Reducing dehydration-induced readmissions post-colorectal surgery: the impact of a prevention bundle.

INTRODUCTION: Ileostomy, frequently created after colorectal resections, hinders the physiologic function of the colon and can lead to dehydration and acute kidney injury due to high stoma outputs. This study aimed to evaluate the effectiveness of preventive measures on ileostomy-induced dehydration and related readmissions in a high-volume unit. METHODS: In this prospective cohort study at a high-volume colorectal surgery department in Turkiye, the Prospective Ileostomy-induced Dehydration Prevention Bundle Project (PIDBP) was assessed from March 2021 to March 2022. The study enrolled patients undergoing colorectal surgery with ileostomy and involved comprehensive inpatient stoma care, education, and a structured post-discharge follow-up. The follow-up included the "Hydration follow-up scale" to monitor ileostomy output and related complications. The primary outcome was the readmission rate due to dehydration-related complications. The patients receiving the bundle intervention were compared with patients treated in the preceding year, focusing on the effectiveness of interventions such as dietary adjustments, fluid therapy, and pharmacological management. RESULTS: In the study, 104 patients were analyzed, divided into 54 pre-bundle and 50 bundle group patients, with no significant differences in patient characteristics. While the overall readmission rate due to dehydration was 12.5%, a significant reduction in dehydration-related readmissions was observed in the bundle group compared to the pre-bundle group (2% vs. 22%, p = 0.002). Univariate analysis identified high stoma output (> 800 ml/24 h) (p < 0.001), chronic renal failure (CRF) (p = 0.01), postoperative ileus (p = 0.03), higher ASA status (p = 0.04), extended hospital stays (p = 0.03), and small bowel resections (especially in J-pouch patients) (p < 0.001) as significant predictors of readmission. Multivariate analysis revealed that the mean ileostomy output before discharge was the sole significant predictor of dehydration-related readmission (OR 1.01), with an optimal cutoff of 877.5 ml/day identified with an area under the curve (AUC) of 0.947, demonstrating high sensitivity (92.3%) and specificity (86.8%) in predicting readmission risk. CONCLUSION: The Prospective Ileostomy-induced Dehydration Prevention Bundle Project significantly reduced readmission rates after colorectal surgery.

Impact of Indocyanine Green Angiography on Postoperative Parathyroid Function: A Propensity Score Matching Study.

Background: Thyroidectomy constitutes an important portion of endocrine surgery procedures and is associated with various complications such as bleeding, recurrent laryngeal nerve injury, and postoperative hypoparathyroidsm. Effective parathyroid preservation during thyroid surgery is crucial for patient well-being, with current strategies heavily reliant on surgeon experience. Among various methods, Indocyanine Green Angiography (ICGA) offers a promising method for intraoperative assessment of parathyroid gland perfusion. Methods: In a retrospective study, patients undergoing bilateral thyroidectomy from January 2021 to January 2023 were analyzed, excluding those with previous thyroidectomy, parathyroid disease, or chronic kidney disease. The study compared a control group (n = 175) with an ICGA group (n = 120), using propensity score matching for statistical analysis. Matched cohorts included 120 patients in each group. The primary outcome of this study was identified as temporary postoperative hypoparathyroidism, with secondary outcomes including the rate of parathyroid reimplantation and the incidence of permanent postoperative hypoparathyroidism. Results: The ICGA group showed significantly more parathyroid autotransplantations (p < 0.01). While not statistically significant, the control group had a higher incidence of temporary postoperative hypoparathyroidism (p < 0.09). Rates of hypocalcemia on postoperative day 1 and permanent hypocalcemia were similar. Subgroup analysis indicated more postoperative day 1 hypoparathyroidism in the control group during central neck dissections (p < 0.049). Conclusions: Intraoperative ICGA use correlated with higher parathyroid autotransplantation and suggested reduced postoperative hypoparathyroidism. Changes in fluorescence intensity following a second ICG injection may provide an objective method to assess parathyroid perfusion. Further large-scale studies are needed to fully understand ICGA's impact on parathyroid preservation.

Performance of CT in the locoregional staging of colon cancer: detailed radiology-pathology correlation with special emphasis on tumor deposits, extramural venous invasion and T staging.

