Pancreaticoduodenectomy in patients < 75 years versus ≥ 75 years old: a comparative study.

OBJECTIVE: This study aimed to compare the postoperative outcomes of < 75-year-old patients and ≥ 75-year-old patients who underwent pancreaticoduodenectomy (PD) for pancreatic head and periampullary region tumors. METHODS: Patients who underwent PD in our hospital between February 2019 and December 2023 were evaluated. Demographics, Eastern Cooperative Oncology Group Performance Status (ECOG-PS) scores, American Society of Anesthesiologists (ASA) scores, comorbidities, hospital stays, complications, and clinicopathological features were analyzed. Patients were divided into < 75 years (Group A) and ≥ 75 years (Group B) groups and compared. RESULTS: The median age of the entire cohort (n = 155) was 66 years (IQR = 16). There was a significant difference between Group A (n = 128) and Group B (n = 27) regarding the ECOG-PS and ASA scores. There was no significant difference between the groups regarding postoperative complications. The 30-day mortality rate was greater in Group B (p = 0.017). Group B had a cumulative median survival of 10 months, whereas Group A had a median survival of 28 months, with a statistically significant difference (p < 0.001). When age groups were stratified according to ECOG-PS, for ECOG-PS 2-3 Group A, survival was 15 months; for ECOG-PS 2-3 Group B, survival was eight months, and the difference was not statistically significant (p = 0.628). CONCLUSIONS: With the increasing aging population, patient selection for PD should not be based solely on age. This study demonstrated that PD is safe for patients older than 75 years. In older patients, performance status and the optimization of comorbidities should be considered when deciding on a candidate's suitability for surgery.

Reinforcement in Laparoscopic Sleeve Gastrectomy: Is It Effective?

BACKGROUND: Despite the success of bariatric surgery in treating obesity, it can still lead to complications. The most serious and feared technical complications are bleeding and leakage from the gastric staple line. In this study, stapler line reinforcement was investigated to determine whether it affects postoperative leakage and bleeding rates and their management. MATERIALS AND METHODS: Overall, 510 patients who underwent sleeve gastrectomy were evaluated retrospectively. They were divided into 2 groups according to whether reinforcement of the staple line with running imbricating sutures was performed. RESULTS: In the reinforcement group, there were two leaks (0.7%), which were diagnosed seven and eight days after surgery. In the non-reinforcement group, there were nine leaks (4%). There was no difference between the two groups in staple line bleeding. CONCLUSIONS: This study shows that reinforcement with continuous imbricating sutures is associated with less stapler line leakage and a lower reoperation rate at the cost of increased operative time.

Prognostic significance of metastatic lymph node ratio in gastric cancer: a Western-center analysis.

BACKGROUND: Tumor-node-metastasis (TNM) staging is the central gastric cancer (GC) staging system, but it has some disadvantages. However, the lymph node ratio (LNR) can be used regardless of the type of lymphadenectomy and is considered an important prognostic factor. This study aimed to evaluate the relationship between LNR and survival in patients who underwent curative GC surgery. METHODS: All patients who underwent radical gastric surgery between January 2014 and June 2022 were retrospectively evaluated. Clinicopathological features of tumors, TNM stage, and survival rates were analyzed. LNR was defined as the ratio between metastatic lymph nodes and total lymph nodes removed. The LNR groups were classified as follows: LNR0 = 0, 0.01 < LNR1 ≤ 0.1, 0.1 < LNR2 ≤ 0.25 and LNR3 > 0.25. Tumor characteristics and overall survival (OS) of the patients were compared between LNR groups. RESULTS: After exclusion, 333 patients were analyzed. The mean age was 62 ± 14 years. According to the LNR classification, no difference was found between groups regarding age and sex. However, TNM stage III disease was significantly more common in LNR3 patients. Most patients (43.2%, n = 144) were in the LNR3 group. In terms of tumor characteristics (lymphatic, vascular, and perineural invasion), the LNR3 group had significantly poorer prognostic factors. The Cox regression model defined LNR3, TNM stage II-III disease, and advanced age as independent risk factors for survival. Patients with LNR3 demonstrated the lowest 5-year OS rate (35.7%) (estimated mean survival was 30 ± 1.9 months) compared to LNR 0-1-2. CONCLUSION: Our study showed that a high LNR was significantly associated with poor OS in patients who underwent curative gastrectomy. LNR can be used as an independent prognostic predictor in GC patients.

