Remzi Kızıltan

An analysis of 13 patients with perforated gastric carcinoma: A surgeon's nightmare?

Background and ObjectivesPerforation is a rare complication of gastric carcinoma and generally not diagnosed preoperatively. To clarify the clinicopathologic characteristics of patients with this condition we reviewed 13 cases of gastric cancer perforation who required emergency surgery.MethodsA total of 13 patients with gastric cancer perforation were retrospectively reviewed. The clinicopathological features including tumor stage and survival and also the type of treatment were analyzed and compared to literature data.ResultsThere were 13 patients (10 males and 3 females) with a mean age of 59.0 ± 9.56 years. The incidence of perforated gastric cancer was 9.6% among gastric carcinoma and 4.2% of all gastric perforation cases. The perforation was more frequently in stage III–IV (2–10), but one case of stage II (T3N0M0) gastric cancer was also observed. None of the patients had curative resection or radical lymph-node dissection. Six (46%) patients were treated by palliative, local surgery. Emergency gastrectomy were performed in 7 (54%) patients. Overall 30-day mortality rate was % 46. The overall survival time was 128.2 ± 184.8 days for all patients, it was 52.8 ± 52.9 days for locally treated group, and 192.9 ± 235.4 days for patients who underwent resectional surgery. The difference between the treatment groups was not significantConclusionPerforation usually occurs in advanced stages of gastric cancer. These patients had a poor prognosis because of the presence of advanced cancer.

Intraoperatively Testing the Anastomotic Integrity of Esophagojejunostomy Using Methylene Blue

Background: Intraoperative testing of gastrointestinal anastomosis effectively ensures anastomotic integrity. This study investigated whether the routine use of methylene blue intraoperatively identified leaks to reduce the postoperative proportion of clinical leaks. Methods: This study retrospectively analyzed consecutive total gastrectomies performed from January 2007 to December 2014 in a university hospital setting by a general surgical group that exclusively used the methylene blue test. All surgeries were performed for gastric or junctional cancers (n = 198). All reconstructions (Roux-en Y esophagojejunostomy) were performed using a stapler. The methylene blue test was used in 108 cases (group 1) via a nasojejunal tube. No test was performed for the other 90 cases (group 2). Intraoperative leakage rate, postoperative clinical leakage rate, length of hospitalization, and mortality rate were the outcome measures. Results: The intraoperative leakage rate was 7.4% in group 1. The postoperative clinical leakage rate was 8.6%. The postoperative clinical leakage rate was 3.7% in group 1 and 14.4% in group 2 (p = 0.007). There were no postoperative clinical leaks when an intraoperative leak led to concomitant intraoperative repair. The median length of hospital stay was 6 days in group 1 and 8 days in group 2 (p < 0.001). One death occurred in each group. No test-related complications were observed. Conclusion: The methylene blue test for esophagojejunostomy is a safe and reliable method for the assessment of anastomosis integrity, especially in cases with difficult esophagojejunostomic construction.

A Rare Complication of Biliary Stent Migration: Small Bowel Perforation in a Patient with Incisional Hernia.

Endoscopic biliary stents have been recently applied with increasing frequency as a palliative and curable method in several benign and malignant diseases. As a reminder, although most of the migrated stents pass through the intestinal tract without symptoms, a small portion can lead to complications. Herein, we present a case of intestinal perforation caused by a biliary stent in the hernia of a patient with a rarely encountered incarcerated incisional hernia.

Potential diagnostic and prognostic significance of plasma prolidase activity in gastric cancer

AIM Plasma prolidase activities (PPAs) in cases of gastric cancer. METHODOLOGY/RESULTS This study was based on a prospective design. 60 patients with gastric cancer (operable cases: 48; inoperable: 12) and 60 healthy controls were included in the study. Prolidase activity was analyzed. The mean PPA levels in the operable, inoperable and control groups were 45.60 ± 4.20, 54.35 ± 4. 9 and 10.92 ± 0.79 U/l, respectively (p < 0.001). PPA decreased significantly after tumor resection. PPA level was significant in differentiating operable cases from inoperable (sensitivity: 91.7%; specificity: 85.2%). DISCUSSION/CONCLUSION PPA was significantly higher in patients with inoperable gastric cancer than in operable cases and the control group. A strong correlation was found between tumor volume and PPA.