PURPOSE: To investigate the performance of computed tomography (CT) in the local staging of colon cancer in different segments, with emphasis on parameters that have been found to be significant for rectal cancer, namely, extramural venous invasion (EMVI) and tumor deposits (TDs). METHODS: CT and pathology data from 137 patients were independently reviewed by radiology and pathology teams. The performance of CT in categorizing a given patient into good, versus poor prognostic groups was assessed for each segment, as well as the presence of lymph nodes (LNs), TDs and EMVIs. Discordant cases were re-evaluated to determine potential sources of error. Elastic stain was applied for EMVI discordance. RESULTS: The T staging accuracy was 80.2%. For T stage stratification, CT performed slightly better in the left colon, and the lowest accuracy was in the transverse colon. Under-staging was more common (in 12.4%), and most of the mis-staged cases were in sigmoid colon. According to the first comprehensive correlative analysis, the sensitivity, specificity, and accuracy of CT for detecting TDs were found to be 57.9%, 92.4%, 87.6%, respectively. These figures were 44.7%, 72.7%, and 63.5% for LN, and 58.5%, 82.1% and 73% for EMVI. The detection rate was better for multifocal EMVI. The detection rate was also comparable (although substantially underestimated) for LNs, with the half of the LNs missed by CT being < 5 mm. Four patients that were classified as TD by CT, disclosed to be LNs by pathology. Correlative analysis led to refinement of the pathology criteria, with subsequent modifications of the initial reports in 13 (9.5%) patients. CONCLUSION: Overall, CT performed well in the evaluation of colon cancer, as did TD and EMVI. It is advisable to include these parameters in CT-based staging. Radiologists should be aware of the pitfalls that occur more commonly in different segments.

A case of seatbelt-induced mesenteric injury and delayed colon ischemia after a car accident.

Trauma is the sixth leading cause of death globally and the leading cause of morbidity and mortality in young patients. Blunt bowel and mesenteric injuries are rare, occuring in only 1-5% of blunt abdominal traumas, and are associated with high morbidity and mortality. In this report, we present a case of a patient with sigmoid colon perforation due to ischemia caused by mesenteric injury, who was admitted to the hospital with abdominal pain two days after a car accident. A twenty-one-year-old man was admitted to the emergency department with abdominal pain and vomiting, having been involved in a car accident as a driver two days prior. Computed tomogra-phy revealed free air in the abdomen, originating from the perforation of the sigmoid colon wall, and free fluid in the pelvic area. The patient underwent immediate laparotomy. Exploration revealed a rupture in the sigmoid mesocolon, causing ischemia and perforation. Additionally, there was a rupture in the mesentery of the terminal ileum close to the ileocecal valve, but without ischemia. Partial sig-moid colon and ileal resections were performed, followed by colocolic anastomosis and double-barrel ileostomy. He was discharged in good health after a 20-day hospital stay. Thorough clinical examination and radiological evaluation can aid in detecting visceral injuries in trauma patients. Early recognition and repair of intestinal damage can prevent severe complications.

Feasibility of totally extraperitoneal inguinal hernia repair in patients with previous prostatectomy.

Objectives: Laparoscopic totally extraperitoneal inguinal hernia repair (TEP) surgery technique includes three key steps: reaching the preperitoneal space, reducing hernias, and placement of mesh. However, reaching the preperitoneal space can be complicated in patients with previous lower abdominal surgeries. This study aimed to assess the feasibility of laparoscopic inguinal TEP in patients with previous prostatectomies. Material and Methods: Inguinal hernia patients who underwent laparoscopic TEP between January 2015 and February 2021 at Koç University Faculty of Medicine, Department of General Surgery, were included in this retrospective study. The operations were performed by five senior surgeons experienced in laparoscopy. Patients were divided into two study groups, as the radical prostatectomy (RP) group which included patients with previous prostatectomy non-RP which included patients without previous radical prostatectomy. Operative time (OT), length of hospital stay (LOS), and postoperative complications were compared within two groups. Results: Three hundred and forty-nine patients underwent laparoscopic TEP, and 27 had previous prostatectomies. Among them, 190 patients had unilateral inguinal hernias, and 159 had bilateral inguinal hernias. Mean age of the patients in the non-RP and RP groups was 58.1 ± 14.7 and 73.9 ± 9.6 years, respectively. Only one (3.7%) case was complicated with urinary tract infection in the RP group, and 10 (3.1%) were complicated in the non-RP group. Complications for the non-RP group include hematomas in six cases, urinary tract infection in three cases, and urinary retention in one case. No significant difference in mean operative time was seen between non-RP and RP groups (p= 0.43). There was no significant difference in the means of the length of hospital stay between the two groups (p= 0.7). Conclusion: Laparoscopic TEP in patients with a previous prostatectomy can be performed safely without prolonging the operative time and increasing the length of hospital stay.

