Sinan Yol

Comparison of propofol-based sedation regimens administered during colonoscopy

BACKGROUND The ideal sedative agent for endoscopic procedures should allow a rapid modification of the sedation level and should not have any adverse effects. AIM To evaluate and compare the efficacy, safety, cost and patient satisfaction of some propofol-based sedation regimens administered during colonoscopy. MATERIAL AND METHODS One hundred twenty one patients scheduled for elective outpatient colonoscopy with conscious sedation were randomized to four groups to evaluate the administration of dexmedetomidine, sufentanil, meperidine and midazolam in combination with propofol to maintain sedation during the procedure. Evaluated outcomes were efficacy, safety, cost and patient satisfaction of sedation procedures. RESULTS Patients receiving dexmedetomidine achieved a higher degree of sedation when compared with the other groups (p < 0.05). The lapse to recover protective reflexes and motor function, was significantly shorter in groups receiving dexmedetomidine or sufentanil than in groups receiving meperidine or midazolam (p < 0.05). There were no differences between groups in pre-sedation and post-sedation neurophysiologic performance, measured by the Trail Making A and B tests. CONCLUSIONS Sedation for endoscopy can be safely and effectively accomplished with low doses of propofol combined with dexmedetomidine, intranasal sufentanil, IV meperidine and IV meperidine with midazolam.

The impact of PET/CT on the management of hepatic and extra hepatic metastases from gastrointestinal cancers

PURPOSE To investigate the efficacy of positron emission tomography/computed tomography (PET/CT) in detection and management of hepatic and extrahepatic metastases from gastrointestinal cancers. MATERIALS AND METHODS Between February 2008 and July 2010, patients histopathologically diagnosed with gastrointestinal cancer and showing suspected metastasis on CT screening were subsequently evaluated with PET/CT. All patients were subgrouped according to histopathological origin and localization of the primary tumor. Localization of gastrointestinal cancers was further specified as lower gastrointestinal system (GIS), upper GIS, or hepato-pancreato-biliary (HPB). Both accuracy and impact of CT and PET/CT on patient management were retrospectively evaluated. RESULTS One hundred and thirteen patients diagnosed histopathologically with gastrointestinal cancers were retrospectively evaluated. Seventy-nine patients had adenocarcinoma and 34 patients other gastrointestinal tumors. Forty-one patients were in the upper GIS group, 30 patients in the HPB group, and 42 patients in the lower GIS group. Evaluation the diagnostic performance of PET/CT for suspected metastasis according to histopathological origin of the tumor, revealed that the sensitivity of PET/CT - although statistically not different - was higher in adenocarcinomas than in non-adenocarcinomas (90% (95% CI, 0.78-0.96) vs. 71.4% (95% CI, 0.45-0.88), P=0.86). The specificity was not significantly different (85.7% (95% CI, 0.70-0.93) vs. 85% (95% CI, 0.63-0.94), P=1.00). In the overall patient group; CT was significantly more sensitive than PET/CT for detection of hepatic metastases (94.7% vs. 78.9%, P=0.042), whereas PET/CT was significantly more specific than CT (48% vs. 98.7%, P<0.001). In subgroup analysis, sensitivity was not significantly different (P>0.05) but specificity was significantly higher in PET/CT than CT (P<0.05). The specificity of PET/CT was highest in upper GIS (100%) and HPB (100%) subgroups. In the overall patient group; for detection of extrahepatic metastasis, the sensitivity of CT (75%) and PET/CT (87.5%) showed no significant difference (P=0.437). However, PET/CT was significantly more specific than CT (88.7% vs. 70.4%, P=0.007). In subgroup analysis, no significant difference was found between CT and PET/CT either in sensitivity or in specificity (P>0.05). The specificity of PET/CT was highest in the lower GIS subgroup (93%). The management of 45 patients (39.8%) was revised after PET/CT evaluation. CONCLUSIONS PET/CT has a higher specificity than CT in detecting suspected hepatic and extrahepatic metastases of gastrointestinal cancers, and has an impact of nearly 40% on changing patient management strategies.

The Effect of Rabeprazole on LES Tone in Experimental Rat Model

ABSTRACT Introduction: Despite adequate treatment with proton pump inhibitors (PPIs), symptoms of gastroesophageal reflux disease (GERD) may remain persistent as well as Barretts esophagus may emerge. It may be proposed that the relaxant effect of PPIs on the smooth muscles may lead to resistance of symptoms. The aim of this study is to investigate effects of rabeprazole on the lower esophageal sphincter (LES) pressure with a rat model. Materials and Methods: Sixteen rats were grouped as control and treatment groups. After obtaining LES tissues followed by a 60 min equilibration period for stabilization, contractile response to carbachol was obtained by application of single dose of carbachol to have a final concentration of 10−6 M in the organ bath. After the contractions reached a plateau, concentration-response relationships for rabeprazole were obtained in a cumulative manner in the treatment group. Results: In the carbachol contracted LES preparations; 1.5 × 10−6 and 1.5×10−5 M of rabeprazole caused 6.08% and 11.34% relaxations respectively which were not statistically significant. However, mean integral relaxation value for 4.5 × 10−5 M of rabeprazole was 17.34% and this relaxation was significant compared with controls. Conclusions: In the present study, rabeprazole caused no direct significant change in LES tone in the therapeutic dose range applied to the organ bath. However, rabeprazole at the high dose caused a significant decrease in the LES tone.