Older is worse? Elderly patients who underwent gastrectomy: A single-center study.

AIM: Gastric cancer is common cancer, and its incidence remains relatively high in elderly patients with increasing life expectancy. However, few studies have examined the clinical and prognostic characteristics of elderly gastric cancer patients undergoing gastrectomy. This study aimed to evaluate the clinical and prognostic features of elderly gastrectomy patients. MATERIALS AND METHODS: Patients over 65 years of age who underwent gastric cancer surgery at Marmara University were retrospectively analyzed. The patients' demographics, American Society of Anesthesiologists scores, prognostic nutritional index (PNI), complications, intensive care unit duration, and length of stay were examined. The patients were divided into two groups: young-old (65-74 years old) and old-old (≥ 75 years old). Two groups were compared in terms of postoperative outcomes and overall survival. RESULTS: Two hundred sixty-three patients were analyzed. The mean age was 79 years, and the female to male ratio was 85/178. Reoperation rates and hospital mortality were significantly higher in the old-old group (p=0.001 and p=0.01, respectively). The hospital stay was significantly longer in the old-old group (5.8 vs. 7.8 days, p= 0.02). Complications were significantly higher in the group with a PNI < 40 (49% vs. 23%, p=0.005). There was a significant difference between the two groups regarding 5-year overall survival (33% vs. 55%, p= 0.002). CONCLUSIONS: Gastrectomy can be performed on the elderly. However, an increase in complications and in-hospital mortality is recognized over 75. These problems should be considered in this old-age group. KEY WORDS: Aged, Carcinoma stomach, Elderly, Gastric cancer, Gastrectomy.

Outcomes of Proximal Versus Total Gastrectomy for Proximal Gastric Cancer: A Propensity Score-Matched Analysis of a Western Center Experience.

PURPOSE: In this western study, we aimed to compare perioperative outcomes, postoperative complications, and overall survival in patients who underwent total gastrectomy (TG) or proximal gastrectomy (PG) for proximal gastric cancer (GC). METHODS: Patients who underwent GC surgery at Marmara University Hospital between January 2014 and December 2021 were evaluated retrospectively. Propensity score matching (PSM) was performed to balance the baseline characteristics of patients undergoing PG and TG. Data on patients' demographics, clinicopathological features of tumors, complications, and survival rates were analyzed. Perioperative outcomes and overall survival of the patients were compared between PG and TG groups. RESULTS: A total of 212 patients were included in this study, with 53 patients in the PG and 159 in the TG group. After 1:1 matching according to PSM, 46 patients in the PG group were matched to 46 in the TG group. After PSM, there were no differences in clinicopathological outcomes except retrieved lymph nodes. In terms of short-term outcomes, overall perioperative morbidity (Clavien Dindo ≥ 3a) was significantly higher in the PG group (p = 0.01). However, there was no significant difference when the complications were considered separately. In the long-term follow-up, reflux esophagitis was associated with the PG group (p=0.04). In multivariate analysis, positive surgical margin and lymphovascular invasion were significant factors related to overall survival. Overall, 5-year survival was 55% in matched patients. The difference in survival was not statistically significant (57 vs. 69 months, p = 0.3) between the two groups. CONCLUSIONS: Proximal gastrectomy is applicable to patients up to stage 3 disease, with no difference in overall survival, with caution in early complications and reflux esophagitis. Among all demographic and oncological factors, lymphovascular invasion and resection margin were significantly associated with worse survival.