The diagnosis of acute appendicitis in pregnant versus non-pregnant women: A comparative study

Objective: To investigate whether the diagnosis of acute appendicitis is affected by pregnancy or not. Method: A retrospective study with the analysis of the medical records of all women suspected of having appendicitis who underwent appendectomy at our hospital between June 2010 and March 2015 were reviewed. The patients were divided into two groups according to whether they were pregnant or not during the surgery: group I, pregnant women, and group II, non-pregnant women. Results: During the study period, 38 pregnant women and 169 non-pregnant women underwent appendectomy. The time from admission to the operation was not statistically different (2.17±1.47 days in group I vs. 1.98±1.66 day in group II; p=0.288). The pregnant group had longer hospital stay than the non-pregnant group (p=0.04). Ultrasonography (USG) was used as the first diagnostic modality in 36/38 patients in group I and 161/169 in group II. The non-visualized appendix on ultrasound was seen in 17 patients in group I and 51 patients in group II, which was not statistically different. Sensitivity and specificity of USG in diagnosis of acute appendicitis were 61.29 and 80.00% in group I, and 93.0 and 31.6% in group II, respectively. Conclusion: Although the diagnosis of appendicitis in pregnant women is not delayed, careful assessment of these patients suspected of having appendicitis should be encouraged when USG examination is normal or nondiagnostic.

Factors affecting mortality in emergency surgery in cases of complicated colorectal cancer.

AIM To evaluate retrospectively demographic, clinical and histopathological variables effective on mortality in patients who had undergone emergency surgery due to complicated colorectal cancer. METHODS A total of 39 patients underwent urgent surgical interventions due to complicated colorectal cancer at the Department of General Surgery, Dursun Odabaş Medical Center, between January 2010 and January 2015. Thirty three of these were included in the study. Six patients were excluded because complete medical records had been missing. Medical records of the 33 cases were retrospectively reviewed. RESULTS There were 14 (42.5%) male and 19 (57.5%) female patients. Mean age was 60 years (range: 32- 83 years); 14 (42.5%) patients were less than 60 years old , while 19 (57.5%) were 60 years old or older. Operations were performed due to perforation (39.3%) and obstruction (60.6%) in 13 and 20 patients, respectively. Tumor localization was in the right and transverse colon in nine (21.2%) and in the left colon in 24 cases (72.7%). Eleven (33.3%) patients underwent resection and anastomosis, 13 (39.3%) resection and ostomy, and nine (27.2%) patients underwent ostomy alone without any resection. Postoperative mortality occurred in nine cases (27.2%). CONCLUSIONS High mortality should be expected in females older than 60 years with a left sided colon tumor or with another synchronous tumor and in perforated tumors. Unnecessary major resections should be avoided and primary pathology should be in the focus of treatment in order to decrease the mortality and morbidity rates.

MATERNAL AND FETAL OUTCOMES AFTER LAPAROSCOPIC VS. OPEN APPENDECTOMY IN PREGNANT WOMEN: DATA FROM TWO TERTIARY REFERRAL CENTERS

Objectives Appendectomy is the most common cause of non-obstetric surgery in pregnant women. Our aim was to compare the clinical characteristics, peri-and post-operative data of pregnant women undergoing either laparoscopic appendectomy (LA) or open appendectomy (OA). Materials and methods This was a retrospective study of medical records of all pregnant women diagnosed and treated surgically for acute appendicitis at two referral centers of Yuzuncu Yil University Medical Faculty and Kafkas University Medical Faculty, from January 2010 to January 2015. Results The study included 48 patients, divided to two groups (12 - LA and 36 - OA). There were no significant differences in demographic characteristics of the studied population, including age, BMI, gestational age at operation, gravidity, parity, and history of cesarean sections. A far as obstetric and fetal outcomes are concerned, no significant differences were found in terms of preterm delivery, fetal loss, delivery mode, birth weight, APGAR score, and maternal death between the two investigated groups. One perioperative complication of intra-abdominal abscess was noted in the OA group. However, the LA group had shorter hospital stay (3.25±2.45 vs. 4.28±3.31, p=0.004), earlier mobilization time (8.1±2.2 vs. 10.1±1.6, p=0.025), and shorter time to first flatus (2.3±0.3 vs. 4.0±1.6, p=0.032) as compared to the OA group. The OA group had statistically shorter operation time than the LA group (38.61±11.5 vs. 49.42±11.38, p=0.007). Conclusion LA is related to shorter hospital stay, faster return to daily activities, and shorter time to first flatus. LA appears to be as safe and effective as OA in pregnant patients without increasing adverse perinatal outcomes.