Pancreatic extragastrointestinal stromal tumor invading the duodenum

Extragastrointestinal stromal tumors that arise in the pancreas are extremely rare and managing them can be difficult, particularly if located in the head of pancreas. This case report aims to contribute to the existing data in the literature regarding extragastrointestinal stromal tumors with rare and unusual locations. We present a 56-year-old man who presented with recurrent mild right upper quadrant abdominal pain. Abdominal computed tomography and magnetic resonance imaging revealed a mass lesion with a diameter of 10 cm localized in the head of pancreas. Pancreaticoduodenectomy with complete tumor excision was performed. He was discharged on the postoperative day 14. Only 15 extragastrointestinal stromal tumors cases have been reported. Of these 15 cases, tumors were located in the head of pancreas in six cases. Here we report the seventh case of pancreatic extragastrointestinal stromal tumor arising in the head of pancreas and also the largest of these seven tumors.

Preoperative immunonutrition regulates tumor infiltrative lymphocytes and increases tumor angiogenesis in gastric cancer patients

Introduction An increased number of tumor infiltrative lymphocytes (TILs) is considered a favorable prognostic factor in various cancers because it is a marker of antitumoral activity of the immune system. In this prospective, non-randomized clinical trial, we evaluated the impact of preoperative immunonutrition on tumor infiltrative lymphocytes and neoangiogenesis in cancerous tissue in patients with locoregional and resectable gastric adenocarcinoma. Material and methods Patients with locoregional and resectable gastric adenocarcinoma were divided non-randomly into two study groups. The first (control) group included patients who had standard nutrition, and the second group included those who had immunonutrition for 7 days before surgery. The biopsy samples taken endoscopically in the preoperative period, as well as the gastrectomy samples, were subjected to immunohistochemical staining for quantitative analysis of CD4, CD8, CD16, CD56, CD31 and CD105 antibodies. Main outcome measures were CD4-to-CD8 ratio and CD105 levels. Results Fifty patients were included in the study between January 2013 and December 2014. Twenty-five patients were assigned to each of the first and second group. The CD4-to-CD8 ratio and CD105 levels determined in endoscopic biopsy samples were similar in both groups. The CD4-to-CD8 ratio in gastrectomy samples was significantly higher in the first group (p = 0.0001). The CD105 levels in gastrectomy samples were significantly lower in the first group (p = 0.01). Conclusions Seven-day preoperative immunonutrition use regulates TILs in gastric cancer patients, but prolonged use increases tumor angiogenesis.

Comment: Leiomyosarcoma of the retrohepatic vena cava: Report of a case treated with resection and reconstruction with polytetrafluoroethylene vascular graft.

To the Editor, We read with interest the paper titled “Leiomyosarcoma of the retrohepatic vena cava: Report of a case treated with resection and reconstruction with polytetrafluoroethylene vascular graft” by Yankol et al. (1). In this case report, the authors describe a successful treatment of a retrohepatic vena cava leiomyosarcoma with resection and polytetrafluoroethylene vascular graft reconstruction. As mentioned in the manuscript surgical resection with negative margins is the gold standard treatment. But after resection, in conjunction with inferior vena cava (IVC) reconstruction options, there also stands another choice which is ligation without reconstruction, which is not discussed in the manuscript. Regarding to this case report, we aimed to present a patient (S.O,prot:806/59,F) from our clinic to whom we performed segmented IVC resection and ligation for diagnosed level 2 vena cava leiomyosarcoma. IVC was ligated above aortoiliac bifurcation and below renal veins. Because of the high graft thrombosis risk this approach was preferred instead of anastomosis. Intermittent pneumatic compression was applied and low dose fractioned heparin was given at therapeutic dosage in order to protect from deep venous thrombosis risk and lower-extremity edema. On postoperative day 3, the patient had underwent a second laparotomy because of intraabdominal bleeding. Perioperative exploration revealed an oozing type bleeding from the proximal caval stump. After hemostasis the patient sent to intensive care unit for close follow-up. On postoperative day 8, chylous drainage was encountered and oral feeding was stopped following total parenteral nutrition (TPN) support. 2 weeks after TPN treatment the drainage was turned to serous character and oral feeding was restarted with abolishment of TPN support. Finally the patient was discharged with compression stocking and 5-mg. coumadin tb./day orally one month after surgery and she did not suffer from renal failure or lower extremity edema during her hospitalization. Pathologic findings revealed a grade 2 leomyosarcoma with negative margins. Immunohistochemistry panel showed that SMA: (+), Desmin: (+), S-100: (−) CD117: (−) Ki-67 index: 30%. Six cycles of chemotherapy was given to the patient following discharge from our clinic. Now the patient is on postoperative 8th month and there is no documented recurrence or metastasis. The proper technique following IVC resection in the literature is lacking. Caval reconstruction is associated with longer operative time and has its own morbidity and mortality rates. On the other hand in the absence of sufficient collateral venous flow or in cases of interruption of vital organ vasculature, it is necessary to make a vascular reconstruction (2). Daylami et al. (3) claimed in their paper that reconstruction of the IVC was not necessary for resection of tumors below the level of the hepatic veins in most if not all cases. They also mentioned lower-extremity edema and acute renal failure as an albeit transient and early postoperative complication. According to their series with 6 patients, 2 of them developed chylous leak and 1 of them was treated with dietary modification and percutaneous drainage and the other with a Denver shunt. We wonder if the authors have checked the patency of graft during follow-up because as Hirohashi et al. (4) suggested in their case report, thrombosis may occur as a late complication in an inferior vena caval graft. In conclusion, we believe that whenever possible, primary IVC resection without reconstruction in the management of lower IVC leiomyosarcoma should be preferred due to its benefits by means of shorter operation time and acceptable morbidity and mortality rates.