A Spontaneous Transomental Hernia: A Rare Cause of Bowel Obstruction.

Internal hernias (IH) are rare situations that account for 0.5-3% of all cases of intestinal obstruction. Transomental hernia is a rare subtype, hardly diagnosed, and represents approximately only 2% of internal hernias. In 2018, a 41-year-old female patient presented to Marmara University Hospital emergency service with abdominal pain, nausea, and vomiting. Her medical history included asthma, and she had no abdominal surgery. With the preliminary diagnosis of small bowel obstruction, laparotomy was done and showed a loop of ileum was herniated through into an unusual defect of the omentum. The obstructed loop of the small intestine into the hernia site was reduced. It was seen as viable, so no resection was necessitated. We divided the greater omentum into two parts from the edge of the defect area to prevent recurrences. The patient's postoperative period was uneventful, and she was discharged on the second postoperative day. Small bowel strangulation is more seen in transomental hernia than in other internal hernia types. So it is related to high morbidity and mortality. Surgery should not be delayed to reduce complications.

Ileal gastrointestinal stromal tumor presenting as retroperitoneal mass.

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal (GI) tract. It represents a wide range of clinical tumors with different clinical presentations, locations, and prognoses. Retroperitoneal GISTs are rarely seen and may be associated with the GI system. In this case report, we present the laparoscopic excision of retroperitoneal ileal GIST in a patient who was admitted to the outpatient clinic with abdominal pain.

Factors Predicting Surgical Treatment in Patients with Adhesive Small Bowel Obstruction: Retrospective Single-centre Study.

OBJECTIVE: To investigate the factors which predict treatment strategy in patients with adhesive small bowel obstruction. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: General Surgery Clinic, Marmara University Medical Faculty, Istanbul, Turkey, between January 2016 and December 2020. METHODOLOGY: Data of the patients with adhesive small bowel obstruction (ASBO) was retrospectively collected. The demographic characteristics and laboratory findings were evaluated. Patients, who underwent conservative treatment and surgical intervention, were compared. Differences between the two groups in terms of demographic characteristics, prognostic nutritional index (PNI) scores, and neutrophil (NEU)-to-lymphocyte (LYM) ratio (NLR), were evaluated. RESULTS: One-hundred thirty-seven patients were included in the study. Seventy-four (54%) of the patients had conservative treatment. There was no statistically significant difference between the surgical and conservative treatment groups according to the age, gender, and ASA score (p=0.77, 0.21 and 0.95 respectively). The patients with congenital aetiology and low PNI scores were in significantly higher numbers among the surgical treatment group (p <0.001 and p=0.004, respectively). In patients, who underwent surgery, the resection rate was found significantly higher in older age (63 vs. 52, p=0.01). CONCLUSION: Patients with low PNI scores and congenital adhesive small bowel obstruction undergo operative treatment more frequently than conservative treatment. Future studies focusing on diagnostic scores to predict early surgery in ASBO patients may include these variables. KEY WORDS: Adhesive small bowel obstruction, PNI, Treatment strategy, Surgery.

Does Gastric Expansibility Affect Weight Loss Success After Laparoscopic Sleeve Gastrectomy?

Reduced excess weight loss (EWL) or regain is a worrying problem after metabolic surgery. Factors attainable from the resected specimen that can predict this outcome are investigated. We retrospectively analyzed 64 patients who had undergone laparoscopic sleeve gastrectomy. We collected demographic data, preoperative gastric emptying measurements, volume, expansion capacity, and 6-dimensional measurements of sleeve gastrectomy specimens. Correlations between EWL, body mass index levels, and gastric specimen measurements related to gastric remnant dimensions were also scrutinized. We found a significant correlation between the gastric specimen and remnant gastric volume, the resection line length in the gastric specimen, and 12th-month EWL%. Antrum expansibility was significantly increased in patients with weight regain. There was also a negative correlation between weight loss and age at postoperative first and third years. Sleeve resection line measurement and resected antrum diameter measurements can be used to predict weight loss, especially in the first year postoperatively.