Reliability and validity of the Turkish version of the New Cleveland Clinic Colorectal Cancer Quality of Life Questionnaire.

PURPOSE: This study aims to adapt and validate the Cleveland Clinic Colorectal Cancer Quality of Life Questionnaire (CCF-CaQL) in Turkish, addressing the significant need for reliable, language-specific QoL measures for colorectal cancer (CRC) in Turkiye. This effort fills a critical gap in CRC patient care, enhancing both patient-provider communication and disease-specific QoL assessment. METHODS: The CCF-CaQL was translated into Turkish, verified for accuracy, and reviewed for clarity and relevance. Eligible patients who underwent colorectal surgery for cancer between July 2021 and July 2022 from six hospitals completed the CCF-CaQL and SF-36 questionnaires. For analysis, confirmatory factor analysis using Smart PLS 4 and descriptive statistics were employed. The questionnaire's reliability and validity were assessed using Cronbach alpha, composite reliability, and the heterotrait-monotrait (HTMT) ratio, along with multicollinearity checks and factor loadings. Nonparametric resampling was used for precise error and confidence interval calculations, and the Spearman coefficient and split-half method were applied for reliability testing. RESULTS: In the study involving 244 colorectal cancer patients, confirmatory factor analysis of the CCF-CaQL indicated effective item performance, with one item removed due to lower factor loading. The questionnaire exhibited high internal consistency, evidenced by a Cronbach alpha value of 0.909. Convergent validity was strong, with all average variance extracted (AVE) values exceeding 0.4. Discriminant validity was confirmed with HTMT coefficients below 0.9, and no significant multicollinearity issues were observed (VIF values < 10). Parallel testing with the SF-36 scale demonstrated moderate to very strong correlations, affirming the CCF-CaQL's comparability in measuring quality of life. CONCLUSION: The Turkish version of the CCF-CaQL was validated for assessing quality of life in colorectal cancer patients. This validation confirms its reliability and cultural appropriateness for use in Turkiye. The disease-specific nature of the CCF-CaQL makes it a useful tool in clinical and research settings, enhancing patient care by accurately monitoring treatment effects and interventions in the Turkish colorectal cancer patient population.

Multimodal assessment after total neoadjuvant therapy versus standard neoadjuvant chemoradiotherapy in locally advanced rectal cancer accurately predicts complete responders.

PURPOSE: This study aimed to compare local regrowth rates after total neoadjuvant therapy (TNT) versus standard neoadjuvant chemoradiotherapy (SNCRT) in locally advanced rectal cancer (LARC) patients that were strictly selected and assessed with a multimodal approach. Secondary outcomes were 4-year disease-free (DFS) and overall survival (OS) rates. METHODS: Locally advanced rectal cancer patients without distant metastases treated at Koç Healthcare Group between January 2014 and January 2021 were included. Patients were assessed for complete response with a combination of digital rectal exam, endoscopy, and magnetic resonance imaging with a dedicated rectum protocol. The systemic evaluation was performed with an upper abdomen MRI using intravenous hepatobiliary contrast agent and a thorax CT. RESULTS: Of the 270 patients with LARC, 182 fulfilled the inclusion criteria. Ninety-seven (53.3%) underwent TNT, while 85 (46.7%) underwent SNCRT. A cumulative combination of pathological and sustained clinical complete response was significantly higher in the TNT group than in the SNCRT (45.4% vs. 20.0%, p < 0.0001). After a median follow-up of 48 months, seven patients in the W&W group had regrowth [TNT: 4 (10.8%) vs. SNCRT: 3 (23.1%), p = 0.357]. Based on pathological examination, complete/near complete mesorectum rates (p = 1.000) and circumferential resection margin positivity rates (p = 1.000) were similar between the groups. The 4-year DFS and OS rates were comparable. The patients with clinical or pathological complete response had significantly longer overall survival (p = 0.017) regardless of the type of neoadjuvant treatment. CONCLUSIONS: Multimodal assessment after TNT effectively detects complete responders, resulting in low local recurrence and increased cumulative complete response rates. However, these outcomes did not translate into a survival advantage.