Laparoscopic treatment of a mesenteric cyst

A 45-year-old male patient was admitted to our hospital with dyspeptic symptoms. Imaging studies had revealed 2 cm of mesenteric cyst 5 years previously. In the course of his controls the patient was referred to our hospital because of enlargement of the cyst by size and development of a solid component of the cyst content. Physical examination was normal. No abdominal mass was palpated. Tm markers and other blood samples were normal in laboratory tests. Computerised tomography revealed a 48 × 45 mm hypodense heterogenic contrast uptake lesion 5 cm above the iliac bifurcation. The lesion seemed to be derived from the intestinal wall (Figure 1 A, ​,BB). Figure 1 A – Computerised tomography shows heterogenic structure of the cyst marked with red arrow. B – Sagittal slice of the CT image indicating mesenteric cyst marked with white arrow Because of the imaging patterns and the growth of the cyst, a minimally invasive surgical approach was decided on for the patient. In the operation 4 ports were used to access the abdomen. Two 5-mm ports were placed in the right inferior and left superior abdominal quadrant. Two 10-mm ports were placed in the umbilicus and left inferior abdominal quadrant. In the laparoscopic exploration the cystic mass was seen on the mid mesojejunum (Figure 2). The mass was enucleated by blunt and sharp dissection with a harmonic scalpel. One running arterial vessel into the mass was encountered during dissection and was ligated with hem-o-lok clip and divided. An Endobag was used to take the specimen out of the abdominal cavity through the umbilical port orifice. The postoperative course was uneventful and the patient was discharged on the second postoperative day. Finally, the histopathological examination report was of a benign cystic mass. Figure 2 Laparoscopic camera view of the mesenteric cyst marked with white arrow Mesenteric cysts are rare benign abdominal lesions with no classical clinical features. They have an incidence that is less than 1 in 100,000 patients [1]. Frequently they are benign and asymptomatic. They can also present with different symptoms such as abdominal pain, nausea, vomiting, anorexia, and changing of intestinal habitus. Mesenteric cysts are hard to diagnose accurately before surgery because of the rarity of the lesion and no specific symptoms. The treatment of choice is the complete surgical excision, which may be safely performed by laparoscopy [2]. Simple aspiration and drainage of the cyst is not recommended because of the high incidence of recurrence rates. Laparoscopic resection provides less pain, shorter hospital stay, and early recovery for the patient [3]. In this case, we present a patient with a mesenteric cyst that was growing during 5-year follow up and was treated with laparoscopic excision.

Midesophageal pulsion diverticulum: A case report -

Midesophageal pulsion diverticula are rare and asymptomatic clinical entities, which usually develop secondary to esophageal motor dysfunction. Diverticulectomy with myotomy is one of the surgical treatment options. In this case report, we present a patient with midesophageal pulsion diverticulum in whom we managed the postoperative leakage following excision of the diverticulum, by endoluminal esophageal stenting.

In Vitro Effects of Rabeprazole on Human Pylorus Tone

Background/Aims It has been reported that proton pump inhibitors induce relaxation in different types of smooth muscles. The aim of this study is to investigate in vitro effects of proton pump inhibitors on human pylorus muscle. Methods Pyloric sphincters were studied in 10 patients who were operated for stomach cancer. In isolated organ bath, control and response to rabeprazole were recorded following contraction with carbachol. During the treatment experiment, while distilled water was applied during the control experiment in every 5 minutes, rabeprazole was administered in every 5 minutes at doses of 10−6, 10−5, 10−4, and 10−3 M respectively. Contraction frequencies, maximum contraction values and muscle tones were measured. Results The contraction frequencies in the control group were greater than the rabeprazole group in the second, third and fourth intervals while the maximum contraction values in the rabeprazole group were lower in the fourth interval. Even though muscles tones were not different in both groups during all intervals, it was remarkable that the muscle tone was significantly decreased in the rabeprazole group during the fourth interval compared to the first and second intervals. Conclusions In the present study, high doses of rabeprazole reduced contraction frequencies, maximum contraction values, and muscle tone of human pylorus.