Assessment of Esophagectomy Videos on YouTube: Is Peer Review Necessary for Quality?

INTRODUCTION: Various online platforms, such as YouTube, are used for surgical education. Esophageal surgery is sophisticated and surgical videos may help reduce the time it takes for surgeons to learn these complicated operations. There is no clear consensus regarding the quality and reliability of esophagectomy videos on YouTube. We aimed to evaluate esophageal surgery videos published on YouTube in terms of quality and reliability. METHODS: The keywords "esophagectomy" and "surgery" were both searched on YouTube and the first 150 results were evaluated. Eighty two videos were included in the analysis. The quality and reliability of the videos were determined using the esophagectomy scoring system (ESS) developed by the authors, the Journal of the American Medical Association benchmark criteria, and the video power index. RESULTS: A total of 82 videos were reviewed. About two-thirds of the videos demonstrated the Ivor Lewis technique and included surgeries performed using the thoracoscopic/laparoscopic method. The videos were analyzed as per the source of the upload: academic (25.7%), industry-sponsored (9.7%), or individual (64.6%). When the scores were compared by the origin of the videos, industry-sponsored videos scored significantly higher than the videos produced by individuals and academic centers (P = 0.01). While the ESS and Journal of the American Medical Association benchmark criteria scores were significantly correlated (P = 0.00), no correlation was found between video length, video power index score, and ESS score. CONCLUSIONS: Conducting a professional evaluation of videos before they are published on YouTube may enhance video quality. Moreover, valuable videos of better quality can be produced by improving the ESS and by assessing more videos.

Appendiceal Diverticulitis Presenting as Acute Appendicitis and Diagnosed After Appendectomy.

Introduction Diverticular disease of the appendix (DDA) is a rare appendiceal pathology. It is usually present similar to acute appendicitis. Because of its rarity, the DDA is poorly comprehended. This study evaluates the incidence, clinical and pathological characteristics of appendiceal diverticulitis diagnosed after appendectomy. Methods We performed a retrospective analysis of patients who underwent appendectomy between January 2016 and January 2022 at the Istanbul Sultanbeyli State Hospital General Surgery Clinic. The following parameters were analyzed: age and gender, preoperative diagnosis, laboratory results, radiological imaging findings, surgical technique, histopathological examination of specimens, and complications. Results A total of 1586 patients were analyzed. In the pathology, diverticular disease of the appendix was detected in 10 patients (0.63%). The DDA patients' mean age was 34.4 years, and the male to female ratio was 4:1. We detected low-grade appendiceal mucinous neoplasia in one of our patients. Conclusion Appendiceal diverticulitis is rare and usually presents as acute appendicitis. Most DDAs are detected incidentally during the postoperative period and are associated with an increased risk of appendiceal neoplasm. Appendectomy specimens should be carefully examined histopathologically to detect diverticular disease of the appendix.

Esophagogastroduodenoscopy in Patients Aged 75 Years and Older: A Single-Center Study.

