larger numbers of patients are needed to resolve the question of the prognostic value of disseminated tumor cells in lymph nodes in patients with resectable gastric carcinoma. There have been several reports about evaluation of relationship between micrometastasis and prognosis in gastric cancer. Although most studies reported the micrometastasis affected on the prognosis of gastric cancer, the degree of influence was variable according to the groups of patients [2]. These findings have been speculated to be the result of tumor dormancy. An alternative explanation is that the disseminated tumor cells in some of the patients arose from the spread of nontumorigenic cells and only when tumor stem cells disseminate and subsequently self renew will metastatic tumors form [3]. Interest in gastric cancer stem cells (CSCs) has arisen in the broader context of the CSC hypothesis, which first appeared more than a century ago; however, it was not until 1997 that malignant stem cells were isolated from patients with acute myeloid leukemia. The leukemic stem cell, which was defined as specific markers of CD34+/CD38–, could serially reproduce the disease in immunodeficient mice, and it was consistent with their properties of longevity and self renewal [4]. Despite some limitations, the growth of tumor cells with defined markers in immunodeficient mice has become the gold standard for identifying a CSC in other solid tumors such as breast cancer, brain cancer, prostate cancer, melanoma, colon cancer, liver cancer, pancreatic cancer, and head and neck cancer. In these studies, as few as 100 cells of CSC subpopulation showed better growth in immunodeficient mice compared to non-CSC subpopulation. At a recent American Association for Cancer Research workshop, a working group used the available data to create a consensus definition of the CSC as “cells within a tumor that possess the capacity for selfrenewal and that can cause the heterogeneous lineages of cancer cells that constitute the tumor.” Recent findings also support the existence of gastric CSCs in the human gastric tumors. The origin of human gastric CSCs has yet to be elucidated, but data obtained from a mouse model of Helicobacter-induced gastric cancer has implicated bonemarrow-derived cells as a potential candidate source [5, 6]. Cancer stem cells may derive from mutations in normal stem cells. Alternatively, differentiated tumor cells may acquire the characteristics of stem cells. Genomic instability cause spontaneously transformation of human nontumorigenic stem cells to cancer stem cells. Currently, it is believed that cancer stem cells are present in small numbers in tumors. The standard analysis to examine the existence of a subpopulation of cancer stem cells is the demonstration of these cells can transfer the tumor and recapitulate the phenotypic heterogeneity present within the parental tumor. The same subpopulation should again fulfill these criteria when reisolated from a secondary tumor [5]. In conclusion; the CSC hypothesis may explain clinical influence of micrometastasis in gastric cancer prognosis and may facilitate the development of additional novel therapies. Langenbecks Arch Surg (2009) 394:195–196 DOI 10.1007/s00423-008-0424-1