A novel scoring system for the early detection of anastomotic leakage: bedside leak score-a pilot study.

Background: Anastomotic leakage is a major complication in colorectal surgery, resulting in significant morbidity and mortality rates. Despite substantial progress in surgical technique, anastomotic leakage rates remain stable. An early diagnosis of anastomotic leaks was proven to reduce adverse outcomes and improve survival. Objective: This study aims to find a novel scoring system for detecting anastomotic leaks using inflammatory and nutritional indicators after colorectal surgery. Our purpose was to analyze the diagnostic accuracy of leak scores ((CRPPOD3)(CRPPOD1)∗preoperativealbuminlevel) in predicting postoperative complications. Design: The study included colorectal cancer patients who underwent curative surgery at Koc University Hospital between 2014 and 2018. Patients were categorized into two groups depending on the presence of anastomotic leaks and compared in terms of preoperative albumin levels, CRP levels in postoperative days 1 and 3, anastomotic leakage rates, length of hospital stay, and CRP quotient, which was calculated by dividing POD 3 CRP level to POD 1 CRP level. The bedside leak score is calculated by dividing the CRP quotient by the preoperative albumin level. The predictive value of bedside leak score, CRP quotient, and preoperative albumin levels in estimating anastomotic leakage was analyzed, and a cutoff value for the leak score was calculated. Results: A total of 184 patients were included in the study. The leak score, CRP POD 3-1 ratio, and preoperative albumin levels were found to successfully detect anastomotic leakage. The area under the curve for the leak score was calculated as 0.78. The optimal cutoff value was found to be 50.3 for the bedside leak score, which shows 90.9% sensitivity and 59.3% specificity. Conclusion: The leak score may represent a valuable diagnostic tool for detecting patients at risk for anastomotic leakage after colorectal surgery and planning a better strategy to reduce morbidity and mortality rates and associated costs. However, further multicenter studies with large cohorts are necessary to confirm these results.

Pancreatic surgery in elderly patients: results of 329 consecutive patients during 10 years.

Introduction: There is a progressive shift from a younger population to an older population throughout the world. With the population age shift, surgeons will be more encountered with older patient profiles. We aim to determine age-related risk factors of pancreatic cancer surgery and the effect of patient age on outcomes after pancreatic surgery. Materials and methods: A retrospective review was conducted with data obtained from consecutive 329 patients whose pancreatic surgery was performed by a single senior surgeon between January 2011 and December 2020. Patients were divided into three groups based on age: patients younger than 65 years old, between 65 and 74 years old, and older than 74 years old. Demographics and postoperative outcomes of the patients were evaluated and compared between these age groups. Results: The distribution of a total of 329 patients into the groups was 168 patients (51.06%) in Group 1 (age <65 years old), 93 patients (28.26%) in Group 2 (age ≥65 and <75 years old), and 68 patients (20.66%) in Group 3 (age ≥75 years old). The overall postoperative complications were statistically significantly higher in Group 3 than in Group 1 and Group 2 (p = 0.013). The comprehensive complication index of the patients in each group was 23.1 ± 6.8, 20.4 ± 8.1, and 20.5 + 6.9, respectively (p = 0.33). Fisher's exact test indicated a significant difference in morbidity in patients with ASA 3-4 (p = 0.023). In-hospital or 90-day mortality was observed in two patients (0.62%), one from Group 2 and one from Group 3. The 3-year survival rates for each group were 65.4%, 58.8%, and 56.8%, respectively (p = 0.038). Conclusion: Our data demonstrate that comorbidity, ASA score, and the possibility of achieving a curative resection do have significantly more impact than age alone.

Is there no need to discuss adjuvant chemotherapy in stage II colon cancer patients with high tumor budding and lymphovascular invasion?

