Volkan Oter

Effects of preoperative endoscopic pneumatic balloon dilatation on postoperative achalasia symptoms after Heller esophageal myotomy plus Dor fundoplication

BACKGROUND/AIMS Currently, forceful endoscopic pneumatic balloon dilatation (PBD), laparoscopic Heller myotomy (LHM) with or without an anti-reflux procedure, and peroral endoscopic myotomy are the preferred treatment options for achalasia. The aim of the present study was to retrospectively compare postoperative outcomes after LHM plus Dor fundoplication (DF) between patients who underwent prior endoscopic balloon dilatation and those who did not. MATERIALS AND METHODS Sixty-five patients who underwent HM+DF between January 2008 and December 2016 were retrospectively analyzed. Of these, 45 had a history of endoscopic PBD. Pre- and postoperative achalasia symptoms, including weight loss, dysphagia, heartburn, and regurgitation, were evaluated using the Eckardt score. RESULTS Fifty (76.9%) patients underwent laparoscopic surgery and 15 (23.1%) underwent open surgery. When patients were compared according to the presence of preoperative endoscopic PBD, no significant difference were observed in terms of age, sex, preoperative lower esophageal sphincter pressure, operation time, hospitalization period, and follow-up period (p>0.05). The mean Eckardt score at the first postoperative year was significantly lower than the preoperative Eckardt score (4.51±1.8 vs. 0.52±0.7; p<0.001). In contrast, no significant difference was found between patients with and without previous PBD on the pre- and postoperative Eckardt scores (p=0.43). CONCLUSION HM+DF is an effective procedure in relieving achalasia symptoms as a first-line therapy as well as in individuals unresponsive to repeated endoscopic PBDs.

Porto-mesenteric venous thrombosis after laparoscopic sleeve gastrectomy: A case report and systematic review of the 104 cases

INTRODUCTION Porto-mesenteric venous thrombosis (PMVT) is a rare but fatal complication after bariatric surgery. However, an increasing number of PMVT complications have been observed in the last years after laparoscopic sleeve gastrectomy (LSG) operations. CASE REPORT A 35-year-old male was admitted to the emergency clinic in a septic status with a sudden once of abdominal pain and vomiting. The patient underwent laparoscopic sleeve gastrectomy (LSG) 15 days ago. His physical examination revealed diffuse abdominal tenderness. Abdominal computerised tomography showed a thrombus which was elongated from vena mesenterica superior to vena porta. An emergent laparotomy was performed. A 40 cm of ischemic small bowel segment which began at the 60th cm of Treitz ligament was resected. The gastrointestinal continuity was provided by an end-to-end anastomosis. Patients postoperative course was uneventful. He was discharged on the 7th postoperative day and was medicated on oral anticoagulation (Warfarin 5 mg/day) for six months. RESULTS A total of 104 morbidly obese patients who developed PMVT after bariatric surgery are reported in the English literature between 2004 and April 2017. Most of the patients were female (63 cases, 60.5%). The median age was 42.5 years (14-68) and the median body mass index (BMI) was 44 kg/m2 (31.8-74.6). The most common cause of coagulopathy disorders was protein C and/or S deficiency (9.6%) followed by prothrombin gene mutation (6.7%). LSG was performed in 83 patients (78.8%) and the median intraoperative pressure was 15 mmHg (14-20). The median operation time was 70 min (min-max: 37-192). Fifty-five patients (52.8%) underwent preoperative oral anticoagulant prophylaxis. The median time for PMVT development was 14 days (min-max: 1-453). Of the 104 patients with PMVT, 75 cases (72.1%) underwent postoperative anticoagulant agents such as low-molecular weight heparin (LMWH), heparin drip or infusion, streptokinase or warfarin, whereas the remaining did not receive prophylactic medication. CONCLUSION PMVT after sleeve gastrectomy is a rare but fatal complication. Therefore, anti-coagulation prophylaxis with LMWH should be considered at least one month postoperatively.

Assessment of risk factors on morbidity and mortality in patients undergoing percutaneous endoscopic gastrostomy

Aim: Percutaneous endoscopic gastrostomy (PEG) is a minimal invasive procedure that is performed in patients who are unable to take oral feeding. Herein, we aimed to assess the risk factors for morbidity and mortality in patients who undergo PEG. Material and Methods: This study was conducted, in a total of 143 patients who underwent PEG for enteral feeding, who were retrospectively analyzed in terms of clinical features, biochemical, hematological and microbiological parameters, and also morbidity and mortality. Results: The study enrolled 140 of 143 consecutive patients who underwent PEG, and a total of 206 interventions were performed. The rate of successful insertion was 98.5% (140/142). Complications were peristomal leakage (%29.3), infection due to PEG (9.3%), and tube blockage (6.4%), respectively. In multivariate logistic regression analysis; a ≤ 3.5cm length of the PEG tube between the gastric mucosa and the skin (95% CI: 1.290-33.442 and P= 0.023) and a low platelet lymphocyte ratio (OR = 0.994, 95% CI: 0.989-0.999 and p = 0.022) were risk factors of peristomal leakage. The 30-day mortality rate was 16%. Discussion: In patient with PEG, the complication rate varies between 5% and 66% according to follow-ups in the literature. The mortality usually depends on the primary disease, and it has been reported between 5% and 20%. Conclusion: PEG is a safe, effective, and minimal invasive procedure. A ≤3.5 cm length of a PEG tube between the gastric mucosa and skin and a low platelet lymphocyte ratio are risk factors for the development of peristomal leakage.

Five Years Experience in This Enigmatic Problem: Colorectal Endometriosis

Introduction Endometriosis affects primarily women of reproductive age and is responsible for impairing their quality of life. Presence of severe symptoms, stenosis of the intestinal lumen, diagnostic difficulty (suspicion of malignancy) and intolerance to hormonal therapy are indications for surgery. Despite numerous studies concerning endometriosis, there is still considerable controversy about its incidence, pathogenesis, diagnosis and optimal treatment. Methods This retrospective observational study includes 11 patients who were diagnosed with intestinal endometriosis between January 2009 and December 2013. Demographic data, clinical presentation, diagnostic modalities, localization of the disease and intraoperative data were collected. Results Median age of the patients was 43 (34–63). Eight patients had intermittent abdominal pain, seven had change in bowel habits and three had for rectal bleeding. Seven patients were operated on for severe stenosis of the intestinal lumen (intestinal obstruction) and three for a suspected malignancy. Postoperatively all of the patients who underwent resection were free of pain. No patient had any disease recurrence on USG or CT images. Discussion Intestinal endometriosis should be considered in female patients of reproductive age presenting with constipation, rectal bleeding and abdominal pain. Also repeated inadequate biopsies should raise suspicion of intestinal endometriosis. Intestinal endometriosis is a rare disease with diagnostic difficulties and despite medical management, treatment options are usually surgery. But in patients who were diagnosed preoperatively and did not have intestinal obstruction, medical therapy may be tried.Endometriosis primarily affects women of reproductive age, and is responsible for impairing their quality of life. The presence of severe symptoms, including stenosis of the intestinal lumen, diagnostic difficulty (suspicion of malignancy) and intolerance to hormonal therapy, are indications for surgery. Despite numerous studies on endometriosis, there is still considerable controversy about its incidence, pathogenesis, diagnosis and optimal treatment.