Intraperitoneal Infusion of Neutral-pH Superoxidized Solution in Rats: Evaluation of Toxicity and Complications on Peritoneal Surface and Liver

Background Superoxidized water (SOW) is known to be a potent disinfectant. The aim of this study was to evaluate the toxicity and complications on the peritoneal surface and liver after infusion of pH-neutral SOW into the peritoneal cavity of rats. Material/Methods Thirty Wistar-Albino rats weighing 250–300 g were randomly divided into 3 groups (10 rats/group). Group1 (control group) rats received single dose of 10 mg/kg saline solution intraperitoneally. Group 2 (single-dose group) rats received a single dose of 10 mg/kg pH-neutral SOW intraperitoneally. Group 3 (multiple-doses group) rats received multiple doses of 10 mg/kg pH-neutral SOW intraperitoneally on days 1, 3, and 5. All animals were killed at 1 week after infusion. Blood specimens were taken to the laboratory and macroscopic and microscopic examinations were performed on each rat. Results All 30 rats survived after the infusion. The gross-macroscopic examinations revealed no pathologic findings in any of the 3 groups. The microscopic examination of peritoneum and liver showed no signs of toxicity or complications in any of the 3 groups. There were no statistically significant differences among the 3 groups with regards to the blood biochemistry, including hemoglobin, hematocrit, platelets, aspartate aminotransferase, alanine aminotransferase, urea, or creatinine levels (p>0.05). However, the leucocyte counts were lower in group 3 than in groups 1 and 2, but this was not statistically significant (p=0.189). Conclusions Intraperitoneal infusion of pH-neutral SOW does not result in any significant toxicity or complications on the liver and peritoneal surface. However, multiple infusions lead to low leucocyte counts and future studies with longer follow-up times are needed.

Changing trends and experience with esophageal cancer surgery in a single university hospital: are the results similar or not?

Objective: The main treatment modality for esophageal cancer remains to be surgery. Over the last decades, surgical strategies have evolved remarkably. When neoadjuvant chemoradiotherapy became standard, discussions about the role, type, and timing of surgery began. In this study, we share results we obtained after operating our patients using various surgical techniques. Material and Methods: Reliable data from 51 esophageal cancer patients were evaluated retrospectively. Of the 51 cases, 31 were operable. These operable cases were further classified according to surgical method and neoadjuvant therapy status. Median survival time in months, complications, hospital mortality, length of hospital stay, and pathology results (total lymph nodes harvested and pathologic tumor node metastasis stage [p_TNM]) were documented for the different surgical approaches. Results: Open surgical methods were performed in 21 cases, while in 10 cases the Minimally Invasive Surgery (MIS) method was used. The MIS group received neoadjuvant therapy more frequently than the open surgical methods group (p=0.013). Although more complications were observed in the MIS group, the difference to the open esophagectomy methods group was not significant. Patients in the MIS group also had longer hospital stays, but again the difference was not significant. Although a pathologic complete response was seen in 8 of the 11 (72.7%) patients in our study who received chemoradiotherapy as neoadjuvant treatment, the surgical results of patients who received chemoradiotherapy were worse, although not to a statistically significant extent. Conclusion: Despite changing trends and treatment options in esophageal cancer surgery, we have yet to see the expected improved results.

Successful Treatment of a Large Pelvic Abscess Using Intraluminal VAC: A Case Report

The most feared complication of the surgical treatment of rectal cancer is anastomotic leakage, which is related to high rates of mortality and morbidity. Here, we present a patient who could not be treated with surgical drainage but treated by intraluminal Vacuum Associated Closure (VAC). A 34-year-old male patient was treated for rectal cancer by low anterior resection, colorectal anastomosis, and diverting ileostomy following neoadjuvant CRT. The patient reported with a postoperative anastomotic disruption and a large pelvic abscess. Due to the continuation of foul-smell drainage inspite of perianal incision and drainage, intraluminal VAC was applied and the pelvic abscess and the foul-smell were successfully treated. The presence of an adequate anal sphincter tonus is a disadvantage in anastomotic leakage, since it prevents the emptying of the intestinal content and also precludes the drainage of the pelvic abscess. The endoluminal application of VAC, similar to the results of application of VAC in open wounds, has been demonstrated to decrease fibrin and necrotic tissue in the pelvic cavity and increase granulation tissue. VAC, which has long been used in the treatment of open wounds, is a promising method in the treatment of large pelvic abscesses due to anastomotic leakage following rectum resection.