PURPOSE: The aim of this study is to evaluate the clinicopathologic associations of tumor budding (Bd) as well as other potential prognosticators including lymphovascular invasion (LVI) in T3/4aN0 colon cancer patients and to investigate their impact on the outcome. METHODS: The patients were enrolled in three groups according to the number of budding as Bd1 (0-4 buds), Bd2 (5-9 buds), and Bd3 (> 10 buds). These groups were retrospectively compared in terms of demographic features, other tumor characteristics, operative outcomes, recurrences, and survival. The mean follow-up time was 58 ± 22 months. RESULTS: A total of 194 patients were divided as follows: 97 in Bd1, 41 in Bd2, and 56 in Bd3 groups. The Bd3 group was associated with significantly higher LVI and larger tumor size. The rate of recurrence increased progressively from 5.2% in Bd1 to 9.8% in Bd2 and to 17.9% in Bd3 group (p = 0.03). More importantly, the 5-year overall survival (OS: Bd1 = 92.3% vs. Bd2 = 88% vs. Bd3 = 69.5%, p = 0.03) and disease-free survival (DFS: Bd1 = 87.9% vs. Bd2 = 75.3% vs. Bd3 = 66%, p = 0.02) were significantly worse in Bd3 group. In addition, in the subgroup of patients with the presence of Bd3 and LVI together, the 5-year OS (60% vs. 92%, p = 0.001) and DFS (56.1% vs. 85.4%, p = 0.001) were significantly worse. In multivariate analysis, Bd3+LVI was significantly associated with poor OS and DFS (p < 0.001). CONCLUSION: In patients with T3/4aN0 colon cancer, high tumor budding negatively affects long-term oncological outcomes. These findings strongly suggest that adjuvant chemotherapy be considered for the patients with Bd3 and LVI together.

The role of tissue inhibitor of metalloproteinases in the aetiology of inguinal and incisional hernias.

Inguinal and incisional hernias are the two most common types of hernias caused by abdominal wall weakness and defects in connective tissue. The structure of the extracellular matrix, mainly collagen and metalloproteinases (MMPs), and their regulators have been studied extensively and found to play a significant role in the pathophysiology of hernias. One of the regulators of MMPs, tissue inhibitor metalloproteinases (TIMPs), bind to MMPs and inhibit its activity significantly shifting the balance towards collagen synthesis rather than degradation. Due to their importance in collagen metabolism, their metabolism might be significant in the aetiology of hernias. Our study used immunohistochemical techniques to investigate the possible effects of TIMP 1 and 2 on the samples taken from the abdominal walls of patients with inguinal and incisional hernias, compared them with control patients, and reviewed the literature. In this study, samples of 90 patients (30 patients from control, inguinal hernia, and incisional hernia groups) were taken and analysed. These samples were stained with TIMP-1 Ab-2 and TIMP2 Ab-5 (Clone 3A4) antibodies and evaluated under ×100 magnification. The degree of staining was classified as (a): No staining (0), (b): Staining less than 10% (I), (c): Staining between 10% and 50% (II), (d): Staining more than 50% (III). Statistical analyses were done. No significant difference was found between groups in terms of patient demographics. Smoking and family history of hernia was not found to be associated with TIMP expression. TIMP1 expression was significantly higher in the incisional and inguinal hernia group than in the control group (P < .05), while the level of TIMP2 was higher in the control group. (P < .05). TIMP1 and TIMP2 levels did not significantly differ between incisional and inguinal hernia groups. We found significantly increased TIMP-1 levels in tissue samples from patients with hernia supporting its suggested role in hernia pathophysiology. Local alterations in MMP and TIMP levels might play a role in the pathogenesis of hernias. Thus detection of TIMP in tissues can be important for clinical use after further validation studies. In the era of molecular medicine, detecting TIMP levels in hernia patients can impact clinical practice.

Mid-transverse Location in Primary Colon Tumor: A Poor Prognostic Factor?