INTRODUCTION: Esophagogastroduodenoscopy is frequently used for the elderly population. Older patients are more fragile than younger patients because of multiple age-related chronic diseases and the common use of polypharmacy. There is no adequate data in the existing literature regarding the application of upper gastrointestinal system endoscopy in the elderly population. Therefore, in this article, we evaluated esophagogastroduodenoscopy procedures that were performed on patients aged 75 years or older in the secondary care hospital. METHODS: We performed a retrospective observational study of patients aged 75 years or older who underwent esophagogastroduodenoscopy between January 2016 and January 2021 at the Istanbul Sultanbeyli State Hospital Endoscopy Unit. Indications of endoscopy, ages, genders, endoscopic diagnoses, polyp/tumor/biopsy localizations, histopathological examination of biopsies, and complications of esophagogastroduodenoscopy were analyzed. RESULTS: A total of 202 patients were analyzed. The most common indication was dyspepsia (25%), followed by gastrointestinal bleeding, reflux, anemia, and screening/surveillance. For patients aged 75-79 years and patients aged ≥80 years, endoscopic diagnoses of esophageal and gastric malignancies were observed as 6.4% and 18%, respectively. Very relevant findings of endoscopy (esophageal and gastric malignancies; gastric and duodenal ulcers) were detected in 39 (19.3%) of all included patients. No complications due to endoscopic procedures were observed, but complications due to sedation (hypotension and hypoxemia) were observed in 5.0%. CONCLUSION: After pre-procedural evaluation, we must be careful while doing endoscopic procedures in the elderly because of multiple age-related chronic diseases and the common use of polypharmacy. This present study showed that esophagogastroduodenoscopy is a safe procedure with a high diagnostic yield in patients aged 75 years and older.

Gastric Cancer Surgery During the Pandemic: What It Costs?

BACKGROUND: From the early days of 2020, the COVID-19 pandemic continues to change whole life all around the world. Oncological patients are the most affected populations since these days. Because of decreasing numbers in surgery and endoscopy, gastric cancer patients had difficulties in treatment and diagnoses. Therefore, the early and long-term results may be affected during the pandemic. In this study, we aimed to evaluate pandemia effects on gastric cancer surgery in a single center. PATIENTS-METHODS: Patients were categorized as the COVID group and the Pre-COVID group. Patients who received neoadjuvant chemotherapy were excluded from the study. In the COVID period, 50 patients underwent gastric cancer surgery, while 64 were operated on in the pre-COVID period. Patients' demographics and clinical and pathological outcomes were evaluated. RESULTS: There was no statistically significant difference in both periods among patient characteristics such as age, gender, and body mass index. Pre-operative laboratory results were similar between two groups. Although there was no difference in operation types, an increase was detected in Clavien-Dindo grade 3 and higher complications during the COVID period. During the pandemic, there was a significant difference in the pathological outcomes. Peritoneal cytology-positive patients were higher in the COVID group. More lymphovascular invasions were also detected in the COVID period. Finally, it resulted stage differences between two groups. CONCLUSION: Because of COVID-19's heavy burden on healthcare system, delays in the diagnosis and treatment of oncological patients may occur. Therefore, this may be affected pathological and survival outcomes of cancer patients. Finally, further investigations are needed.

Recurrent Perianal Abscess in a Patient With Hermansky-Pudlak Syndrome Associated Granulomatous Colitis: A Case Report.

Hermansky-Pudlak syndrome (HPS) is a rare genetic disease consisting of the triad of oculocutaneous albinism, bleeding diathesis, and pigmented reticuloendothelial cells. In HPS patients' granulomatous colitis could be an additional feature and perianal abscess could be seen in such patients. We report a patient with HPS-associated granulomatous colitis, refractory to medical treatment, and perianal involvement. Patients with HPS-associated granulomatous colitis and perianal involvement may require multiple surgical interventions and there is no consensus yet for treatment in such patients.

Gastric medullary carcinoma: clinicopathological features and prognosis-a single-center study.