BACKGROUND: The location of colonic tumors has been linked to different clinical and oncologic outcomes. Transverse colon cancers are generally included as right colon cancers. Furthermore, hepatic and splenic flexure tumors are usually included as components of the transverse colon. OBJECTIVE: This study was aimed at comparing the clinicopathologic characteristics and long-term outcomes between mid-transverse and right and left colon cancers and determining the prognostic impact of the primary tumor location in the mid-transverse colon. DESIGN: This was a retrospective study. SETTINGS: Two specialized colorectal centers were included. PATIENTS: Patients who underwent curative surgery for colon cancer were analyzed. Tumors located in the transverse colon, excluding the flexures, were defined as mid-transverse colon cancers. MAIN OUTCOME MEASURES: Demographic characteristics, operative outcomes, pathologic results, and long-term outcomes were the primary outcome measures. RESULTS: Of the 487 patients, 41 (8.4%) had mid-transverse, 191 (39.2%) had right, and 255 (52.4%) had left colon cancers. For mid-transverse colon cancers, the mean length of hospital stay, mean length of the resected specimen, and the mean number of harvested lymph nodes were significantly higher. For patients with stage I to III cancer, the 5-year overall and disease-free survival rates were significantly worse in the mid-transverse colon cancers than in the right and left colon cancers (overall survival: 55.5% vs 82.8% vs 85.9%, p = 0.004, and disease-free survival; 47.7% vs 72.4% vs 79.5%, p = 0.003). After adjustment for other clinicopathologic factors, mid-transverse colon cancers were significantly associated with a poor prognosis (HR = 2.19 [95% CI, 1.25-3.83]; p = 0.006). LIMITATIONS: Molecular and genetic information were unavailable in this retrospective study. CONCLUSIONS: In our case series, colon cancers located in the mid-transverse colon showed poorer prognosis than cancers in other locations. The impact of tumor location in the mid-transverse colon on prognosis, including molecular and genetic markers, should be investigated further in prospective studies. See Video Abstract at http://links.lww.com/DCR/B631. LOCALIZACIN TRANSVERSA MEDIA EN EL TUMOR DE COLON PRIMARIO UN FACTOR DE MAL PRONSTICO: ANTECEDENTES:La ubicación de los tumores de colon se ha relacionado con diferentes resultados clínicos y oncológicos. Los cánceres de colon transverso se incluyen generalmente como cánceres de colon derecho. Además, los tumores del ángulo hepático y esplénico suelen incluirse como un componente del colon transverso.OBJETIVO:Este estudio tuvo como objetivo comparar las características clínico-patológicas y los resultados a largo plazo entre los cánceres de colon transverso medio y derecho e izquierdo y determinar el impacto pronóstico de la ubicación del tumor primario en el colon transverso medio.DISEÑO:Este fue un estudio retrospectivo.AJUSTE ENTORNO CLINICO:Se incluyeron dos centros colorrectales especializados.PACIENTES:Se analizaron los pacientes que fueron sometidos a cirugía curativa por cáncer de colon. Los tumores ubicados en el colon transverso, excluidos los ángulos, se definieron como "cánceres de colon transverso medio".PRINCIPALES MEDIDAS DE RESULTADO VOLARACION:Las características demográficas, los resultados quirúrgicos, los resultados patológicos y los resultados a largo plazo fueron las principales medidas de resultado valoracion.RESULTADOS:De los 487 pacientes, 41 (8,4%) tenían cáncer de colon transverso medio, 191 (39,2%) derecho y 255 (52,4%) cáncer de colon izquierdo. Para los cánceres de colon transverso medio, la duración media de la estancia hospitalaria, la duración de la muestra resecada y el número medio de ganglios linfáticos extraídos fueron significativamente mayores. Para los pacientes en estadio I-III, las tasas de supervivencia general y sin enfermedad a 5 años fueron significativamente peores en los cánceres de colon transverso medio que en los cánceres de colon derecho e izquierdo (supervivencia general: 55,5% frente versus a 82,8% frente versus a 85,9%, p = 0,004 y supervivencia libre de enfermedad; 47,7% frente a 72,4% frente a 79,5%, p = 0,003, respectivamente). Después del ajuste por otros factores clínico-patológicos, los cánceres de colon transverso medio se asociaron significativamente con un pronóstico desfavorable (Razón de riesgo: 2,19; intervalo de confianza del 95%: 1,25-3,83; p = 0,006).LIMITACIONES:La información molecular y genética no estuvo disponible en este estudio retrospectivo.CONCLUSIONES:En nuestra serie de casos, los cánceres de colon localizados en el colon transverso medio mostraron un peor pronóstico que los cánceres en otras localizaciones. El impacto de la ubicación del tumor en el colon transverso medio sobre el pronóstico, incluidos los marcadores moleculares y genéticos, debe investigarse más a fondo en estudios prospectivos. Consulte Video Resumen en http://links.lww.com/DCR/B631. (Traducción-Dr Adrián Ortega).

Effects of the Largest Metastatic Lymph Node Size on the Outcomes of Patients who Underwent Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma.

Objectives: Prognostic importance of metastatic lymph nodes in pancreatic cancer is always garnered attention due to dismal prognosis, with some quantitative factors drawing attention for significantly predicting outcomes. Size is one of the easy approach morphological characteristics of the lymph node, and data for effect of largest metastatic lymph node (LMLN) size on survival outcomes are lacking in pancreatic cancer. We aim to evaluate the effect of LMLN size on the prognosis of patients with pancreatic ductal adenocarcinoma (PDAC). Methods: This retrospective study evaluates the effect of LMLN size on survival outcomes by grouping the patients who were surgically treated for PDAC, according to their lymph node stage and calculated cutoff value for LMLN size, between February 2015 and May 2020. Results: In the study cohort of 131 patients, the mean age was 63.9±10.8 years and 77 patients were female. Ninety-nine of the patients had pN1, 32 had pN2 stage disease. The optimal cutoff point of LMLN size for predicting the prognosis was calculated as 7.5 mm (sensitivity = 81% and specificity = 81%). 34 (34.3%) of pN1 and 7 (21.9%) of pN2-staged patients had lymph node smaller than 7.5 mm. Three-year survival was significantly longer for patients whose LMLN size was <7.5 mm (56.2-18.2%, p<0.001). Whereas, the patients with LMLN size <7.5 mm had statistically significant longer median survival rate in the subgroup of patients with pN1 lymph node stage, no significant difference in median survival rates was observed between subgroups of pN2 patients (p=0.237). Conclusion: The present study demonstrated that the LMLN size was one of the potential predictors of survival in patients with PDAC.

The Role of Minimally Invasive Surgery in Gastric Cancer.

OBJECTIVE: This study aims to investigate the efficacy and safety of minimally invasive surgery (MIS) in gastric cancer and to compare MIS versus open gastrectomy (OG) in terms of early mortality and morbidity, long-term oncological outcomes, and recurrence rates. METHODS: A total of 75 patients who underwent MIS or OG for gastric cancer at Koç University School of Medicine between December 2014 and December 2019 were retrospectively analyzed. Postoperative complications and disease-specific survival were compared between surgical approaches. RESULTS: Of the patients, 44 were treated with MIS and 31 with OG. In the MIS group, 33 patients underwent laparoscopic surgery, and 11 patients underwent robotic gastrectomy. Duration of operation was significantly longer in the MIS group than in the OG group (p<0.0001). The median amount of blood loss was 142.5 (range, 110 to 180) mL in the MIS group and 180.4 (range, 145 to 230) mL in the OG group (p<0.706). The median number of lymph node dissection was 38.9 (range, 15 to 66) and 38.7 (range, 12 to 70) in the MIS and OG groups, respectively (p<0.736). The median length of hospitalization, twelve days in the OG group and nine days in the MIS group. Median follow-up was 19.1 (range, 2 to 61) months in the MIS group and 22.1 (range, 2 to 58) months in the OG group. The median OS and DFS rates were 56.8 months and 39.6 months in the MIS group, respectively (log-rank; p=0.004) and 31.6 months and 23.1 months in the OG group, respectively (log-rank; p=0.003). CONCLUSION: Our study results suggest that, despite its technical challenges, MIS is an effective and safe method in treating gastric cancer with favorable early mortality and morbidity rates and long-term oncological outcomes, and acceptable recurrence rates.

Right paraduodenal hernia accompanying superior mesenteric vein thrombosis: a rare case.

A 59-year-old man with abdominal pain was admitted to the emergency department. Investigations had revealed a right-sided paraduodenal hernia and superior mesenteric vein (SMV) twisting around the superior mesenteric artery in rotation, the 'whirlpool sign'. Owing to the increasing severity of abdominal pain and the presence of SMV thrombosis complicated with strangulated paraduodenal herniation associated with high mortality rates, diagnostic laparoscopy was performed. Resection of the intestines was not needed and paraduodenal hernia was repaired. The patient was uneventfully discharged.