BACKGROUND: Gastric medullary carcinoma (GMC) is a distinct histologic subtype of gastric adenocarcinoma, which prominently associated with Epstein-Barr virus infection. This study aimed to evaluate the clinicopathological features and prognosis of patients with medullary carcinoma in one center. METHODS: Data regarding patients with gastric cancer were retrospectively analyzed at Marmara University between 2014 and 2019. Demographics, pathological features, and overall survival of patients with GMC were evaluated. The primary outcome of this study was to compare the pathological features of GMC to non-GMC (NGMC). The secondary outcome was comparing overall survival between the two groups. RESULTS: A total of 412 patients were enrolled in the study. Of 412 patients, 19 (5%) were diagnosed with medullary cancer. Compared to NGMC, no significant differences were observed in patient age, gender, tumor macroscopic pattern, size, lymphovascular invasion, pathological stage, location and size of the tumors, and the number of metastatic lymph nodes in GMC. However, perineural invasion and Borrmann ulcerated type rates were significantly higher among NGMC. Whereas the microsatellite instability (MSI) rate was significantly higher in the GMC (64% and 11%, respectively, p < 0.001). Multivariate analysis showed that the MSI status was the solely significantly different feature between the two groups. CONCLUSION: This study showed that GMC was associated with MSI, which could explain the better prognosis of medullary carcinomas.

A Case of Peutz-Jeghers Syndrome Presenting With an Inoperable Periampullary Tumor.

Peutz-Jeghers syndrome (PJS) is a syndrome characterized by multiple hamartomatous polyps in the gastrointestinal system and melanin pigments accumulating in the skin and mucous membranes. Patients with PJS have an increased risk of gastrointestinal malignancies. In this syndrome, pancreatic cancer is primarily detected in older ages. In this article, we present a case of a patient with an unresectable periampullary tumor and PJS.

De novo myeloid sarcoma as a rare cause of small bowel obstruction: CT findings and histopathologic correlation.

Small bowel obstruction caused by myeloid sarcoma in a patient with any hematological abnormality is very rare. Myeloid sarcoma occurs most commonly in patients with acute myelogenous leukemia (AML) and less with other hematological disorders. A 57-year-old female presented with abdominal pain, nausea, vomiting, and constipation. Radiological studies showed concentric bowel thickening in distal ileum that caused nearly total luminal compromise and signs of obstruction in proximal ileal bowel loops. She underwent laparotomic surgery and ileal resection was done. Diagnosis of myeloid sarcoma was made by histopathological examination of surgical specimens. Bone marrow biopsy was done to rule out systemic acute myelogenous leukemia (AML). Results of bone marrow biopsy were within normal limits. Finally, the patient was diagnosed as de novo myeloid sarcoma. Although the histopathological examination makes a definitive diagnosis, imaging allows to locate the lesion, evaluate its complications, and guide for correct biopsy. Accurate diagnosis of myeloid sarcoma has important prognostic value as transformation to AML can happen without chemotherapy or stem cell transplantation.

Subcostal Transversus Abdominis Plane Block for Laparoscopic Sleeve Gastrectomy, Is It Worth the Time?

BACKGROUND: Obesity is a complex and multifactorial disease whose incidence has increased, making it a serious public health issue. Laparoscopic sleeve gastrectomy (LSG) is one of the most common surgical procedures that is chosen for bariatric surgery. Decreasing postoperative pain in these patients which will increase patients' compliance and quality of life will lead to better surgical results. This study aims to compare the effectiveness of trocar site infiltration versus bilateral subcostal transversus abdominis plane block (TAP) in controlling postoperative pain in patients. METHODS: Forty-five consecutive patients who have undergone LSG in xxx General Surgery Department have been enrolled in the study. Patients were divided into two groups according to the surgeon's choice. The first group underwent TAP block, while the second group underwent trocar site infiltration. Patients' pain was recorded via visual analogue scale (VAS) in postoperative periods. RESULTS: Twenty-nine female (69%) and 13 (31%) male patients were included in the study. Median age was 41 (18-58) and median BMI was 48 (41.1-68). When the VAS values were compared, in the TAPB group, 6th hour resting and coughing pain was statistically significantly less. Other VAS values measured while resting, coughing, and post-mobilization did not show significant differences. There were no significant differences between the groups' tramadol use. CONCLUSIONS: After LSG, TAP block and trocar site infiltration yield similar pain control. Due to the faster application and fewer side effects, we concluded that trocar site infiltration should be the intervention of choice in controlling postoperative pain in LSG.