Laparoscopic Inguinal Hernia Repair-TAPP versus TEP: Results of 301 Consecutive Patients.

INTRODUCTION: Transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) hernia repair are the two most commonly used techniques in laparoscopic inguinal hernia repair, and the results of comparative studies are conflicting. The objective of this study is to compare the two methods in unilateral inguinal hernia repair. MATERIALS AND METHODS: The data of consecutive patients who underwent TEP and TAPP due to unilateral inguinal hernia between December 7, 2017, and March 15, 2020, were analyzed retrospectively. The primary outcome was to compare the clinical outcomes of the two techniques in terms of complications, conversion, pain, and operative time. The secondary outcome was recurrence rates. RESULTS: A total of 301 (TEP n=234, TAPP n=67) patients were included in the study. The mean age was 43 years, and the follow-up period was two years. The groups were similar in terms of demographic characteristics and hernia type. The mean operative time was longer in the TAPP group than in the TEP group (67 min and 58 min, p=0.007). The recurrence rate was 4.3% in the TEP group and 5.9% in the TAPP group (p>0.05). The conversion rate was 6% in both groups. In total, 19 (6.3%) patients had intraoperative complications (TEP n=16, TAPP n=3), and 23 (7.6%) patients had postoperative complications (TEP n=16, TAPP n=7). Both intraoperative and postoperative complication rates were similar between the groups (p=0.31 and p=0.051, respectively). The early postoperative pain was less in the TEP group (p=0.004). CONCLUSION: Less early postoperative pain and shorter operative time were detected in patients who underwent TEP.

Open mesh and laparoscopic total extraperitoneal inguinal hernia repair under spinal and general anesthesia.

INTRODUCTION: Mesh placement is the main standard in repair of inguinal hernia, and laparoscopic repair is the standard of care via spinal, epidural, or combined anesthesia. Here, we compared open and laparoscopic total extraperitoneal (TEP) repairs under general (GA) and spinal anesthesia (SA). METHODS: Inguinal hernia patients (n=440) were analyzed retrospectively. There were four groups: Group 1 was TEP under GA (TEP-GA) (n=111); Group 2 was open mesh repair (OM) under SA (n=116) (OM-SA); Group 3 was open mesh repair under GA (n=117) (OM-GA); Group four was TEP under SA (n=96) (TEP-SA). The age, body mass index, duration of operation, hospital stay, postoperative Visual Analog Scale scores, recurrence, postoperative pain, urinary retention, headache, and patient satisfaction were all recorded. RESULTS: There was no significant difference in terms of hypotension, vomiting, seroma and scrotal edema, recurrence, and wound infection incidence between the groups. However, the operation duration, hospital stay period, headache, urinary retention, postoperative Visual Analog Scale scores, chronic pain, and patient satisfaction showed significant differences between groups. CONCLUSION: Laparoscopic TEP hernia repair is a safe and effective method along with its advantages of shorter hospital stay, less recurrence, less postoperative pain, higher patient satisfaction, and similar postoperative complication rates. SA has the disadvantage of higher incidence of headache and urinary retention compared to GA.

Arterial disease and vascular access in diabetic patients.

PURPOSE: There are conflicting reports on the effects of diabetes on the outcomes of hemodialysis access procedures. While some found no negative effects, others reported deleterious effects of diabetes on vascular access outcomes. Why is there concern about diabetes and related vascular problems on vascular access procedures? What are the differences of diabetic patients and their vasculature from that of nondiabetics? Do they have an effect on hemodialysis vascular access outcomes? We will try to find answers to these questions in light of the available evidence. METHODS: Recent literature on arterial disease in diabetes and end-stage renal disease (ESRD), and the effects on vascular access outcomes were searched in order to find answers to above questions. RESULTS: There are conflicting and controversial reports on the effects of preexisting vascular problems due to diabetes and chronic kidney disease (CKD) on the outcomes of hemodialysis access procedures. Diabetic vasculature, especially in patients with ESRD, has some specific problems, the most important of which seem to be the calcification and stiffening of the arteries. CONCLUSIONS: Although some authors report inferior outcomes of vascular access procedures in diabetic patients, there is evidence that most of the problems encountered can be dealt with by careful patient selection, surgical skill, and experience.